INTRODUCTION

Pelvic floor services represent the latest exciting development. This integrates Coloproctology, Urology and Gynaecology with obvious advantages to the patient, with multiple pelvic floor disorders.

Pelvic floor is essentially Levator ani. Disorders of this muscular diaphgram, secondary to difficult or prolonged labour, can in years to come lead to defects in one or more of the three compartments – Anterior, Middle and Posterior. In the past, disorders of each of these three compartments have been dealt with by the individual speciality i.e Urology, Gynaecology and Coloproctology.

Pelvic floor services in Coloproctology would also include functional bowel disorders such as slow transit constipation, damaged anal sphincters and recto-vaginal fistulae.

In the East Kent NHS Trust, Pelvic floor services will be based at Royal Victoria Hospital, Folkestone. The proposed moving date is sometime in the last week of August.

Essential to the working of this service is –

a)      Maintenance of separate Pelvic floor records at RVHF, for rapid retrieval and compilation of all relevant Pelvic floor investigations. Only letters of communication to GPs and others can be duplicated and filed in the main bulk of NHS notes. This has the advantage of rapid data retrieval facilitating audit and patient care.

b)      Combined Coloproctology and Urogynaecology clinics on a periodic basis. There is already sufficient enthusiasm for this.

c)      Preservation of all Endoanal and Endorectal scan images on a hard drive, catalogued suitably. This is on the assumption that we will acquire a Lap top computer.

It is convenient to organise the Pelvic floor services on the basis of the Patient pathway through the system.

 

 

 

STEP 1

Named referrals from General Practitioners and Hospital Consultants are marked by the appropriate speciality consultants for the Pelvic floor clinic. These are then sent to the appropriate secretary at RVHF, who will then make the earliest possible appointment for the patient.

In Coloproctology, I will mark the letters as either Urgent or Routine. Urgent cases will include those with severe impairment of Quality of Life due to a large rectal prolapse, severe faecal incontinence and rectal cancers.

At RVHF, my secretary will make the appropriate appointment for my clinic on Monday morning. No more than 5 cases are to be booked into this clinic. Medical records will file the referral letter in the parallel set of notes. In the clinic, patients are seen with both the RVHF notes and the Main bulk of NHS notes.

STEP 2

Patients fill in a symptom questionnaire while waiting to be seen. I will provide this symptom questionnaire soon. They are then seen along with this questionnaire, which is double checked and filed in the patient’s RVHF notes.

STEP 3

Examination findings are recorded on the OP sheet as in any clinic.

STEP 4

I will fill part of the Investigation Check list. A copy of this is enclosed.

STEP 5

As investigations are done and results obtained, secretary will (after the investigations are seen by the consultants) tick the ‘Done’ box on the Investigation check list and when all the investigations are done, patient is listed for another appointment.

STEP 6

In the second visit to the clinic, the diagnosis and management plan is discussed with the patient. If a Combined clinic assessment is thought necessary, a third appointment to a combined clinic is made.

RVHF Notes These notes will have a)      1st page – Patient demographics. b)      2nd page - Symptom questionnaire. c)      3rd page - Clinic Continuation sheet for recording findings. d)      4th page – Investigation Check list (see attatched sheet). e)      5th page – Correspondence (with one copy of the letters to be filed in the main NHS notes). f)        6th page – Physiology data collection form (see attatched sheet). g)      7th page – Addresographs.

 

 

INVESTIGATION CHECK LIST

 

 

 

 

Investigation	Requested	Done
Endoanal/rectal scan
Transit study
Defaecogram
Balloon Expulsion test
Anorectal Physiology
Barium enema
Colonoscopy
Gynaecology referral
Urology referral

 

*Secretaries will tick the done box as and when the relevant investigations are done and results seen by consultants. When all the investigations or referral has been done, a second appointment is scheduled.

 

 

 Physiology DATA COLLECTION FORM

 

 

 

 

 

USS Rectum - Thickness of rectal wall (mm)—

USS Anal canal – Thickness of EAS (mm)-

                              Thickness of IAS (mm) –

Comments on USS -

 

PNMTL -         Left

 

                         Right

 

Resting anal canal pressure (cm H₂O) -

 

Functional anal canal length (cm) -

 

Maximum squeeze pressure (cm H₂O) -

 

Cough response -    Rectal pressure (cm)

                               Anal canal pressure (cm)

 

Valsalva manouvre - Rectal pressure (cm)

                               Anal canal pressure (cm)

 

RAIR -      Sudden distention         Present/absent

 

Balloon expulsion test -        Unable to expel/Able to expel

                

Rectal sensation

Mode of testing:         Rapid distention/Ramp inflation (60ml/min)

 

Parameter	FS	CS	UD	MTT
Volume (ml)
Pressure (cm) (uncorrected)

 

Report -

 

 

 

 

 

 

ANTICIPATED WORK LOAD.

I expect to see no more than 5 patients in my Monday morning clinic. Similarly, no more than 5 patients are to be seen in the Combined clinic.

I would hope to see all Urgent patients within 4 weeks with the exception of Rectal cancers who will be seen within two weeks.