Dr. Jongen and colleagues rightly point out that the article paid too little attention to the aspect of coloproctology (1). Unfortunately, a comprehensive discussion of anal incontinence and anal evacuation disorders would have exceeded the scope of this article. However, there is no doubt that the evaluation of colorectal function is an integral part of any comprehensive pelvic floor assessment and that treatment planning should take into account all aspects of pelvic floor function. According to both the criteria of the German Continence Society and the certification criteria of ClarZert, every accredited pelvic floor center must have gynecology, urology and coloproctology services available. As highlighted by the colleagues, fortunately this interdisciplinary collaboration is flourishing in many practice and hospitals, not only in certified centers.
Professor Jäger cites two studies with disappointing results with regard to anatomic repair and the development of de novo incontinence for sacrocolpopexy, sacrospinous fixation and vaginal mesh implantation. Nygaard et al. report long-term outcomes at 7 years after abdominal sacrocolpopexy. However, only 126 of the initial 233 participants (59%) were available for evaluation after seven years. In 31 of 126 (24%) patients, a recurrence of pelvic organ prolapse according to the study criteria was found, but half of these had complaints. While 49 of 126 patients (39%) experienced symptoms of prolapse, 27 of these patients had no anatomical recurrence. When evaluating these findings, it is also important to keep in mind that prolapses can develop in other vaginal compartments over the years. Abdominal sacrocolpopexy primarily treats vaginal vault prolapse and only 11 of 126 patients (9%) had a recurrence at this compartment. Following abdominal sacrocolpopexy, a new prolapse often develops in the posterior vaginal compartment as this is not satisfactorily accessible during the abdominal procedure.
Recurrences after vaginal sacrospinous fixation commonly involve the anterior vaginal wall as with this technique the vagina is pulled in a posterior, inferior direction with some force. This type of prolapse often remains asymptomatic.
To respond to these suboptimal results with greater reflection alone is not enough. Required are well-designed, randomized long-term studies not sponsored by the industry.
Professor Wenderlein’s comments refer to the clinical history (delivery type) and the limited success of surgical treatment. Hence, a psychosomatic perspective is required. Fundamentally, one can agree with this.
Dr Materna points out that the main symptoms of normal pressure hydrocephalus are abnormal gait and incontinence. When taking the history of a patient, exploratory questions regarding neurological symptoms should always be asked. Abnormal gait in combination with incontinence should always trigger further neurological investigations to exclude any potential neurological causes of incontinence.
Prof. Dr. med. Ursula Peschers
Beckenboden Zentrum München
Conflict of interest statement
Prof. Peschers has served as a paid consultant for Astellas and Allergan and has received reimbursement of medical meeting participation fees from Pfizer. She has received lecture honoraria and reimbursement of travel and accommodation expenses from Coloplast, Allergan, AMS, and Astellas and has been paid for carrying out clinical trials on behalf of Coloplast and Allergan.
|1.||Jundt K, Peschers U, Kentenich H: The investigation and treatment of female pelvic floor dysfunction. Dtsch Arztebl Int 2015; 112: 564–74 VOLLTEXT|