A Collaborative Patient-Centered Service

Source: Ms Juriyah Yatim, RN, MN was speaking at the World Continence Week 2010 Public Forum held on 12 June 2010.
Authors: Ms Juriyah Yatim, RN, MN, Advanced Practice Nurse, SGH Pelvic Floor Disorder Service, Singapore General Hospital

Pelvic floor disorder or pelvic floor dysfunction (PFD) is a general term that describes a wide range of clinical problems that affect the normal function of any of the pelvic organs, namely the urinary system, bowel system and female reproductive system. These are principally classified with reference to anterior pelvic compartment symptoms, mostly concerned with urinary, sexual function and pelvic organ prolapse; and the posterior compartment symptoms related to colorectal function, such as faecal incontinence and disordered defecation. Mechanical, neural, endocrine and environmental factors play a major role in the development of PFD (Davis & Kumar, 2003). These disorders predominantly affect females and undermine the quality of lives of at least one-third of adult women. Many of them suffer in silence hence the true impact of PFD remains unknown but worrisome. The “conspiracy theory” begins when a healthcare provider does not ask and patient does not tell. As this subject matter is not a cocktail conversation, women feel isolated and don’t seek support and treatment. Although rarely life-threatening, the symptoms of PFD are embarrassing and, if left untreated, can lead to social isolation, sexual inhibition, restricted employment and leisure opportunities and potential loss of independence.

Historically, the nature of medical training according to body organ systems has led to a ‘compartmentalised’ medical approach to diagnosis and treatment of PFD symptoms. If a patient has problems involving several systems, he or she will be referred to multiple specialists according to the organ systems involved. Interdisciplinary management for these patients can be disorganised. Currently, opinion is divided about the benefit and effectiveness of providing a service led by one pelvic fl oor specialist versus a comprehensive multidisciplinary team approach with fully integrated services. Inappropriate assessment, delays, multiple referrals and repetitive consultations with different practitioners can result in sub-optimal treatment(s) and may fall short of patients’ expectations and level of satisfaction (Davis & Kumar, 2003). The evolution of the multidisciplinary approach to the management of chronic conditions is a reflection of how medicine has evolved from a singular to a plural effort recognising the complex causations and consequences of such disorders (Chatoor, Soligo & Emmanueal, 2009).

In view of this, the SGH Pelvic Floor Disorder Service, which is a unique seamless, coordinated clinical management pathway, jointly initiated by specialists from the departments of Colorectal Surgery, Urology and Obstetrics & Gynaecology, made its mark since September 2008. At the first visit, the patient is assessed by an Advanced Practice Nurse (APN) trained in management of all functional pelvic floor disorders. A comprehensive history taking and physical examination is carried out, which is confirmed by a specialist doctor trained to assess the pelvic floor. Patient is then counseled and treated while further tests are ordered and coordinated by the APN. A one-stop service, along with combined surgical approach does away with multiple referrals so patients can seek treatment early.

The management of complex pelvic fl oor disorders should not be a singular endeavour in the current era of the multi-disciplinary team. The recipe for this to work depends on the expertise involved and most importantly the willingness for different specialities (medical, nursing, physiotherapy, pharmacy) to communicate and encourage healthy debate. As such, aligning inputs from the various specialists under the SGH Pelvic Floor Disorder Service has allowed us to provide a more holistic approach to patient care, further developing our reputation as a leading center for management of pelvic floor disorders. Although we are still developing, it is our aim to provide excellent quality patient-centered care and simultaneously promoting improved preventive measures through public and patient education so as to offer good value in a resource-limited system.