EASTERN PELVIC FLOOR SOCIETY

Minutes

Eastern Pelvic Floor Society Inaugural Meeting, Wednesday 7th October, 2015

Pontlands Park, Chelmsford

Chair: Subash Vasudevan

Attendees: Subash Vasudevan (Colchester, group chair), Chanidma Halahakoon (Colchester), Lindsay Wheatley (Colchester), Tanya Jewell (Colchester), Samantha Head (Colchester), Shahab Siddiqi (Broomfield), Gianluca Colucci (Broomfield), Joanne Whiting (West Suffolk), Emmanuel Lorejo (West Suffolk), Ami Mishra (West Suffolk, group secretary), Abraham Ayanynde (Southend University), BV Praveen (Southend University), James Wright (Southend), Luca Bonomo (Colchester), Ali Malik (Ipswich), Paula Hughes (EES)

Apologies: Nadeem Ashraf (Basildon)

1. Introductions and apologies

  • Paula Hughes gave a powerpoint presentation (with permission) to demonstrate the benefits of running a joint clinic with physiotherapy.

2. Format

  • Subash Vasuvdevan has been instrumental in setting up the group and was the unanimous selection for Chair of the group.
  • Ami Mishra volunteered to act as Minutes Secretary.
  • Proposals for the format of the meeting were discussed. The plan is to hold a meeting every 3 months. We would to invite guest speakers including radiologists on topics such as interpreting images and how to manage difficult cases.
  • PH noted that the Northern and Southern groups were happy to receive Eastern Pelvic Floor meetings and she would be happy to facilitate this.
  • Trainee attendance is to be encouraged.
  • Pelvic floor fellowships may in future be considered. Southend have obtained funding for a fellowship and would be interested in cross-hospital training. The need for approval TPFS/Royal College was raised, and Paula will discuss this with Tony Dixon and Andy Williams.
  • The group would look to develop local training days, publish as a group, and evaluate and develop local guidelines.
  • The “Research Lead” for the group was offered to Mr Ayantunde.
  • It was suggested we look into the case load per unit. Currently Ipswich and West Suffolk send patients to Norwich for investigation. Southend have set up a diagnostic service and Colchester are close to have a functioning one.
  • Research ideas for the group
  • Samantha Head in conjunction with Professor Jo Jackson of University of Essex is investigating pilates for the management of urinary incontinence.
  • Subash suggested we have a research review as part of the meeting.
  • Research update - Ali Malik has agreed to present a research update at the next meeting.

3. Presentations

  • Mr Praveen presented his experience of setting up a unit. The key messages were:

- engage management

- often have to set up an extra clinic

- Pelvic floor service requires a team approach

- Pelvic floor service is financially attractive to trusts

Other issues

  • SNS – no one in this forum currently provides this, patients are sent to UCH, Royal London and Cambridge. A proper SNS service requires dedicated nursing support.
  • PTNS – shown by CONFIDENT trial to have no benefit over sham, except perhaps in the urgency group.
  • Electroacupuncture – early use in Colchester suggests may be useful but trials are needed.
  • Why is 50% still being used as marker of improvement?

4. Care presentations

  1. SV: 70 year old female patient with faecal incontinence and recurrent prolapse who had had a perineal rectal prolapse repair and SNS previously. The SNS had been switched off years earlier. SV was able to demonstrate an enterocele.

Management options discussed were proceeding to Lap VMR, referring to a tertiary centre to consider reactivating the SNS.

The consensus with respect to management of this patient was to obtain an opinion from Charlie Knowles – with a view to reactivating the SNS prior to surgical correction of the enterocele.

In general, with regards to investigation of pelvic floor disorders, the group felt it was acceptable to proceed with rectopexy to repair overt rectal prolapse, but in cases of ODS / otherwise, investigations were desired for triangulation in case of litigation.

  1. SS: 68 year old female patient with rectocele and enterocele, who had failed to respond to rectal irrigation and physiotherapy. A robotic sacrocolpopexy with Timesh was performed. Down the line. she developed a vaginal discharge, was treated with long term antibiotics and this eventually settled. An MRI demonstrated L4/L5 discitis. There was no recurrence of pelvic floor symptoms. Two neurosurgical colleagues gave advice – one recommended removal of mesh and implied substandard care with tacking to L5. Another neurosurgeon advised no further intervention. An expert opinion was obtained from Tony Dixon who advised no further intervention, and that tacking into L4-L5 was more common than perhaps expected and not incorrect.

The consensus was this patient should be managed non-operatively and that should be left in.

Various meshes were discussed at this point including Timesh, Dynamesh, with mesh erosion rates listed between 0.3 and 1%. This raised the idea of creating a common consent form.

A recent case had been raised regarding a TVT sling used for bladder incontinence.

  1. BP: Long time patient of his since 2006. Had undergone a STARR procedure for ODS and trialled Prucalopride unsuccessfully. He wondered about the use of ACE.

Concerns were raised about caecostomies. We will see more cases of patients with ACEs as they are increasingly being done by Paediatric surgeons. Patient selection for functional problems is important. There may be a role for psychiatrists, but realistically there is a lack of resources.

There are two units specialising in psychiatric assessments – Dr Singh at Good Hope who manages/listens and extracts pertinent sexual abuse histories. He would be a speaker to invite. There is a service in Poole.

This raised an interesting discussion about two fold systems - delivery and evacuatory problems. Mr Siddiqi wondered if in a patient with persistent delivery problems after correction an evacuatory problem there was a role for colectomy. A trial of ileostomy might be considered, and small bowel manometry is performed at the Royal London.

5. Items for next meeting: proposed for 13th January 2016, Pontlands Hotel

- service changes/ unit in preceding 3 months

- template for business case

- research update – Mr Malik

AM 13.10.2015