The ‘Elephant in the Room’

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Why does no one in the Arab world currently address the real problems of female pelvic medicine and surgery? More than two decades ago, during one of the annual AUA conferences, I was engaged in an interesting conversation with the eminent and visionary Professor Mohamed Ghoneim. During our discussion, I asked him very pointedly why a prominent institution such as the Urological Institution of Mansoura – which at that time was the only institute offering several urological subspecialties as an integrated service – does not include a specialist in Female Urology? His answer was simple and convincing. He said, “We have so many bigger urological problems in Egypt”. That was many years ago. Since that time, knowledge of pelvic floor disorders (PFD) has advanced tremendously. The dominance of traditional specialties such as urology, gynaecology, and general surgery has gradually given way to subspecialties such as female urology, urogynaecology, and colorectal surgery. This has allowed experts to focus on a narrower field, and provide more optimal care for women. The ultimate goal is for the ‘vertical’ approach, adhered to by each specialist, to give way to the ‘whole pelvis’ approach. There are many disadvantages to the ‘vertical’ concept, as the effect of therapy on other pelvic organs is not considered, surgical procedures are sequential rather than combined, and there is thus decreased patient satisfaction. One major and important problem with a subspecialty such as Female Urology is that it deals with quality of life, which many specialists might not consider to be of primary importance. However, as seen in the realm of Female Urology, women who are suffering from urological disorders see this as their ‘social cancer’, as the late Dr. Rodney Appel would say. The incidence of urinary incontinence, overactive bladder, pelvic organ prolapse and anal incontinence increases with age and parity. Apart from a few epidemiological studies, there is currently a lack of good epidemiological data in the literature related to the incidence of these PFD in the Arab female population. However, in the Western world, about a third of women are affected by one or any combinations of PFD. Thus, a similar or even greater incidence can be expected in the Arab world. What happens to the millions of Arab women who often suffer in silence from PFD? Are they invisible? Not at all. In fact, they are living longer, are more educated, and many refuse to live in silence, as their mothers did, suffering from PFD. Two decades after my discussion with Professor Ghoneim, it is evident that there is still a strong need for further subspecialization in the field of Female Urology, especially with the ageing population and prevalence of incontinence and PFD. We cannot face this demand and health problem with individual efforts diluted by broader interests and continue non-specialization. It is time to co-operate, reach out to other specialties, broaden our knowledge and hone our skills. We must educate a new generation of urologists who will develop a passion for this subspecialty and become future ‘leaders’ in Female Urology.