Pelvic organ prolapse: a urology perspective

Transcription

1 2675URO / Journal of Clinical UrologyBeckley and Harris Continuing Medical Education: Review Pelvic organ prolapse: a urology perspective Journal of Clinical Urology 6(2) British Association of Urological Surgeons 2013 Reprints and permissions: sagepub.co.uk/journalspermissions.nav DOI: / uro.sagepub.com Ian Beckley and Neil Harris Introduction Pelvic organ prolapse (POP) is defined as the descent of one or more of the anterior vaginal wall, posterior vaginal wall, uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy). 1 This descent may result in protrusion of the vagina, uterus or both. POP may be classified according to the vaginal compartment affected, e.g. anterior wall, posterior wall or apex. It is also common to describe the prolapse in terms of the organ which the vaginal bulge is presumed to contain, e.g. cystocoele for an anterior vaginal wall bulge thought to contain the bladder (see Table 1). Whilst the exact prevalence is unknown, POP is a common condition thought to be present in up to 50% of parous women. 2 The lifetime risk of undergoing a surgical procedure for POP was estimated at 4.4% for a cohort of women in the United Kingdom (UK). 3 The condition has traditionally been managed by urogynaecologists in the UK. However, with the establishment of the British Association of Urological Surgeons Section of Female Neurological and Urodynamic Urology (SFNUU), there is now an increasing expectation that POP should also be assessed and treated by urologists with an interest or specialist practice in female urology as part of the strategy for increasing the standards of care. 4 It is unclear at present to what extent these aims have been put into practice. It should also be noted that in the United States (US) (and to a lesser extent in other European countries) it is much more common for urologists with an interest in female urology to manage POP. Whilst generic female urology training is available in all current UK urology training programmes, there is still only one formal fellowship (Leicester) that offers formalised training specifically in all aspects of prolapse surgery. The aim of this article is to provide an overview of the current management of POP and highlight some of the controversies regarding surgical intervention. Aetiology Risk factors for developing POP include ageing, vaginal childbirth, obesity, chronic straining and connective-tissue disorders. The aetiology is multifactorial, but is mainly thought to result from a loss or weakness of the musculofascial pelvic support structures, allowing the pelvic viscera to descend. One of the main contributory factors in this process is dysfunction of the levator ani muscle complex. During vaginal childbirth, the levator ani muscle group has to stretch significantly, which can result in tearing or avulsion injury. 5 The risk of subsequent prolapse increases with the degree of injury. Women with a unilateral avulsion are up to three times more likely to develop clinically significant prolapse of the bladder or uterus whilst those with a bilateral avulsion have a sevenfold increased risk. 6 History Patients may present with an obvious vaginal bulge, or symptoms of vaginal dragging or fullness. The sensation of a bulge has been shown to strongly correlate with the presence of POP. 7 Patients may also complain of associated urinary and/or bowel dysfunction; however, a direct correlation between the location of the bulge and the symptoms experienced has not been shown. 8,9 Urinary symptoms include frequency, urgency and incontinence, which may be urgency or stress related. Patients may also report obstructive voiding symptoms such as straining or poor stream 10,11 (see Table 2). Reported bowel symptoms include faecal and flatal incontinence, constipation and the need to perform Department of Urology, St James s University Hospital, UK Corresponding author: Ian Beckley, Department of Urology, St James University Hospital. Leeds, UK. ianbeckley@gmail.com

2 Beckley and Harris 69 Table 1. Anatomical site based classification of pelvic organ prolapse. Vaginal compartment Anterior Apical Posterior manual ( splinting ) procedures to assist in defaecation. 12,13 The presence of POP has also been shown to have an adverse effect on sexual function. Patients may report a decreased frequency of intercourse and are more likely to be abstinent as a result of their prolapse. 14 There are a number of validated symptom-specific questionnaires that may be used during the initial consultation for women presenting with POP. These include the incontinence impact questionnaire (IIQ-7), urological distress inventory (UDI-6), pelvic pain urgency/frequency patient survey (PUF) and female sexual function index (FSFI). 