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++++++++++++++++++++++++++++++++++ + + ++++++++++++++++++++++++++++++++++ CLINICAL: WOMEN'S HEALTH +++ +++ Pelvic Surgeons Pelvic Organ Prolapse By Adonis Hijaz, MD human torso. These organs are held in their anatomical positions as a result of the interaction of ligaments, muscular structures and connective tissues and these are referred to collectively as the supportive structures. Pelvic organ prolapse occur when these supportive structures weaken as a result of inherent structural weakness (hereditary factors), insults (vaginal delivery and parity) and decompensating factors (obesity, pelvic surgery and aging). Thus any of the three organs can either prolapse alone or in association with the other organs. From the patient's perspective, the T patient feels or sees a vaginal or introital bulge sometimes associated with a pressure sensation and depending on the degree of bladder or rectal prolapse in the vagina, she can have either bladder symptoms (urgency, frequency, feeling of incomplete emptying, or urinary retention) or bowel symptoms (constipa- tion, obstructed defecation, incomplete emptying of the rectum) to the degree that the patient sometimes manually pushes the prolapse inside the vagina to improve on bladder and bowel function in severe cases. Therefore, not every HE FEMALE PELVIS houses three organs (bladder, uterus and rectum) and is the most dependent portion of the prolapse is the same, and not every patient has the same extent of impact of the prolapse on position or function of the three organs. Traditionally, three different medical disciplines addressed prolapse issues based on their expertise in the organ system that they have expertise in. Urologists managed bladder issues, gynecologists managed the uterus, and colorectal surgeons managed the rectum. And if the patient was to be seen by one specialist in any one of these disciplines, then she would get a procedure that would address one organ with little attention to the others. One can make a strong argument that it is that unilateral approach to the problem that has left the surgical management of prolapse with a bad reputation — a reputation that can be least described as suboptimal. So with such a sensitive and sometimes an embarrassing topic to a female patient if you add the reputation that management is bound to fail, the result would be creation of a big barrier between the patient and deserved care. It was because of the insightful vision of a number of visionary leaders in the three disciplines of medicine that a new generation of surgeons and a new medical subspecialty was born (female pelvic medicine and surgery). Urologist and gynecologist can commit to several years of interdisciplinary subspecialty training to become female pelvic surgeons. Those subspecialists have the knowledge base, the understanding and equipped with the training and tools to handle any issue that relates to disorders of the female pelvis including any form or severity of prolapse. It is the aim of this subspecialty to deliver to patients the comprehensive care plan that can address all the complexities of prolapse restoring anatomy and more importantly function. Moreover, we can argue that the outcomes that the patients would realize would be more durable because the approach would be inclusive and comprehensive. This subspecialty is not a means to create an elite league of surgeons or to secure a market share. It is a necessity to elevate the fi eld's status clinically, academically and scientifi cally through evidence based practice, rigorous clinical trials and novel therapeutics respectively. Dr. Adonis Hijaz is a urologist and fel- lowship trained in female pelvic medicine and reconstruction surgery. He is the director of University Hospitals Urology Institute's Female Pelvic Medicine & Surgery Center. Dr. Hijaz is also associate professor of Urology at Case Western Reserve University School of Medicine. n & 38 | Cleveland-Akron-Canton MD NEWS MDNEWS.COM SEPTEMBER-OCTOBER 2011