Introduction:
Pelvic floor disease affects many patients, with age, female gender and multiparity being
significant associations. This can present clinically as pelvic organ prolapse, internal and
external rectal mucosal intussuception, obstructed defecation syndrome, rectocele,
cystocele and urinary/faecal incontinence. Diagnostic and treatment strategies for the
management of such disorders is significantly varied, and evidence for current surgical
management is poor. This thesis explores diagnostic and operative strategies currently
regarded as state of the art and examines a novel method of pelvic floor assessment using
MRI-based statistical shaped modelling.
Methods:
Meta-analysis in accordance with Cochrane collaboration guidelines was performed to
assess laparoscopic versus open techniques for urinary incontinence, as well as endoanal
ultrasound (EUS) scanning versus MRI in the assessment of faecal incontinence. The
efficacy of sacral nerve stimulation (SNS) was reviewed. In addition, decision analysis
was performed to assess the cost-effectiveness of delayed versus immediate anal sphincter
repairs, and current operative treatments for end-stage faecal incontinence, and operative
strategies for end-stage incontinence. MRI-based statistical shaped biomechanical
modelling was performed to assess normal pelvic floors in comparison with patients with
obstructed defecation syndrome. 15 asymptomatic volunteers aged 18 to 60 years were
scanned and compared against 7 with obstructed defecation (ODS). Finally, 7 patients
who were treated surgically for ODS were reassessed 6 months post-operation. Results:
There were significant benefits to laparoscopic colposuspension for urinary incontinence.
EUS was superior to MRI at detecting internal sphincter lesions, but not for external
sphincter lesions. Immediate sphincter repairs were more cost-effective than delayed
repairs. The artificial bowel sphincter and end stoma were more acceptable to both patient
and institution than dynamic graciloplasty. Patients with obstructed defecation had
significantly more irregular levator muscles with wider levator hiatus. Pressure during
straining was concentrated in the posterior aspect of the hiatus, potentially contributing to
the rectal neuropathy noted in obstructed defecation.
Conclusions:
Sacral nerve stimulation is an effective treatment for faecal incontinence. The artificial
bowel sphincter and end stoma were cost-effective long-term strategies for end-stage
faecal incontinence. A new technique for dynamic imaging and functionally assessing
pelvic floor musculature has been developed and is showing promise as an adjunct to
conventional assessment. Conventional defecating proctography does not provide the
dynamic and functional assessment provided by this technique, and may translate well
into a means of functional radiological assessment in the future.