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PELVIC FLOOR DISORDERS

Pelvic floor disorders (PFDs) include urinary incontinence, pelvic organ prolapse, fecal incontinence, and other sensory and emptying abnormalities of the lower urinary and gastrointestinal tracts. Nearly one-quarter of all women and more than one-third of older women endorse at least one PFD. The lifetime chance of a woman having surgery for stress incontinence and/or prolapse is 20.0%, with the cumulative risk of surgery for stress urinary incontinence being 13.6% and the cumulative risk of prolapse repair surgery being 12.6% by age 80 years.

PFDs increase in prevalence with age. Modern medicine extends life expectancy for our patients well into the eighth and ninth decades. We care for patients longer and more effectively, managing chronic medical problems, such as hypertension, cardiovascular disease, and diabetes, and facilitating longer and more productive lives. According to US Census data projections, by 2030, > 20% of women will be age 65 or older. This means that a large population of women will live up to one-third of their lives after menopause, with attendant health complications.

Urinary incontinence is a prime example. The prevalence increases as the population ages. Urinary incontinence is estimated to affect 50% of American women and results in substantial medical, social, and economic burdens. A 2006 cross-sectional study by Subak and colleagues reported an estimated national annual cost of $16 billion for incontinence in patients of all ages. Despite its pervasiveness and estimated annual costs, up to two-thirds of women do not seek help for incontinence, due to either embarrassment or unawareness that help is available. The societal concept that incontinence is part of the “normal” aging process is no longer acceptable.

ESSENTIALS OF DIAGNOSIS

  • Urinary incontinence involves involuntary leakage of urine.

  • History and physical examination can often effectively diagnose the correct condition.

  • The two most common types are stress incontinence (loss of urine with physical exertion) and urge incontinence (involuntary leakage of urine, associated with a sudden compelling desire to void).

  • The term overactive bladder is defined as urinary urgency, usually accompanied by frequency and nocturia, with or without urge incontinence, in the absence of urinary tract infection or other obvious pathology.

  • The use of pads to protect against soiling undergarments is the most common coping mechanism.

  • Behavioral methods such as fluid restriction, avoidance of dietary triggers, and pelvic floor muscle strengthening can help reduce symptoms.

  • Surgical intervention, such as a midurethral sling, can be an effective cure for stress urinary incontinence.

  • Medications or surgery (ie, neuromodulation or botulinum toxin injection) can be helpful for women with urinary urge incontinence who do not respond to behavioral methods.

Anatomy

The urinary and reproductive tracts are intimately associated during embryologic development. The lower urinary tract can be divided into three parts: the bladder, the trigone (ureteral orifices and bladder neck), and the urethra (Fig. 44–1). The bladder is a hollow muscular organ lined with transitional epithelium ...

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