Introduction 11 1.1 Pelvic floor disorders: epidemiology and pathophysiology Pelvic floor disorders include pelvic organ prolapse, urinary and fecal incontinence, defecatory disorders, pelvic pain and sexual dysfunction. More than a third of women will experience at least one pelvic floor dysfunction during their lifetime, and its prevalence is expected to increase due to aging of the population.1 This thesis focuses on prolapse and urinary incontinence. Although not lifethreatening conditions, its symptoms have a severe impact on the patients’ quality of life and wellbeing. The lifetime risk of undergoing surgery for prolapse or stress urinary incontinence (SUI) is estimated to be 20% by the age of 80 years.2 The pathophysiology of pelvic floor dysfunction is multifactorial. Delancey graphically summarized several causal factors in a ‘life-span model’ (Fig. 1). The life-span model plots a woman’s pelvic floor function in three main life phases. In Phase I, the woman develops her maximum pelvic floor functional capacity, which is dependent on her genetic background, nutrition and environment. In Phase II, the pelvic floor function may deteriorate due to the amount of injury and recovery of it, that occurs during pregnancy and after vaginal birth. Finally, in Phase III, the pelvic floor further deteriorates due to the aging process.3 Women will experience symptoms when their pelvic floor function depletes past a threshold. When, and if, this happens depends on several factors: the maximum functional capacity of the pelvic floor in Phase I, the rate of decline, stress their lifestyle places on the pelvic floor (e.g. chronic constipation, occupational lifting, obesity, chronic cough; Phase III), and in women having children, the events in Phase II (e.g. pregnancy, mode of delivery, obstetrical interventions). Aging may further enhance the deterioration of existing pelvic floor dysfunctions as the pelvic floor tissues weaken with age. As women live longer and lead more active lives, pelvic floor dysfunction is expected to become an increasingly important issue for both women and public health. Fig. 1. Integrated lifespan analysis of pelvic floor function (From Delancey JO et al. Graphic integration of causal factors of pelvic floor disorders: an integrated life span model. Am J Obstet Gynecol. 2008;199:6) Reproduced with permission of the publisher. The diagnosis of prolapse involves identifying the descent of one or more of the following: the anterior vaginal wall (cystocele) (Fig. 2A), the posterior vaginal wall (rectum and/or small bowel,
RkJQdWJsaXNoZXIy MTk4NDMw