Female Pelvic Medicine and Reconstructive Surgery (FPMRS) is a specialized medical field dedicated to the evaluation and treatment of disorders affecting the female pelvic floor and its organs. This discipline addresses conditions related to the support structures within the lower pelvis, including the muscles, ligaments, and connective tissues. Physicians who practice in this area are known as Urogynecologists, focusing on restoring function and comfort for women experiencing these problems. The specialty is a certified subspecialty, jointly recognized by both the American Board of Obstetrics and Gynecology and the American Board of Urology, signifying its dual focus on the female reproductive and urinary systems.
The Scope of Female Pelvic Medicine and Reconstructive Surgery
Practitioners in FPMRS complete extensive training, typically involving a three-year fellowship after completing a residency in Obstetrics and Gynecology or Urology. This post-residency training is required to achieve board certification in the subspecialty. The specialized focus centers on the anatomy of the female pelvic floor, which is the network of muscles and fascia supporting the bladder, uterus, vagina, rectum, and intestines. This anatomical area is often compromised by events like childbirth, chronic disease, heavy lifting, or prior surgeries, leading to a range of conditions. A Urogynecologist’s expertise covers the complex interplay between the urinary, reproductive, and lower gastrointestinal tracts within the pelvic cavity. This comprehensive approach allows the specialist to manage conditions that might otherwise require a patient to consult multiple different physicians.
Conditions Caused by Pelvic Floor Dysfunction
Pelvic floor disorders encompass a broad range of symptoms that significantly affect a woman’s quality of life. These conditions arise when the supporting structures of the pelvis become weakened or damaged.
Urinary Issues
Urinary incontinence is a common reason for referral, presenting in several distinct ways. Stress urinary incontinence (SUI) involves the involuntary leakage of urine during activities that increase abdominal pressure, such as coughing, sneezing, or exercising. This type of leakage is caused by a weakened pelvic floor or a compromised urethral sphincter mechanism.
Overactive bladder (OAB) is characterized by a sudden, intense urge to urinate that is difficult to defer. OAB may or may not be accompanied by urge urinary incontinence, which is leakage following the sudden urge. These symptoms often involve abnormal nerve signals or involuntary contractions of the bladder muscle.
Pelvic Organ Prolapse (POP)
Pelvic organ prolapse occurs when the muscles and connective tissues lose their ability to hold the pelvic organs in their correct anatomical position. This weakening causes one or more organs to descend into the vagina. Patients often describe a sensation of pressure, fullness, or feeling a bulge. Specific types of prolapse are named for the organ that descends:
- Cystocele: The bladder bulges into the front (anterior) vaginal wall.
- Rectocele: The rectum protrudes into the back (posterior) vaginal wall, which can cause difficulty with bowel movements.
- Uterine prolapse: The uterus descends toward or through the vaginal opening.
- Vaginal vault prolapse: Occurs after a hysterectomy when the top of the vagina loses support.
Bowel Dysfunction and Pelvic Pain
Bowel dysfunction treated by FPMRS includes fecal incontinence, which is the inability to control the passage of gas or stool. This condition is often linked to damage to the anal sphincter muscles or the nerves controlling them, frequently resulting from obstetrical trauma. Chronic constipation related to structural issues, such as a rectocele or an inability to coordinate pelvic floor muscles during defecation, also falls under this specialty.
Chronic pelvic pain and certain forms of sexual dysfunction are also managed when connected to pelvic floor issues. Conditions like interstitial cystitis, also known as bladder pain syndrome, cause chronic discomfort and pressure in the bladder area. Dyspareunia, or painful intercourse, can be a symptom of pelvic floor muscle tension or nerve irritation that a Urogynecologist can help diagnose and treat.
Evaluation and Non-Surgical Management
The initial step in managing pelvic floor disorders is a thorough evaluation, beginning with a detailed medical history and a physical examination. The physical exam assesses the strength and coordination of the pelvic floor muscles, checking for weakness or spasms.
Diagnostic tools are utilized to objectively measure function, such as urodynamic testing. This test evaluates the bladder’s ability to store and empty urine, including measuring flow rates and bladder pressures. Urodynamic testing is particularly helpful in diagnosing the specific type of urinary incontinence and is often performed before surgery.
Non-surgical management options are typically the first line of treatment and often provide significant relief. Pelvic Floor Physical Therapy (PFPT) is a cornerstone of conservative care, where a therapist teaches exercises, like Kegels, to strengthen or relax the specific muscles of the pelvic floor. Biofeedback is frequently used alongside PFPT to help patients visualize and control their muscle activity.
Another common non-surgical treatment is the use of a pessary, a removable silicone device inserted into the vagina. Pessaries provide mechanical support to the prolapsed organs and can also be used to manage stress urinary incontinence. For conditions like overactive bladder, medications are available to calm the bladder muscle and reduce urgency and frequency symptoms.
Common Surgical Interventions
When conservative measures fail to provide adequate relief, surgical intervention may be recommended to restore pelvic anatomy and function. These procedures are tailored to the specific condition and the patient’s individual needs.
Surgical repairs for Pelvic Organ Prolapse focus on re-suspending the descended organs and reinforcing the weakened vaginal support structures. Procedures like sacrocolpopexy involve attaching the top of the vagina or the uterus to a strong ligament on the sacrum, often using surgical mesh for long-lasting support. Repairs for cystoceles and rectoceles, known as anterior and posterior colporrhaphy, involve tightening the supportive tissue layers within the vaginal walls.
Surgical treatments for urinary incontinence aim to provide support to the urethra, preventing leakage when abdominal pressure increases. Mid-urethral slings are a highly effective treatment for stress urinary incontinence, where a small strip of material is placed to cradle the urethra. Less invasive options, such as urethral bulking agents, involve injecting a material into the tissues around the urethra to increase its closing pressure.
Many reconstructive procedures are performed using minimally invasive techniques, which can include laparoscopic or robotic-assisted surgery. These approaches utilize small abdominal incisions, leading to reduced blood loss, faster recovery times, and less post-operative pain compared to traditional open surgery. Urogynecologists are trained in all surgical approaches, including abdominal, vaginal, laparoscopic, and robotic techniques, to select the best method for the patient’s condition.