15 A generalised quality of life questionnaire such as The Kings Health Questionnaire may also be employed. The use of such questionnaires enables clinicians to record the nature and severity of the presenting symptoms and to determine the degree of improvement following treatment. Many women with POP are asymptomatic and unaware of the presence of a prolapse. It is important to note that in the absence of bothersome symptoms, surgical intervention should probably not be considered. Clinical examination Prolapse Cystocoele Urethrocoele Cystourethrocoele Cervix/uterus Enterocoele Enterocoele Rectocoele Perineal body laxity The aim of clinical examination is to determine the location and severity (stage) of POP present. Patients may be examined in the lateral or dorsal lithotomy positions using a Sims speculum. If the prolapse cannot be identified in these positions, patients may also be examined standing. The patient is asked to perform a Valsava manoeuvre whilst the speculum is used to reduce the compartment opposite the one being inspected, e.g. to examine the anterior compartment, the posterior wall is reduced. It should be noted that the degree of prolapse identified may be affected by factors such as the duration and quality of the Valsava manoeuvre and the state of bladder and rectal filling. A variety of staging systems have been developed to accurately describe the prolapse and allow detailed and reproducible communication of the defect between clinicians. The two main systems in current practice are the pelvic organ prolapse quantification (POP-Q) and the Baden-Walker halfway scoring systems. POP-Q staging The POP-Q system was introduced by the standardisation subcommittee of the International Continence Society in It utilises specific measurements of six defined points in the midline vaginal wall. These points are measured anteriorly (Aa, B and C) and posteriorly (Ap, Bp and D) with the patient in the dorsal lithotomy position. The measurements are taken with the patient straining, and the hymenal ring is used as the reference point. Three other measurements are taken: the perineal body (pb), the vaginal length at rest (tvl) and the genital hiatus (gh) from the middle of the urethral meatus to the posterior edge of the hymenal ring. The measurements are recorded on a 3 3 grid in centimetres proximal (negative numbers) or distal (positive numbers) to the hymenal ring. 17 The measurements are subsequently translated to the corresponding stage of prolapse (see Table 3). The system is highly reproducible and has shown good intraobserver and interobserver reliability of 64% and 69%, respectively. 18 Whilst the POP-Q is currently the most widely reported staging system in the medical literature, its complex nature has limited widespread adoption by urogynaecologists and urologists Baden-Walker staging The Baden-Walker halfway scoring system is simpler to use and consists of four grades assigned to each vaginal compartment: 0 No prolapse, 1 Halfway to the hymen, 2 To the introitus, 3 Halfway past the hymen and 4 Maximum Table 2. Symptoms associated with pelvic organ prolapse. Urinary Bowel Sexual Frequency Flatal incontinence Dyspareunia Urgency Faecal incontinence Reduced frequency of intercourse Incontinence Straining to defaecate Reduced desire for intercourse Nocturia Urgency Prolonged stream Positional changes to start/ complete voiding Incomplete emptying Weak stream Pushing on/around vagina to start defaecation

3 70 Journal of Clinical Urology 6(2) Table 3. Prolapse staging based on POP-Q system measurements. Stage I II III IV V descent. There is greater interobserver variability with the Baden-Walker system compared with the POP-Q; however, the addition of comments such as scars or site of dominant prolapse improves its use as a descriptive tool. 17 Investigations Basic assessment of patients presenting with POP should include urine dipsticks testing, uroflowmetry, estimation of post-void residual and completion of a frequency volume chart. The risk of lower ureteric obstruction and hydronephrosis rises with increasing stage of prolapse, therefore an upper urinary tract ultrasound scan should be considered particularly in women with advanced prolapse. 22 Urodynamics The role of routine multi-channel filling and voiding cystometry to investigate patients with POP is controversial. The National Institute for Clinical and Health Excellence (NICE) recommends using the test only in women with a suspicion of detrusor overactivity and those with a history of prolapse or incontinence surgery. However, the International Continence Society advises that urodynamic testing prior to POP surgery should be considered mandatory. 1 In addition to diagnosing detrusor overactivity and outflow obstruction, urodynamic assessment is useful to exclude stress incontinence, which may be masked by anterior compartment prolapse due to kinking of the urethra. If possible, the prolapse should be reduced by vaginal packing or pessary placement prior to performing urodynamic studies or at the end of the filling phase. In selected cases, particularly where refractory urinary symptoms co-exist, video urodynamic studies can be utilised to help identify which vaginal compartments are involved in the prolapse and to directly observe the bladder base, bladder neck and urethra during the voiding phase. Ultrasound Definition No prolapse The most distal portion of the prolapse is > 1 cm above the level of the hymen The most distal portion of the prolapse is 1 cm above the level of the hymen The most distal portion of the prolapse is > 1 cm below the hymen but no further than 2 cm less than the total vaginal length Complete eversion of the total length of the vagina Due to its minimally invasive nature and ready availability, two-dimensional (2D) translabial and transperineal ultrasound scanning (USS) has been used by urogynaecologists for many years in the diagnosis of pelvic floor dysfunction. Measurements are taken at rest and on Valsalva to demonstrate the degree of POP, with the inferior border of the pubic symphysis used as the reference point. 