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An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction

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Abstract

Introduction and hypothesis

Next to existing terminology of the lower urinary tract, due to its increasing complexity, the terminology for pelvic floor dysfunction in women may be better updated by a female-specific approach and clinically based consensus report.

Methods

This report combines the input of members of the Standardization and Terminology Committees of two International Organizations, the International Urogynecological Association (IUGA) and the International Continence Society (ICS), assisted at intervals by many external referees. Appropriate core clinical categories and a subclassification were developed to give an alphanumeric coding to each definition. An extensive process of 15 rounds of internal and external review was developed to exhaustively examine each definition, with decision-making by collective opinion (consensus).

Results

A terminology report for female pelvic floor dysfunction, encompassing over 250 separate definitions, has been developed. It is clinically based with the six most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different specialty groups involved in female pelvic floor dysfunction. Female-specific imaging (ultrasound, radiology, and MRI) has been a major addition while appropriate figures have been included to supplement and help clarify the text. Ongoing review is not only anticipated but will be required to keep the document updated and as widely acceptable as possible.

Conclusions

A consensus-based terminology report for female pelvic floor dysfunction has been produced aimed at being a significant aid to clinical practice and a stimulus for research.

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Notes

  1. “Continence” is defined as voluntary control of bladder and bowel function.

  2. “Urgency” replaces “urge” as the “accepted” terminology for the abnormal rather than the normal phenomenon.

  3. This is a common symptom, the mechanism of which has not been adequately researched. It is uncertain whether it should be linked to stress urinary incontinence or urgency urinary incontinence.

  4. Traditionally seven episodes of micturition during waking hours has been deemed as the upper limit of normal, though it may be higher in some populations [7].

  5. It is common to void during the night when sleep is disturbed for other reasons—e.g. insomnia, lactation—this does not constitute nocturia [8].

  6. The use of the word “sudden”, defined as “without warning or abrupt”, used in earlier definitions [2, 8] has been subject to much debate. Its inclusion has been continued. Grading of “urgency” is being developed.

  7. Dyspareunia, the symptom most applicable to female pelvic floor dysfunction, will depend on many factors including a woman’s introital relaxation and/or pain tolerance and her partner’s hesitancy or insistence.

  8. Other symptoms of female sexual dysfunction including (1) decreased sexual desire, (2) decreased sexual arousal, (3) decreased orgasm, and (4) abstention, are less specific for female pelvic floor dysfunction and will not be defined here. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ) is a measure of sexual function in women with urinary incontinence or pelvic organ prolapse [10].

  9. Symptoms of defecatory dysfunction are commonly associated with pelvic organ prolapse, particularly posterior vaginal prolapse.

  10. Rome II Criteria for Constipation: complaint that bowel movements are infrequent (<3/week) and need to strain, lumpy or hard stool bloating, sensation of incomplete evacuation, sensation of anorectal obstruction or blockage abdominal pain, need for manual assistance, in more than one quarter of all defecations.

  11. The definitions of pelvic pain and especially chronic pelvic pain are being debated in several societies with a view to simplification and restructuring of the classification. The chronic (present for at least 3 months) pain syndromes have not been included till consensus is reached.

  12. Commonly suggested criteria for: (1) bacteriuria are >100,000 CFU/ml on voided specimen or >1,000 CFU/ml on catheterized specimen; (2) pyuria are >10 WBC/mm3.

  13. Recurrent urinary tract infections (UTIs) has not been consistently defined. There is the difficulty of balancing the practical clinical definition and the scientific one. Records of diagnostic tests are often inaccessible over the medium to longer term. With a bias towards the former category, a definition might be the presence at least three medically diagnosed UTI over the previous 12 months. “Recur” strictly means to “occur again” or “be repeated”. This would imply a minimum of (1) two or more or the more commonly accepted (2) three or more UTI in the previous 12 months.

  14. Stress incontinence on prolapse reduction is a sign frequently alluded to but not properly defined to date. The means of reducing the prolapse will vary. A pessary or ring might, at times, obstruct the urethra, giving a false negative for this sign.

  15. The ICS POP quantification system which describes the topographic position of six vaginal sites is the subject of a review by the IUGA Standardization and Terminology Committee with a view to simplification. These sites and the methodology behind the measurement format [15] have therefore not been included here.

    Consensus was not reached on inserting a valuation of the different prolapse stages into the report, though it will be subject to ongoing discussion: e.g., considering Stage 0 or 1 as different degrees of normal support. Considering Stage 2 or more, where the leading edge is at or beyond the hymen as definite prolapse [16, 17].

  16. Most gynecologists are generally comfortable with the terms cystocele, rectocele, vaginal vault prolapse, and enterocele. Coupled with the brevity of these terms and their clinical usage for up to 200 years [18], the inclusion of these terms is appropriate. Some regard it as important to surgical strategy to differentiate between a central cystocele (central defect with loss of rugae due to stretching of the subvesical connective tissue and the vaginal wall) and a paravaginal defect (rugae preserved due to detachment from the arcus tendineous fascia pelvis).

  17. More than 20% (young adults) to 33% (over 65 years) has been suggested as excessive [3].

  18. The correlation between MUCP and abdominal LPP may depend on the catheter type used.

  19. Symptomatic women with normal detrusor function do not have to rely as much on an increase in detrusor pressure to achieve successful voiding as men. With a shorter urethra (3–4 cm versus 20 cm), urethral relaxation might suffice. The concept of urethral relaxation, prior to detrusor contraction, is a change from prior definitions [2, 3].

  20. In symptomatic women, detrusor voiding pressure, urine flow (rate), and PVR are important markers of bladder outflow obstruction. In the original definition, only detrusor pressure and urine flow rate were included.

