The problem with human childbirth: A large object must pass through a constricted channel with both the object and the

3. Pelvic floor Damage/dysfunction: Vaginal delivery Pregnancy itself Aging Estrogen deficiency Neurological disease

4. Compounding Problems: Embarrassment leads to silence Time constraints lead to inadequate attention Knowledge limits lead to patient acceptance (changing) Technology limits lead to inadequate investigation (especially rural areas) Resource limits lead to inadequate access

5. Culture: First world women are more active Increasingly less willing to accept these problems Incontinence can destroy sport/recreation/job satisfaction Culture of litigation (Western world). Lawsuits related to pelvic floor just a matter of time Outcast 3rd world women

6. Statistics: 10-60% of women report urinary incontinence Objective studies - lower prevalence 50% of women that have had children develop prolapse Only 10-20% seek medical care Billions of dollars spent annually on incontinence products (in North America)

7. Statistics: 10-25% of women age 15-64 report urinary incontinence 15-40% of women over age 60 in the community report incontinence More than 50% of women in nursing homes are incontinent W.H.O. recognizes incontinence as an international health concern

8. Statistics: Anal incontinence is the current greater�pelvic floor closet issue� Incidence and prevalence figures vary Approximately 10% or more women with urinary incontinence have incontinence of flatus or stool Only 39% of anal incontinence after delivery cleared in 10 months (MacArthur C,et al: BR J Obstet Gynaecol 104:46-50,1997)

10. Quality of Life Impact: Impact on lifestyle and avoidance of activities Fear of losing bladder control Embarrassment Impact on relationships/sexual satisfaction Increased dependence on caregivers Discomfort and skin irritation

11. Demographics: (first world:) Aging baby boomers Increased percentage of older people Percentage of life after reproductive age the most in human history Percentage of life spent being pregnant the lowest in history Most Western countries have low and dropping fecundity (Canada: 1.5) Italy: now 60 million; 3000 � 20 million Trend to having children laterProf Bruno Lunenfeld: Andrology in the Nineties International Symposium on Human Sub-Fertility. 24 March 1999 Cape Town, South Africa

12. Aging: Gravity Neurologic changes with aging Loss of estrogen Changes in connective tissue crosslinking and reduced elasticity

13. Symptoms: Frequency Nocturia Dysuria Incomplete emptying Incontinence Urgency Recurrent infections Dyspareunia Prolapse

14. Hormone Effects: Common embryonic origin of bladder urethra and vagina from urogenital sinus High concentration of estrogen receptors in tissues of pelvic support General collagen deficiency state in postmenopausal women due to the lack of estrogen Urethral coaptation affected by loss of estrogen However; HRT not very effective!

15. Increased Intra-abdominal Pressure: Pulmonary disease Constipation/straining Lifting Exercise Ascites/hepatomegaly Obesity

16. Pregnancy and Childbirth: Hormonal effects in pregnancy Pressure of uterus and contents Denervation (stretch or crush injury to pudendal nerve) Connective tissue changes or injury (fascia) Mechanical disruption of muscles and sphincters

17. C/S vs Vaginal: OR for Vaginal delivery and stress incontinence: 11 RR of parity for prolapse: 10.85 Rectal sphincter complex damaged in 35 - 80% of first vag births (endoanal ultrasound)* Most damage in first birth Cumulative damage in later births*Tetzschner et al. Acta Obstet Gynecol Scan 1997; 76: 324

18. Risk factors: Big baby Long labour/second stage Forceps (vacuum protective?) Episiotomy? Elective (not emergency) C/S protective for anal incontinence (Sultan AH et al: N Engl J Med 329:1905-1911, 1993 BMJ 308:887-891, 1994)(MacArthur C,et al: BR J Obstet Gynaecol 104:46-50,1997)

19. Risk of C/S vs Vaginal: Nonelective C/S rate > 27% might yield higher maternal mortality than universal elective C/S Universal C/S - extra 1/18000 maternal mortalities 36 to 360 fetuses saved for each maternal mortality related to elective C/S. (1/50 - 1/500 fetuses suffer disaster in utero after maturity)Feldman G.B, Freiman J.A; N Engl J Med 312, 1264-1267 Insert reference and more info/onothere slikdeInsert reference and more info/onothere slikde

20. Risk of Cesarean birth: Little data on purely elective C/S in healthy women Data usually include all C/S Sweden 1973-79: Mortality rate:emerg C/S: 0.18/1000elective C/S: 0.04/1000 (5:1) Other studies suggest smaller difference Risk C/S:vaginal 5:1 (not only elective!) We can probably do even better (heparin, universal A/B profilaxis etc.)Lilford R,J et al; Br J Obstet 1990; 97:883-892

21. Cost of C/S vs vaginal birth: Depends on society (medical system) No level playing field in studies;all C/S usually lumped together Later prolapse/incontinence related costs, direct & indirect, not included Thus: most data biased

22. Surgery statistics (US): Ratio of surgery for prolapse vs incontinence: 2:1 Lifetime risk of surgery for prolapse: 11.1% Estimated re-operative rate: 29% 1/2 million prolapse surgeries /year (US) 2030 estimation: 7 mil/y + 2 mil reoperations(Bump R, Norton P: OB/Gyn Clinics 25, # 4, Dec. 1998)(Mailet VT et al: Presentation to AUGS, Sep 1997)

23. Informed concent: Culturally based Difficult and time consuming NOT appropriate in labour Taking into consideration fertility wishes and age (eg. # of children wished)(37yo wanting 1; vs 20yo wanting 4) Full discussion of relative risks, pros/cons Financial/resource issues - patient/society

24. TIMEIt is a dimensionIt is a quantum waveIt is a vibrating stringWhatever it is, we don�t have enough!

25. Elective cesarean birth for some women? �On the basis of current available evidence, the concept of an elective prophylactic cesarean section being outrageous, has been shattered by the fact that almost a third of female obstetricians would choose it for themselves� Paterson-Brown S; Queen Charlotte�s and Chelsea Hospital, London.Lancet 1996,347:544

26. Future issues: Risk prediction models (like in maternal-fetal medicine and oncology) Computer technology/neural network technology Cooperative efforts: Colorectal/Gyn/Urology(Check structural integrity of the whole building, not only one room�)

27. Future research: MRI pelvimetry (new fast scan technology) Collagen/DNA/muscle studies Nerve studies Age Family history Number of children planned

28. Evaluation/documentation of pelvic floor dysfunction:

29. ICS standardized prolapse system

30. Evaluation: Contrast radiography: (voiding colpocystourethrographydefecography MRI, CT: (not dynamic, and supine) Ultrasound: (not very practical) Testing of pelvic floor muscles:(inspection, palpation, EMG, pressures)

31. Treatment:

32. Non-surgical Treatment: Physiotherapy Pelvic floor exercises Vaginal cones Devices for reinforcement

33. Surgical Treatment