23 Ultrasound can also be used to assess the puborectalis muscle to demonstrate trauma of the levator ani muscle, which is a significant aetiological factor in the development of POP. In the anterior compartment, USS can diagnose a urethral diverticulum, which may be mistaken for a low anterior vaginal wall prolapse. It can also differentiate between a cystocoele and a cystourethrocoele, which may not always be possible on clinical examination alone. In the posterior compartment, translabial USS can determine whether a clinically detected rectocoele is a true rectocoele, a combined entero-rectocoele, an abnormally distensible but intact rectovaginal septum or even a rectal intussusception. 24 With the more recent introduction of three-dimensional (3D) and fourdimensional (4D) USS, it is possible to directly observe downward displacement of pelvic organs on Valsalva, the development of prolapse and the opening up of fascial or muscular defects. 25 The main limitation of pelvic floor USS is operator dependence, and the newer techniques are not currently in widespread use. Unlike X-ray, computed tomography (CT) and magnetic resonance imaging (MRI), USS is the only modality through which transvaginal mesh can be visualised. 26 It can therefore be used to detect mesh suspension failure, a potential and increasingly important cause of prolapse recurrence. It is likely that in the future, pelvic floor USS will play a significant role in assessing the outcomes of surgical intervention for POP and diagnosing treatment failure. Defaecatory studies Imaging the lower gastrointestinal tract should be considered in patients with prolapse who present with predominantly bowel symptoms as these have not been shown to strongly correlate with treatment outcome. 27 It is therefore debatable whether patients with predominantly defaecatory symptoms (as opposed to mainly bulge-type prolapse symptoms) should be offered surgical intervention for POP without first excluding alternative diagnoses such as rectal intersusseption. Defaecography (defaecating proctography) involves the use of a thick barium paste to obtain static and dynamic images of the rectum and anal canal during defaecation in a semi-private setting. Findings consistent with a rectocoele include anterior out-pouching of the anterior rectal wall and bulges with dislocation of the opacified vaginal lumen during straining and evacuation. 28 Additional function information can be provided using techniques such as anal manometry and electromyography. Whilst defaecography has been reported to have good validity and reproducibility, some authors suggest the test has limited

4 Beckley and Harris 71 clinical relevance and may not be representative of physiological defaecation. 29 MRI Since the 1990s, MRI has increasingly replaced radiographic studies for the investigation of POP. The advantages of this imaging modality include a lack of ionising radiation, avoidance of contrast agents and superior softtissue resolution. In addition, MRI allows dynamic imaging (imaging obtained at rest, during straining, and defaecation) to be performed. The degree of pelvic floor descent can be quantified by measurement of standardised reference lines (e.g. H line and M line) and estimation of the levator plate angle. 30 Broekhuis and colleagues demonstrated good correlation between clinical staging (POP-Q) and dynamic MRI for assessing the anterior compartment but only moderate to poor agreement in central and posterior compartments. 31 MRI is generally recommended for pre-operative planning in women with symptomatic multicompartment, or recurrent prolapse, in whom a complex repair is being considered. 32 It remains unlikely, however, that additional clinical benefit would be derived from incorporating this imaging modality into the pre-operative assessment of patients undergoing routine POP repair, and it is therefore not recommended. Conservative management The most common non-surgical treatment options for women with POP are lifestyle modification, oestrogen replacement, pelvic floor muscle exercises and pessaries. There are, however, few high-quality (level 1 of the Oxford classification) studies comparing the outcomes of these treatments to surgical intervention. Oestrogens Following the menopause, oestrogen deprivation leads to atrophy of the vaginal tissues and is thought to contribute to the development of POP. There is currently no definitive proof of this hypothesis, and some authors have suggested that systemic oestrogen therapy may in fact be a risk factor for POP. 33 The role of topical or systemic oestrogen therapy for the treatment or prevention of POP in postmenopausal women has been the subject of a recent Cochrane review. 