The politics of prolapse: A revisionist approach to disorders of the pelvic floor in women

L. L. Wall 1 and J. O. L. DeLancey 2 1Section of Gynecology, The Emory Clinic, Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA; 2Division of Gynecology, Department of Obstetrics and Gynecology, University of Michigan Medical Center, Ann Arbor, MI, USA 'And this, he said, is the reason why the cure of many diseases is unknown to the physicians of Hellas, because they disregard the whole, which ought to be studied also; for the part can never be well unless the whole is well.' Socrates, in Plato's Charmides [1] Pelvic floor dysfunction, particularly as manifested by genital prolapse and urinary or fecal incontinence, remains one the 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 at 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 multi- million-dollar campaign to promote the sales of a vast array of absorbent pads, panty-liners, and undergar- ments in hope of opening up this gigantic source of *This paper has been reproduced from Perspectives in Biology and Medicine 1991 ;34(4):486-96 with kind permission of the University of Chicago. (9 1991 the University of Chicago. All rights reserved). Correspondence and offprint requests to: Dr L. Lewis Wall, Section of Gynecology, The Emory Clinic, 1365 Clifton Road NE, Atlanta, GA 30322, USA. potential profits. Despite the enormity of these problems and our longstanding clinical experience in treating them, however, prolapse recurring after an attempt 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 specialities, with resultant neglect of the interrelationships among the pelvic organ systems. Over the past 2000 years western medicine has dramatically narrowed its focus and changed its pre- occupations. Greek medicine, which dominated medical thought in many ways until the 17th and 18th centuries, viewed illness largely as a disruption of generalized bodily processes, an imbalance among four humors whose interrelationships constituted the foun- dations of human pathology. The rise of empiric and experimental science gradually replaced this conception of illness with one which 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 20th century this process has been hastened by the development of techniques which permit specia- lized examination of discrete organ systems - and which also allow large professional fees to be collected by the specialists capable of performing these procedures [6]. This financial factor has created a 'territorial impera-