Managing Pelvic Floor Disorders

Documents to Request

• Completed pelvic floor symptom questionnaires (PFDI-20 and PFIQ-7 minimum)
• Voiding diary (3-day minimum with fluid intake, void volumes, and leak episodes)
• Prior urodynamic study results (if performed)
• Prior pelvic imaging (MRI, ultrasound, defecography)
• Operative reports from prior pelvic/prolapse surgeries
• Pelvic floor physical therapy progress notes (if PT has been attempted)
• Current medication list with dosages
• Referral notes from primary care or other specialists

Step 1: POP-Q Staging (Pelvic Organ Prolapse Quantification)

POP-Q Reference Points

POP-Q Staging System

POP-Q Documentation Grid

       Aa ___  Ba ___  C  ___
       gh ___  pb ___  tvl ___
       Ap ___  Bp ___  D  ___
       Stage: ___

Step 2: Continence Assessment

Urinary Incontinence Classification

Urodynamic Evaluation — When to Order

• Symptoms do not clearly fit SUI or UUI pattern
• Failed previous surgical treatment for incontinence
• Planned surgical intervention for SUI or POP (to identify occult SUI)
• Elevated post-void residual (> 150 mL)
• Neurologic disease affecting bladder function
• Mixed incontinence where predominant type is unclear

Key Urodynamic Parameters

Step 3: Conservative Management

Pelvic Floor Physical Therapy (PFPT)

• First-line treatment for SUI (Grade A evidence), UUI, and POP Stage I–II
• Supervised Kegel exercise program with biofeedback: 3 sets of 10 contractions (5-second hold, 10-second rest) daily
• Duration: minimum 12 weeks of supervised therapy before assessing response
• Adjuncts: electrical stimulation, vaginal weights, behavioral training (urge suppression techniques)
• Outcome measures: reduction in leak episodes per voiding diary, improvement on PFDI-20 score

Pessary Management

Pessary Follow-Up Protocol

1. Initial fitting: trial in office; patient ambulates, voids, and performs Valsalva to confirm retention
2. First follow-up: 2 weeks — assess comfort, erosion, voiding, retention
3. Routine follow-up: every 3–6 months — clean pessary, inspect vaginal mucosa for erosion, apply estrogen cream if postmenopausal
4. Red flags: vaginal bleeding, foul discharge, inability to void, pessary incarceration — evaluate urgently

Step 4: Surgical Management

Surgical Options by Compartment

Surgical Decision Framework

1. Identify all compartments affected — multi-compartment repair is common
2. Determine if uterine conservation is desired (hysteropexy vs. hysterectomy)
3. Assess occult SUI with prolapse reduction testing (if POP ≥ Stage II, occult SUI prevalence ~30–40%)
4. Discuss mesh risks per FDA guidance: transvaginal mesh for POP is restricted; sacrocolpopexy mesh has more favorable risk profile
5. Set realistic outcome expectations: anatomic success ≠ symptomatic success; discuss functional outcomes
6. Plan concomitant procedures (hysterectomy, sling, perineorrhaphy) at the time of prolapse repair when indicated

Step 5: Fecal Incontinence Assessment and Management

Fecal Incontinence Evaluation

Fecal Incontinence Treatment Ladder

1. Dietary modification: Fiber supplementation (25–30 g/day), avoid trigger foods (caffeine, lactose, FODMAPs)
2. Antidiarrheal agents: Loperamide 2–4 mg before meals when diarrhea-predominant
3. Pelvic floor PT with biofeedback: First-line for mild-moderate FI; 60–70% improvement rate
4. Sacral nerve stimulation (SNS): InterStim device for moderate-severe FI unresponsive to conservative measures; 70–80% improvement
5. Sphincteroplasty: Overlapping repair for discrete sphincter defect identified on ultrasound
6. Injectable bulking agents: Solesta (dextranomer/hyaluronic acid) for mild-moderate FI
7. Colostomy: Last resort for refractory severe FI significantly impacting quality of life

Checkpoint B: Post-Management Alignment (Mandatory)

1. Was the POP-Q staging completed with all nine measurement points documented?
2. Was the continence evaluation (type classification, voiding diary, PVR) performed before treatment selection?
3. Was pelvic floor physical therapy offered as first-line treatment before surgical intervention (unless contraindicated)?
4. Were validated symptom questionnaires administered pre- and post-treatment for outcome measurement?
5. Were surgical risks, alternatives, and expected outcomes discussed and documented in informed consent?

Quality Audit

Guidelines

• Always perform a complete POP-Q examination with maximum Valsalva — partial exam misses occult prolapse compartments
• The POP-Q system is the only internationally standardized staging system; avoid subjective terms like "mild" or "moderate" without corresponding POP-Q stage
• Pelvic floor PT must be supervised (not just a handout) for minimum 12 weeks before it can be deemed to have "failed"
• Pessary management is a long-term treatment, not a bridge to surgery — many women manage successfully with pessaries for years or decades
• Post-void residual must be checked before starting anticholinergic medications and periodically thereafter, as urinary retention is a dose-dependent adverse effect
• After FDA reclassification of transvaginal mesh for POP as Class III (2016) and market withdrawal orders (2019), use of transvaginal mesh for prolapse repair is significantly restricted — sacrocolpopexy mesh remains supported for abdominal/robotic approaches
• Always assess for occult stress incontinence with prolapse reduction (e.g., pessary in place or speculum-assisted reduction) before prolapse surgery — unmasked SUI post-operatively is a common cause of patient dissatisfaction
• Coordinate care across urogynecology, colorectal surgery (for fecal incontinence), and pelvic floor physical therapy — PFDs are multi-disciplinary