34 The reviewers were able to identify only four trials suitable for inclusion in the review, one of which had no useable data. None of the trials investigated the use of oestrogens alone for prevention or treatment of POP. The majority of subjects in the review (n=6984) were from a meta-analysis of the adverse effects of a synthetic oestrogen receptor modulator (SERM), raloxifene, used to treat osteoporosis in postmenopausal women. The authors demonstrated a statistically significant reduction (1.51% vs. 0.75%, p <.005) in the need for prolapse surgery in women over 60 who used raloxifene, at three years follow-up. It should be noted that only a very small proportion of women in the study (n=69) underwent surgical intervention. 35 One of the main uses of oestrogen therapy is to improve vaginal tissue maturity in order to reduce complications prior to and immediately following prolapse surgery. 36,37 A recent large review, however, found no evidence to recommend this practice. 38 Pelvic floor muscle training (PFMT) The aetiology of prolapse is generally considered to involve loss of support of the pelvic floor musculature. 39 It is therefore logical to assume that PFMT may be an effective strategy in the conservative management of POP. Clinical studies of this approach have also been the subject of a Cochrane review. Pooled data from trials of PFMT vs. controls suggested a 45% likelihood of improved symptoms, but only a 17% chance of improvement in prolapse stage in patients receiving PFMT compared with no treatment. 40 Pessaries The use of mechanical devices to reposition prolapsed organs dates back to ancient times. 41 Nowadays, several different types of pessaries exist, including ring, shelf, Gellhorn and donut. The choice of pessary is influenced by factors such as the stage of prolapse and the woman s desire to be sexually active. Whilst pessaries can be used to treat all types and stage of prolapse, the likelihood of opting for pessary treatment over surgery increases with patient age and decreases with the severity of prolapse. 42,43 Ideally, the patient should be taught to fit and remove the pessary herself for cleaning and intercourse, although in practice most patients in the UK have their pessaries changed by their general practitioner. Fitting success rates are around 85% and common side effects include bleeding, vaginal discharge, pain and constipation. 44 Severe urinary, rectal and genital complications such as fistula and urosepsis occur rarely, although they are usually associated with long-term usage and negligence of care. 45 It is therefore of vital importance that follow-up arrangements are in place and adhered to if pessary treatment is chosen. Although continuation rates generally decrease over time, a significant proportion of patients have reported continued long-term usage with demonstrable improvements in quality of life. 46,47 Surgery Patients with symptomatic POP who decline or fail conservative measures should be considered for surgical intervention. The aims of surgery are to restore normal pelvic anatomy, improve functional symptoms and quality of life

5 72 Journal of Clinical Urology 6(2) Table 4. Reconstructive surgical procedures for pelvic organ prolapse. Prolapse Procedure Route Anterior Anterior repair Vaginal Paravaginal repair Apical Sacral colposuspension Abdominal (open/ laparoscopic/robotic) Sacrospinous fixation Vaginal Abdominal (laparoscopic) Iliococcygeal fixation Vaginal Uterosacral suspension Vaginal Abdominal (open/ laparoscopic) Posterior Posterior repair Vaginal Transanal Site-specific repair Vaginal Perineorrhaphy and to avoid complications. POP surgery can be broadly classified into obliterative or reconstructive techniques. Obliterative procedures include total colpocleisis, which involves reducing the prolapse back into the pelvis and closing off the vaginal canal. Colpocleisis is rarely performed and tends to be reserved for older patients who no longer wish to be sexually active. 48 It is associated with low morbidity; however, patients should be counselled they may experience persisting storage and lower urinary tract symptoms. 49 Reconstructive procedures aim to correct the distorted pelvic anatomy and reduce the prolapsed organs, whilst maintaining vaginal length and sexual function. It is not uncommon for a combination of surgical procedures to be required in order to address multiple compartment defects. Surgery may be performed by the abdominal or vaginal route, the latter being the preferred and most common option. Abdominal procedures may be open, laparoscopic or robot assisted. When we consider these procedures may or may not be augmented with synthetic transvaginal mesh, it is clear that a myriad of surgical treatment options exist for POP (see Table 4). Overall, re-operation rates of 15.8% with a median interval of three years have been reported for women undergoing POP repair in the UK. 3 Therefore it is important the most appropriate procedure is selected at the outset of treatment and that patients are aware of the risk of prolapse recurrence. Anterior compartment repair According to the National Prolapse Survey, the most common procedure performed by UK urogynaecologists for anterior compartment prolapse is an anterior colporrhaphy (repair). 