The proper management of the patients suffering for a lower anourogenital disease requires to overcome the boundaries between the traditional areas of specialisation. A patient centered and coordinated care, through the planning of a “lower female anourogenital network”, is the only way to ensure an optimal and streamlined management of these dysfunctions, with a holistic and multidisciplinary approach. To reach a good clinical care and governance, avoiding a fragmented approach in such a complex group of patients, a team collaboration is crucial: the integration among the different involved specialists converging in a shared overlapping knowledge (Gynecology, Urology, Proctology, Vulvology and/or Dermatology, Physiatry, Radiology, Pathology, Sexology, Physical Therapy and Midwifery) is the cornerstone of the management.

Keywords: urogenital tract, urogynecology, perineal disfunction, women's health, patient care, vulvar disease, urinary incontinence

Lower female anourogenital tract is to be considered as a composite group of different organs that interact one another from a functional point of view. Consequently, a single disease may affect more than one organ, with many interacting comorbidities involving different disciplines. Until ‘90s, the close relationship between vaginal birth and the resultant pelvic floor injuries led to the belief that the management of pelvic floor was “what all gynaecologists do”. In the following years there was an upcoming focus on care of women affected by urogenital tract disorders, particularly devoted to the complex problems requiring a gyneco-urological approach. The Integral Theory by P. Petros,¹ which states ‘prolapse and symptoms of urinary stress, urge, abnormal bowel & bladder emptying, and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue’ is the first pioneering care management system based on sophisticated interplay between pelvic organs and complicated anatomy and physiology of the urogenital tract. During the years the intensive development of social implication of urogenital tract associated disorders has increased the number of women referred for these diseases. The definition and classification of vulvovaginal disorders, vulvar pain and vulvodynia, perineal pain and dysfunctions, interstitial cystitis, descending perineal sindrome with associated anorectal dysfunctions, somatization and sexual interest and arousal disorder (FSIAD), have increased the complexity and the comorbidity of the lower female anourogenital tract diseases.

It is no longer possible for any physician dealing with these disorders to achieve an in depth expertise in more than one or two of the rapidly expanding specialist fields. The boundaries between the traditional areas of specialisation become inappropriate for the proper management of the patients suffering for such a disease. The unitary view of the lower female genital tract is the only way to ensure to the patients more rational and efficient solutions. It is unusual that specialists actually listen to what the colleague of the “near door” has to say and too often the patient has to follow a fragmented management.

Nowadays, it is clearly accepted that the proper management of the patients suffering for a lower anourogenital disease requires overcoming the boundaries between the traditional areas of specialisation. A patient centered and coordinated care, through the planning of a “lower female anourogenital network”, is the only way to ensure an optimal and streamlined management of these dysfunctions, with a holistic and multidisciplinary approach.²

The network is a new clinical and organizational model, representing not a concrete management unit for single disease but a new mental approach, without walls, to treat different diseases in the same patient, according to a “woman-centered role”. To reach a good clinical care and governance, avoiding a fragmented approach in such a complex group of patients, a team collaboration is crucial: the integration among the different involved specialists converging in a shared overlapping knowledge (Gynecology, Urology, Proctology, Vulvology and/or Dermatology, Physiatry, Radiology, Pathology, Sexology, Physical Therapy and Midwifery) is the cornerstone of the management.

The first step, in this organization model, consists in the definition of the fields of competence among the different specialists. The second step is the establishment of the clinical pathway for each disease to be managed. That is the task of the team of specialists, individually involved in anourogenital tract diseases, designated as Coordination Group, representing the core of the network. Identification of a research coordinator chair permits to conduct discussions, to update the protocols according to the recent literature, to define trials of new and emerging treatments, and apply for research funding. The group defines the level of action of the different health care workers, starting from the correct assessment and access of the patient to the network (level 1, general practitioners and outpatient services), to multidisciplinary treatment approach (level 2, hospitals), to expert decision management (level 3). Similarly, the coordination group is set up with a specifically “trained” midwife. This position represents the most important peculiarity and innovation in respect of other clinical model. Her competences are the requisite qualifications to face up the wide range of needs occurring in such a complex network. The trained midwife:

1. Supervises all perineal rehabilitation’s services of the network,
2. Organizes professional training of midwives and physical therapists,
3. Defines clinical protocols with other professionals,
4. Participates to periodical meeting with Coordination Group in order to analyze network’s second level clinical care,
5. Is involved in national and international scientific community in order to update clinical evidence’s information, and, finally,
6. Evaluates quality care’s results.

Midwifey is a complex kind of health professional with a great management potential in the lower anourogenital disorders. It is well known that the professional role of midwife could not only be limited to the childbirth care. Midwife follows women during all their life phases: in adolescence, in sexual life, during childbirth, in menopause. Midwife has specific core competences to approach the counselling, the education and the care of sexual and reproductive women’s health. So, even lower genital tract disorders are theoretically included in midwife’s range of professional activity, the midwife training, to achieve a high standard knowledge in the complex management of women affected by lower female anourogenital tract disorders, consists of post graduated study in: perineal rehabilitation, management of pelvic pain disorders, and management of health care professional.

Clinical case discussion, interdisciplinary course organization about lower genital tract disorders management, starting from junior-level to advanced-level in the main topics, self-education of the group in specific topic (rehabilitation, psychosexual therapy, minimally invasive surgery) may permit to achieve a high standard and uniformity in the different procedures.

A lower anourogenital coordinated network organization² permits to achieve a human resources rationalization, an expenses reduction, knowledge diffusion, and a woman health care improvement, both in prevention and in management. Utilizing the same language (terminology and classification), the same diagnostic and therapeutic approach (guidelines), it is possible to improve the health care management of the women referred to the network.³ Following this method, the participants may become specialists in lower female anourogenital tract diseases.

None.

The author declares no conflict of interest.

1. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl. 1990;153:7–31.
2. Bogliatto F, Boraso F. A new model of care: the lower female anourogenital network. J Low Genit Tract Dis. 2016;20(1):105–106.
3. Andrews JC, Bogliatto F, Lawson HW, et al. Speaking the same language: using standardized terminology. J Low Genit Tract Dis. 2016;20(1):8–10.