Updates on Pelvic Floor Disorders: Evaluation and Management

Anna R. Spivak, DO

Pelvic floor disorders (PFDs) encompass multiple conditions that affect the proper functioning of pelvic organs. It mostly affects women, however with increased longevity more commonly seen in men. One in three women is affected in a lifetime, 17% of women have more than one symptom ranging from incontinence, obstructive defecation, fistula, or pelvic organ prolapse. The prevalence increases with age and nearly half of women over the age of 80 are affected by a pelvic floor condition. These diseases are benign, however, they can be debilitating and have a tremendous effect on patients' quality of life. The symptoms take years to develop and there is rarely a “simple” treatment solution. It is a well-established fact that multidisciplinary collaboration is needed when treating patients with disorders of the pelvic floor. In this edition of Clinics in Colon and Rectal Surgery, a group of pelvic floor experts brings together 10 articles that discuss different aspects of the diagnosis and treatment of PFD.

The first documented rectal prolapse dates back to 1500 BC, the history of the rectal prolapse article will take you through time and different management strategies that were utilized. Unfortunately, one theme remains the same, the etiology of rectal prolapse is poorly understood and there is still no perfect treatment procedure. The only change in the 21st century is our understanding that rectal prolapse, like all disorders of the pelvic floor, is not an isolated diagnosis of just one organ and requires a multidisciplinary approach to treatment. In our practice, we collaborate closely with physiotherapists, behavioral gastrointestinal psychology, urogynecology/urology, gastroenterology, and other subspecialties. In this edition, I invited our colleagues to share their perspectives on diagnosis and treatment and discuss the strategies each specialty uses to treat PFD. Pelvic floor physiotherapists (PFPTs) are our closest collaborators. Oftentimes, the only role of the colorectal surgeon is to make a diagnosis and PFPT takes over treatment. PFPT is not one-size-fits-all and treatment strategies utilized by a therapist vary with each patient and diagnosis, the article by the physiotherapist describes such techniques and the role of PFPT.

Psychology is another close collaborator who is an incredibly valuable resource. Many of the patients with PFD have coexisting anxiety, depression, eating disorders, chronic pain syndromes, and posttraumatic stress disorders. The article by a group of psychologists who specialize in brain–gut connection and pelvic pain provides their perspective and treatment options for PFD patients.

PFD symptoms can be difficult to quantify and characterize as they vary and can overlap, an excellent description of current tools is summarized for the reader by Dr. Liliana Bordeianou. Recurrent prolapse, low anterior resection syndrome, multicompartment prolapse, and fistula to neovagina are unique challenges for the pelvic floor surgeon. Experts in the field are sharing their knowledge in managing these diagnoses in their articles.

Pelvic floor patients oftentimes do not need surgery but do require longitudinal follow-up past the diagnosis and close collaboration with advance practice provider (APP) is an essential part of a successful pelvic floor practice. Lieba Savitt, CNP, describes Massachusetts General Hospitals (MGH's) journey to building pelvic floor practice, a collaborative treatment model of APP and colorectal surgeons to provide safe patient care and improve patient outcomes and satisfaction.

Diagnosis and treatment of PFDs are complex and start with listening to the patient and taking a deep dive into the medical records. Dr. Tracy Hull shares her reflection on 30 years of taking care of patients with PFDs.

Treatment of patients with PFDs requires a thoughtful collaboration between multiple specialties, we are fortunate to have a group of like-minded providers at the Cleveland Clinic, and we discuss complex patients at our weekly conference where every subspecialty has an opportunity to weigh in on a comprehensive collaborative treatment plan.

When compiling this edition, I aimed to bring different experts' views and opinions to the reader to highlight the importance of addressing variable aspects of the PFD, as well as resources that can help with the treatment of this challenging diagnosis. I hope that you will find this pelvic floor edition of Clinics in Colon and Rectal Surgery educational and interesting.

Publication History

Article published online:
20 February 2025