50 The traditional procedure involves central plication of the fibromuscular layer of the anterior vaginal wall and sometimes removal of excess vaginal epithelium (skin). 51 Alternatives to anterior repair (AR) include the paravaginal repair, which involves reattaching the lateral vaginal tissue to the arcus tendineus fascia pelvis. Treatment success rates for AR (variably defined) range from 55% to 81%. 52,53 Complications include urinary retention, de novo urgency or stress urinary incontinence, vaginal shortening and prolapse recurrence. The significant rates of prolapse recurrence eventually led to the introduction by Julian (1996) of polyprolene mesh to augment the repair of anterior compartment defects. 54 In a small non-randomised study (n=24), he reported a 0% recurrence rate at two years in patients undergoing mesh-augmented AR, although most pelvic floor surgeons would regard a zero recurrence rate as clinically and practically unattainable. The outcomes for patients undergoing standard AR vs. mesh-augmented AR were reviewed by the Cochrane collaboration in 2010 and recently updated by Maher and colleagues. The authors found that standard AR with native tissue was associated with more anterior compartment failures than polypropylene mesh-augmented repair (relapse rate (RR) 2.14, 95% confidence interval (CI) ). Whilst these results suggest superior efficacy for mesh-augmented repairs, it should be noted there were no differences in subjective outcomes, quality of life data, de novo dyspareunia, stress urinary incontinence or reoperation rates for prolapse. 55 Apical/vault prolapse repair Procedures to treat apical prolapse include abdominal sacral colpopexy, or hysteropexy which involves suspending the upper vagina to the sacral promontory and vaginal sacrospinous ligament suspension where the upper vagina or cervix is attached to the sacrospinous ligament transvaginally. 56 These two procedures were also compared in the previously mentioned Cochrane review. The authors identified three randomised controlled trials (RCT) evaluating 287 women. Abdominal sacral colpopexy was associated with a lower rate of recurrent prolapse (RR 0.23, 95% CI ) and dyspareunia compared with vaginal sacrospinous ligament suspension. However, this was at the expense of increased operating times, longer hospital admission, higher costs and delayed recovery. 57 One of the limitations of the review is that it was unable to draw any conclusions on the outcomes of minimally invasive (laparoscopic or robotic assisted) abdominal sacral colpopexy because of the paucity of suitable studies. Several recent small studies reporting outcomes for robot-assisted and laparoscopic abdominal sacral colpopexy have shown similar short-term anatomical and symptomatic improvements compared with the open approach Properly conducted prospective RCTs comparing all three techniques are still required to truly determine the role of minimally invasive surgery in the management of POP. Posterior compartment repair Posterior compartment prolapse has traditionally been treated by posterior colporrhaphy. The aim of this procedure

6 Beckley and Harris 73 is to reapproximate the prerectal fibres of levator ani and plicate the rectovaginal fascia, thereby reducing the defect in the levator hiatus. Whilst posterior colporrhaphy is highly effective, with cure rates up to 95%, it has been shown to result in unacceptable functional results, especially dyspareunia. 61 This led to the evolution of site-specific repairs of the rectovaginal fascia with success rates of %. 62,63 The use of mesh augmentation in posterior repairs has not been shown to result in more favourable anatomic or functional outcomes compared with native tissue alone. 64 Controversial issues in POP surgery Use of synthetic transvaginal mesh kits Following on from the success of mid-urethral sling surgery, in recent years there has been a seemingly exponential rise in the number of commercially available polyprolene mesh kits used to augment the different types of POP repair. Examples include the Perigee and Apogee systems for anterior and posterior compartment prolapse, respectively. As the use of mesh has increased, so has the reporting of complications such as bleeding, infection, visceral injury, chronic pelvic pain and graft extrusion. 65 The incidence of these adverse events has risen to the extent that the International Urogynaecological Association and International Continence Society have now developed a joint terminology and classification of the complications as an aid to clinical practice and research. 