  21. In scientific studies, consideration should be given to standardization of the Valsalva strength e.g. by using an intrarectal pressure transducer.

  22. The use of transvaginal ultrasound with an empty bladder optimizes this assessment [38].

  23. This is the most common urogynecological diagnosis, occurring in up to 72% patients presenting for the first time [48]. This diagnosis may be made in the absence of the symptom of stress (urinary) incontinence in women who have the sign of occult or latent stress incontinence.

  24. The prevalence of detrusor overactivity can vary widely between 13% [48] and 40% [49] of patients undergoing urodynamic studies at different centers.

  25. The prevalence of the oversensitive bladder in urogynecology and female urology patients (from studies on the now obsolete term “sensory urgency”) is around 10–13% [51, 52].

  26. Depending on definition, voiding dysfunction has a prevalence of 14% [54] to 39% [48], the latter figure making it either the third or fourth most common urodynamic diagnosis (after urodynamic stress incontinence, pelvic organ prolapse, and possibly detrusor overactivity).

  27. Approximately 2% of post-void residual measurements are over 200 ml [28]. This is a suggested cut-off.

  28. Around 61% [48] of women presenting for initial urogynecological assessment will have some degree of prolapse, not always symptomatic. Objective findings of prolapse in the absence of relevant prolapse symptoms may be termed “anatomic prolapse”. Approximately half of all women over the age of 50 years have been reported to complain of symptomatic prolapse [55]. There is a 10% lifetime incidence for women of undergoing surgery to correct pelvic organ prolapse [56].

  29. Using this definition, two or more and three or more UTIs can occur with a prevalence of 19% and 11%, respectively, in women presenting with symptoms of pelvic floor dysfunction [57]. This then becomes a significant, generally intercurrent, diagnosis likely to require treatment additional to that planned for the other diagnoses found.

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Acknowledgements/addendum

No discussion on terminology should fail to acknowledge the fine leadership shown by the ICS over many years. The legacy of that work by many dedicated clinicians and scientists is present in all the reports by the different standardization committees. It is pleasing that the ICS leadership has accepted this joint IUGA/ICS initiative as a means of progress in this important and most basic area.

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This document has involved 12 rounds of full review, by co-authors, of an initial draft, with the collation of comments (and figures—version 14). Following website publication, there have been a further two rounds to review the comments made. Versions 7, 9, 11, and 17 were subject to live meetings in London (June 2008), Taipei (September 2008), Cairo (October 2008), Lake Como, Italy (June 2009) and San Francisco (September 2009). The co-authors acknowledge the input to an early version of the document by Professor Don Wilson and Dr. Jenny King. Versions 9, 10, and 12 were subject to external review. The extensive comments by those reviewers, Professor Gunnar Lose (version 9), Dr. Sǿren Brostrǿm (version 10), Mr. Philip Toozs-Hobson (version 10), Mr. Ralph Webb, Dr. Kristene Whitmore, and Professor Cor Baeten (version 12) are also gratefully acknowledged. The comments by the following reviewers in response to website publication (December 2008–January 2009) are also much appreciated: Dr. Kiran Ashok, Dr. Rufus Cartwright, Dr. Johannes Coetzee, Professor Peter Dietz, Dr. Howard Goldman, Mr. Sharif Ismail, Mrs. Jane Meijlink, and Professor Don Ostergard. Version 16 was subject to a further invited external review by Professor Ted Arnold, Professor Jacques Corcos, Dr Harry Vervest, and Professor Jean-Jacques Wyndaele and the consideration of comments by Professor Paul Abrams and Professor Werner Schaefer. Version 17 will be for website and dual journal publication.

Conflicts of interest

BT Haylen: assistance from Boston Scientific to attend London Terminology Meeting.

D De Ridder: Advisor for Astellas, Allergan, Ipsen, Bard, American Medical Systems, Xention; Speaker for Astellas, Allergan, American Medical Systems, Bard, Pfizer; and Investigator for Ipsen, American Medical Systems, Allergan, Astellas, Johnson & Johnson.

RM Freeman: Past Advisory Boards: Lilly/BI, Astellas, and Pfizer.

SE Swift: no disclosures.

B Berghmans: no disclosures.

J Lee: no disclosures.

A Monga: Consultant for Gynecare and Advisor for Astellas and Pfizer.

E Petri: no disclosures.

DE Rizk: no disclosures.

PK Sand: Advisor for Allergan, Astellas, GSK, Coloplast, Ortho, Pfizer, Sanofi, Aventis, and Watson; Speaker for Allergan, Astellas, GSK, Ortho, Pfizer, and Watson; Investigator for Boston Scientific, Pfizer, Watson, Ortho, and Bioform.

GN Schaer: Advisor (in Switzerland) for Astellas, Novartis, and Pfizer

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Correspondence to Bernard T. Haylen.

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Bernard T. Haylen, Robert M. Freeman, Steven E. Swift, Joseph Lee, Eckhard Petri, Diaa E. Rizk, Peter K. Sand, and Gabriel N. Schaer are members of the Standardization and Terminology Committees, IUGA. Dirk de Ridder, Robert M. Freeman, Bary Berghmans, Ash Monga, and Peter K. Sand are members of the Standardization and Terminology Committees, ICS. Bernard T. Haylen, Dirk de Ridder, Robert M. Freeman, Steven E. Swift, Bary Berghmans, Ash Monga, and Peter K. Sand are members of the Joint IUGA/ICS Working Group on Female Terminology.

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Haylen, B.T., de Ridder, D., Freeman, R.M. et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J 21, 5–26 (2010). https://doi.org/10.1007/s00192-009-0976-9

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