Pelvic floor disorders include bowel, bladder and sexual dysfunction, incontinence and prolapse. There are multiple contributing factors which include anatomical and functional abnormalities, as well as psychological aspects. Continence nurses, clinical nurse specialists in colorectal, urology and urogynaecology, physiotherapists, colorectal surgeons, urologists, urogynaecologists, clinical scientists, radiologists and administrative support are all required. To deliver joint up care and ensure joint up thinking our tertiary referral centre have been holding a once monthly joint multidisciplinary team meetings (MDM) involving these team members. Prevalence of pelvic floor disorders is expected to increase (1) (2). We present our experience in the hope that this model can be used and expanded upon to help deliver the high standard of care which should be offered worldwide (3).

Data Collection 
Retrospective data collection was performed using the MDM lists which had been prospectively collated. Data was obtained using the hospital electronic reporting systems. The following was collected; name, age at time of discussion, parity, main presenting complaint, secondary presenting complaint, name of presenting team, investigations, outcome from MDM, final treatment (conservative, surgical), if surgical then nature of surgical procedures and surgical specialities operating, length of follow up.
The Multidisciplinary Meeting 
From 2010 to 2021 a once monthly to once fortnightly joint MDM was held for one hour. Prior to the Covid pandemic this was a face to face meeting but changed to a virtual meeting with the onset of social distancing. The meeting was in addition to the separate weekly MDMs for pelvic floor dysfunction in the colorectal, urology and urogynaecology departments. The attendance of at least one member of each surgical team (colorectal, urology and urogynaecology) was mandatory. The team also included physiotherapists, clinical nurse specialists, clinical scientists, radiologists and administrative support. A register was taken. At the end of each discussion a letter was dictated by one of the surgical consultants. 
Patients could be referred to the MDM by any member of the team, provided a clear question was asked. Inclusion criteria were patients with symptoms affecting more than one compartment who required more input than could be required by the parent team already providing treatment. The senior pelvic floor fellow and clinical nurse specialist prepared the MDM by providing a clinical summary. The radiologist reviewed imaging in advanced. 
The joint MDM ran in conjunction with a joint surgical clinic attended by colorectal, urology and urogynaecology surgeons. Once discussed in the joint MDM patients could be booked into the joint surgical clinic if required. 
Treatment
Conservative treatment in the unit consisted of a combination of face to face and telephone clinic appointments with a continence nurse, clinical nurse specialist or physiotherapist. Techniques adopted included lifestyle and dietary modifications, toilet positioning, pelvic floor retraining, medications (for example; laxatives, Imodium, glycerine suppositories) and adjuncts (for example; rectal irrigation, pessaries, anal plugs).

Data from 102 patient episodes were analysed from 30 separate Joint Pelvic Floor multi-disciplinary meetings from January 2017 to February 2018. The median age of patient at time of discussion was 50 years. There was a heavy female preponderance with a ratio of 99F: 3M. Median length of follow up is 705 days (101 weeks).
93 patients (91.2%) had presenting symptoms from more than one pelvic floor compartment. The remainder of patients presented with other non-pelvic floor general surgical problems or co-existing pathology that warranted discussion in the joint MDM. 
Presenting complaints included the following; 55 urinary incontinence (stress and urge), 21 faecal urgency and incontinence and 18 obstructed defecation. Reason for initial referral included the following: 121 rectocoele, 10 rectal prolapse, 11 other urinary pathology, 12 vaginal vault prolapse, 19 cystocele, 5 uterine prolapse, 6 intussusception and 4 other (rectovaginal fistula, vesico-vaginal fistula, sinus, fissure).
46 patients were brought to the meeting by the colorectal team, 42 patients were brought by the uro-gynaecology team and 14 patients by the urology team. 
82 patients (80.1%) had at least one pelvic floor investigation. 63 patients (61.8%) had at least two pelvic floor investigations. Investigations performed were as follows; 61 anorectal physiology, 59 defaecation Barium proctography, 57 integrated total pelvic floor ultrasound, 4 endoanal ultrasound (no transperineal or transvaginal scans), 29 urodynamics, 2 defaecation MRI, 1 endoscopy, 1 MRI abdomen. The largest proportion of patients had anorectal physiology, defecating proctogram and/or Integrated total pelvic floor ultrasound.
MDM outcomes were recorded (Figure 1).


45 patients (44.1%) had surgery as their definitive management (57 patients continued with conservative management). 8 patients had joint procedures between the pelvic floor specialties (Figure 2)

Just over half of patients required conservative measures alone, 45% required surgery and only 8% required joint surgery. Only 10% of patients required joint clinic review. Almost 20% required review in another specialist’s clinic.  Without the joint MDM all patients may have been referred for review in a joint clinic unnecessarily. It also may have taken longer for review in another specialist’s clinic.  The MDM is a useful forum for clinicians to discuss patients with multiple symptoms so that only those who require joint review by multiple specialities are seen in the joint clinic. It also allows access into other clinics if needed. This ensures an efficient use of the clinicians’ time and a streamlined pathway for the patient.

The joint MDM ensures that those patients with multi-compartmental symptoms are discussed by the appropriate specialty. It means that only those who require review by multiple specialties are seen in joint clinic and that patients have access into clinics run by other specialties.

Abrams P, Cardozo L, Wagg A, Wein A. 2017. Incontinence. 6th. Tokyo: ICS.
Brown HW, Rogers RG, Wise ME. 2017. “Barriers to seeking care for accidental bowel leakage: a qualitative study.” International Urogynaecology Journal 4 (April): 543-551.
Society, The Pelvic Floor. 2021. Seizing Pelvic Floor Services in 2021 and beyond. London: The Pelvic Floor Society.