66 In October 2008 the US Food and Drug Administration (FDA) released a warning to pelvic floor surgeons using synthetic transvaginal mesh, which was subsequently updated in July The recommendations advise surgeons to: Obtain specialised training for each mesh placement technique Perform careful preoperative counselling/consent Be vigilant for complications associated with mesh placement, especially bowel and bladder injuries Be vigilant for adverse events, especially extrusion and infection Provide patients with a written copy of the patient information leaflet from the mesh manufacturer Following the FDA warnings and a series of legal actions in the US, several mesh products have now been withdrawn, including the Prosima Pelvic Floor Repair System and the Prolift Pelvic Floor Repair System. In early 2012, the UK-based Medicines and Healthcare Products Regulatory Authority (MHRA) commissioned a report from the York University Health Economics Consortium to summarise the complications associated with mesh augmented transvaginal surgery. The investigators reported a 2-15% overall risk of complications following POP surgery with the highest rates associated with sexual dysfunction 67. In response to these findings, the MHRA has advised clinicians to familiarise themselves with the relevant NICE guidance, participate in regular audit of their outcomes and report any adverse events. In addition, the MHRA website now provides a selection of patient information leaflets including a set of questions which patients should ask their surgeons when considering POP surgery. The British Society for Urological Gynaecology (BSUG), The Royal College of Obstetricians and Gynaecologists (RCOG) and BAUS have all subsequently issued statements in support of the findings of York report and the recommendations of the MHRA. We believe that with appropriate clinician training, patient selection and counselling, transvaginal meshaugmented repairs may still represent a viable treatment option, particularly in patients with recurrent POP. It is clear, however, that these patients should be followed-up closely for a prolonged period in order to identify and treat any complications that arise. Concomitant stress urinary incontinence surgery As previously mentioned, POP repairs (particularly those treating the anterior compartment) may be complicated by the development of post-operative stress urinary incontinence (SUI). Continent women with advanced POP and even those who present with voiding difficulties due to urethral kinking may become incontinent after POP repair. 68 This has led to some surgeons opting to perform a prophylactic procedure such as insertion of a mid-urethral sling at the time of prolapse repair. 69 Others believe that this approach is associated with unacceptable additional morbidity and may represent overtreatment. The Colpopexy and Urinary Reduction Efforts (CARE) trial randomised 322 continent women undergoing POP repair to receive abdominal sacral colpopexy with or without the addition of a Burch colposuspension. At three months follow-up bothersome SUI was reported by significantly fewer women in the Burch group compared to the control group (6.1% vs. 24.5%, p < 0.001). 70 In contrast to these findings, another single-centre study with fewer patients but longer follow-up found higher rates of incontinence in the group randomised to sacral colpopexy with Burch, compared to sacral colpopexy alone (29% vs. 16%), although this result was not statistically significant (p < 0.553). 71 The 2010 Cochrane review of the surgical management of POP concluded that the addition of a continence procedure would prevent de novo SUI in approximately 20% with occult SUI. 57 This finding needs to be considered against the fact that 80% of patients would therefore undergo an unnecessary additional procedure. In our opinion, in the absence of an agreed surgical algorithm, thorough preoperative counselling should be performed to enable the surgeon and patient to agree on

7 74 Journal of Clinical Urology 6(2) the extent of surgical intervention that is appropriate for that individual. Conclusions POP represents a challenging condition to accurately diagnose and successfully manage. In addition to the basic investigations, urodynamics should be considered in patients with urinary symptoms or those at risk of postoperative urinary incontinence or voiding dysfunction. The role of radiological investigations has not yet been determined, but may be useful for patients with complex or recurrent prolapse. Surgical intervention should be considered for patients with symptomatic POP only if conservative measures fail or are undesirable. Careful preoperative counselling and consent is vital to ensure patients are aware of the potential complications. This is particularly important if the operation will involve transvaginal mesh placement. Urologists wishing to take on management of prolapse need to be aware of the available evidence for assessment and treatment of the condition. In addition it is increasingly recognised that patients presenting with mixed symptoms of urinary defaecatory and sexual dysfunction, as well as the vaginal manifestations of POP, will usually require investigation and treatment within a multidisciplinary pelvic floor team. This is likely to involve urologists, colorectal surgeons and gynaecologists as well as the specialised supporting services of radiology and neurophysiology. Some patients will also benefit from input from specialist nurses, physiotherapists and psychologists. Most importantly, appropriate training and mentoring of urologists who perform pelvic floor surgery must be obtained, ideally through completion of a subspecialty fellowship in female and functional urology. Conflict of interest The authors declare that there are no conflicts of interest. 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