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Title: Diagnostic strategies in pelvic floor disorders
Author: Ramage, Lisa
ISNI:       0000 0004 8499 3942
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2019
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Introduction: Management of pelvic floor disorders is undertaken within tertiary-level referral centres. However, the majority of patients do not require surgery. This thesis sets out to identify who is most likely to require surgery versus who could be initially managed in a primary care setting. Methods: Patient reported outcome measure (PROM) tools and investigatory data collated prospectively was explored alongside maximal treatment interventions. Additionally, MR-defecography (MRD) results were analysed in a cohort of patients with symptoms of obstructed defecation (ODS). Specific patient populations forming a large proportion of those requiring surgery were explored separately: patients with obstetric anal sphincter injury (OASI), and patients who had undergone surgery for ultralow rectal cancer with either a handsewn or stapled anastomosis. Results: 276 patients with faecal incontinence (FI) and 129 patients with ODS were explored. 17.39% of those with FI and 20.93% with ODS ultimately required surgery. The majority of patients required only Biofeedback. The FI domain of the BBUSQ and several domains of the SF-36 were fair predictors of the need for surgery in FI sufferers. On anorectal manometry, only the squeeze endurance increment was predictive of the need for surgery in patients with FI. There was no demonstrable relationship between the PROMS or MRD and the requirement for surgery in ODS sufferers. Patients with a missed OASI had worse function at initial follow-up. At early follow-up no differences were found between different OASI grades. Patients with a handsewn coloanal anastomosis had worse function than those with a stapled anastomosis. Conclusion: There needs to be a move towards more community-based care in patients presenting with pelvic floor dysfunction to ease the burden on tertiary-level services with development of an integrated care pathway which streamlines referrals based on the likelihood for the need for more invasive treatment strategies.
Supervisor: Kontovounisios, Christos ; Tan, Emile ; Tekkis, Paris Sponsor: Not available
Qualification Name: Thesis (M.D.) Qualification Level: Doctoral