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  • Neuro-urogynecology & Urogenital Pain

SIG Leadership

Chair: Sohier Elneil

Background

The pelvic floor is a highly complex structure made up of skeletal and striated muscle, support and suspensory ligaments, fascial coverings, and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system is damaged, either directly or as a consequence of an underlying neurological condition, pelvic floor failure ensues along with organ dysfunction. The etiology is inevitably multi-factorial, and seldom as a consequence of a single etiological factor. It can affect one or all three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (fecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalization of the pelvic floor has resulted in the partitioning of patients into urology, gynecology, colo-rectal surgery, or neurology, depending on the patient’s presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialties. While the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. These patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioral and lifestyle changes, conservative treatments, pharmacotherapy, minimally invasive surgery, and radical specialized surgery. It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only necessary, but critical, if good clinical care and governance is to be ensured.

Neural Control of the Uro-genital System

Voluntary control over the uro-genital system is critical to our social existence. Since its peripheral innervation derives from the most distal segments of the spinal cord, integrity of the long tracts of the central nervous system for physiological function is immediately apparent. In a survey of patients referred with bladder symptoms, spinal cord involvement of various pathologies was found to be the most common cause of bladder symptoms. Because of the commonality of innervation shared by the bladder and genital organs, it might be expected that abnormalities of these two systems inevitably occur together. This, however, is not the case because although the organs share the same root innervation and have common peripheral nerves within the pelvis, each is controlled by its own unique set of central nervous system reflexes. The bladder performs only two functions - storage and voiding of urine- and the modern view of the control of these two mutually exclusive activities is that whereas storage is organized within the spinal cord, micturition results from activation by suprapontine influences of a center in the dorsal tegmentum of the pons, the pontine micturition center (PMC). In neurological disease, this delicate interaction can be severely disrupted, and manifests as a disorder of voiding or storage depending on the condition such as multiple sclerosis, Parkinson's disease, multiple system atrophy and others. But commonly, it is direct injury to pelvic nerves that can give rise to quite marked bladder and pelvic floor dysfunction. The peripheral innervation of the pelvic organs can be damaged by extirpative pelvic surgery such as resection of rectal carcinoma, radical prostatectomy, or radical hysterectomy. The dissection necessary for rectal cancer is likely to damage the parasympathetic innervation to the bladder and genitalia, as the pelvic nerves take a medio-lateral course through the pelvis on either side of the rectum and the apex of the prostate. The nerves may either be removed together with the fascia which covers the lower rectum or may be damaged by a traction injury as the rectum is mobilized prior to excision. Urinary incontinence following radical hysterectomy which includes the upper part of the vagina, is probably also due to damage to the parasympathetic innervation of the detrusor and in the case of a radical prostatectomy, there may be additional direct damage to the innervation of the striated urethral sphincter. The focus in the literature tends to focus on the effects of neurological disease on the bladder, but other pelvic floor effects should not be ignored, such as pelvic organ prolapse, pain syndromes, and sexual dysfunction.

Aims and Objectives

This SIG will focus on improving obstetricians and gynecologists understanding of the neurological basis of pelvic floor dysfunction and the associated clinical disorders, which hitherto have not been fully characterized in the literature.