Perspectives in Biology and Medicine

THE POLITICS OF PROLAPSE: A REVISIONIST APPROACH TO DISORDERS OF THE PELVIC FLOOR IN WOMEN L. LEWIS WALL* andJOHN O. L. DELANCEYf And this, he said, is the reason why the cure of many diseases is unknown to the physicians ofHellas, because they disregard tL· whole, which ought to be studied abo; for the part can never be well unless the whole is well.—Socrates [1] Pelvic floor dysfunction, particularly as manifested by genital prolapse and urinary or fecal incontinence, remains one of the largest unaddressed issues in women's health care today. These problems result in substantial social embarrassment, emotional distress, and physical discomfort and are the cause of tens of thousands of surgical operations each year. However, many women with these afflictions continue to bear them stoically in resigned silence, regarding them as normal and inevitable parts of aging—which they are not. The economic costs of these problems are also immense and similarly unappreciated. At a consensus development conference held in October 1988, for example, the National Institutes of Health estimated the total direct and indirect costs of managing adult urinary incontinence alone at $10.3 billion per year—far more than the current costs of the AIDS epidemic [2]. While the public at large has remained oblivious to these facts, the paper products industry has launched a miltimillion dollar campaign to promote the sales of a vast array of absorbent pads, panty liners, and undergarments in hope of opening up this gigantic source of potential profits. Despite the enormity of these problems and our long-standing clinical experience in treating them, however, prolapse recurring after an at- *Department of Gynecology and Obstetrics, Emory University School of Medicine, 69 Butler Street, SE, Atlanta, Georgia 30303. tDepartment of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor, Michigan 48109-0718.© 1991 by The University of Chicago. All rights reserved. 003 1-5982/9 1 /3404-0735$0 1 .00 486 I L. Lewis Wall andJohn O. L. DeLancey ¦ The Politics ofProlapse tempt at surgical repair remains a significant clinical problem, and the approach to uterine prolapse by gynecologic surgeons appears to have changed little in 60 years. Why? What has led to such an impasse? Why has our thinking about these problems remained so narrow and so unfruitful? We propose that this is largely due to the compartmentalization of the pelvic floor into unnatural spheres of influence by competing medical specialties with resultant neglect of the interrelationships among the pelvic organ systems. Over the past 2,000 years, Western medicine has dramatically narrowed its focus and changed its preoccupations. Greek medicine, which dominated medical thought in many ways until the seventeenth and eighteenth centuries, viewed illness largely as a disruption of generalized bodily processes, an imbalance among four humors whose interrelationships constituted the foundations of human pathology. The rise of empiric and experimental science gradually replaced this conception of illness with one that saw it as arising from specific disease processes in a local group of tissues or organs. This reorganization of medicine around the "anatomic idea" led to the development of specialties dealing with disorders of specific organ systems: ophthalmology, cardiology, gastroenterology , urology, gynecology, etc. [3-5]. In the twentieth century this process has been hastened by the development of techniques that permit specialized examination of discrete organ systems—and that also allow large professional fees to be collected by the specialists capable of performing these procedures [6]. This financial factor has created a "territorial imperative" in medical practice as specialties fight to control their own turf—as any gynecologist who has got into a fight over the use of a sigmoidoscope or a cystoscope can attest. The organ systems have become narrow medical kingdoms with their own little boundaries and specialized sets of data, and woe betide the unwary practitioner who traverses a border without the proper stamp on his passport. The "Hole" Pelvis and the "Whole" Pelvis Nowhere is this fragmentation more evident than in the pelvic floor where gynecologists, colorectal surgeons, gastroenterologists, and urologists all practice within millimeters of one another and yet have little interaction with each other concerning the disorders that they treat. Examination of a female patient immediately reveals that...