Pelvic Floor Dysfunction OB & GYN Hospital, Fudan University Lei Yuan, MD ylronda@163.com

Pelvic Floor Dysfunction

OB & GYN Hospital, Fudan UniversityLei Yuan , MD

ylronda@163.com

Questions

What does pelvic floor consist of?

Where are they?(Location, Function)

Pelvis

Anatomy of Pelvic flooranal triangle urogenital triangle

skin

subcutaneous tissue

superficial perineal fascia

bulbospongiosus m./ ischiocavernosus m./

ischiorectal fossa superfical transverse perineal m.

Inferior fasica of UG diaphragm

deep transverse perineal m.

Superior fasica of UG diaphragm

Inferior fasica of Pelvic diaphragm

levator ani m., coccygeus m.

superior fasica of Pelvic diaphragm

髂尾肌 (Iliococcygeus)

耻尾肌 (Pubococcygeus)

耻骨直肠肌 (Puborectalis)

Pelvic diaphragm

坐骨尾骨肌

盆筋膜腱弓 ( 白线 )

(Arcus tendineus fasciae pelvis)

肛提肌腱弓 (Arcus tendineus levator ani)

Arcus tendineus（white line）

Fascia and ligaments

Anatomy of Pelvic flooranal triangle urogenital triangle

skin

subcutaneous tissue

superficial perineal fascia

bulbospongiosus m./ ischiocavernosus m./

ischiorectal fossa superfical transverse perineal m.

Inferior fasica of UG diaphragm

deep transverse perineal m.

Superior fasica of UG diaphragm

Inferior fasica of Pelvic diaphragm

levator ani m., coccygeus m.

superior fasica of Pelvic diaphragm

Longitudinal view

Function of pelvic diaphragm

Function of pelvic floor

Supportive structure

Orchestrate a series of physiological function

Parturition Micturition Defecation

Pelvic organ prolapse

Lower urinary tract disorder (SUI)

Anorectal Disorder ( fecal incontinence)

Anatomic anomaly functional

abnormalities

Site specific defects LEVEL 1 ligaments(cardinal lig. Uterosacral lig.) LEVEL 2 pelvic diaphragm, muscle( levator ani.) LEVEL 3 perineum & soft tissue

Integral Theory (Petros）

RFRFRestoration of form(structure) leads to Restoration of function

Principles of surgery Retain; Reconstruction; Replacement(mesh)

Integral Theory (Petros）

3 levels of support

Delancey, 1994

Three zones (compartments )of pelvis

Anterior zone

Middle zone

Posterior zone

Case discussion

Chief complain： feeling a ball in the

vagina for 4 years and progressively worsen for the last 6 months

www.china-obgyn.net

What else would you like to know about the patient’s history?

Question

Risk factors for PFD

Pregnancy

Vaginal childbirth

Menopause

  Aging

  Hypoestrogenism

Chronically increased intra-abdominal pressure

  Chronic obstructive pulmonary disease (COPD)

  Constipation

  Obesity

Pelvic floor trauma

Genetic factors

  Race

  Connective tissue disorders

Hysterectomy

Spina bifida

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Age?

The causes of uterine prolapse?chronic coughing? Chronic diarrhea or constipation? Cachexia?

Clinical symptomsbulge symptom; urinary and bowel symptoms; sexual symptom; pain

Accessory examination and history acquiringHistory of pregnancy and parturitionHistory of DM 、 TB, etcAccessory examination to exclude malignant disease and other nervous system disease

Previous treatment

Chief complain:feeling a ball in the vagina for 4 years and progressively worsen for the last 6 months

History:Previous menstruation: regular, 7/27-32 ， moderate volume; dysmenorrhea(-). Natural menopause for 30 yrs and never receive HRT after menopause. No abnormal vaginal bleeding and vaginal discharge.Sensation of a vaginal protrusion 4 yrs ago and the size was the same like a bean, the symptom was deteriorated when standing or pelvic pressure increased while alleviated after lying down. Pessary use was recommended 1 yr ago, however, the patient didn’t use it because of the difficulty of removing the pessary.

The complete case

The symptom was deteriorated in the last 6 months with the egg-like ball bulged totally from the vagina when walking and only part of it can be returned to the vagina after lying down. However, the protrusion can be totally returned to the vagina by hand. No concurrent urinary frequency, urinary urgency, seldom complain of voiding dysfunction but didn’t receive any treatment. Good control of urination and never had involuntary leakage of urine with coughing.No abdominal pain or low back pain, no abnormal vaginal discharge. No change in appetite or sleep pattern, no cachexia, complain of constipation in recent months.

Previous history: Hypertension for 1 yr, BP ： 130-140/50-60mmHg,maxium:

180/80mmHg. Current treatment: Levamlodipine Beslate p.o DM for 6-7yrs ， Current treatment: Insulin 14u(am), 0u(noon), 5u(pm), s.c; Acarbose: 1# tid, p.o

No previous surgery

Marital and Fertile History: G2P2 ， 1963 ， 1966 vaginal delivery ， fetal birth weight :3kg

No dystocia history

Pelvic examination – Vagina: no congestion– Cervix: atrophy, decent totally beyond the hymen– Uterus: decent totally beyond the hymen, atrophy,

unfixed, no tenderness– Adnexal: normal– Vagino-recto-abdominal examination: normal

Valsalva maneuver

+3 +5 +5

4 2 7

+3 +5 +6

POP-Q

Initial diagnosis? 1. Pelvic floor dysfunction: Anterior III, Middle

IV, Posterior III

2. II-DM

3. Chronic hypertension

Question

Next step? (Accessory examination)

UrodynamicsDetect blood glucose(BG), BP

ECG+Holter Pulmonary function (>70ys) Echocardiography(>70ys)

Question

Treatment( Principle? Option?) Pessary Laprotomy Laproscopy Vaginal surgery

Transvaginal hysterectomy +Pelvic floor reconstruction(Total prolift)

Transvaginal hysterectomy + anterior and posterior vaginal wall repair

Transvaginal hysterectomy + Sacrospinous Ligament Fixation + Midurethral Slings (tension free vaginal tape , TVT) Transvaginal hysterectomy +Lefort surgery Lefort surgery

Question

Treatment principles（ 1）

Treatment choice depends on the type and severity of symptoms, age and medical co-morbidities, desire for future sexual function and/or fertility, and risk factors for recurrence

Treatment principles(2)

Conservative treatment Indication: mild-moderate prolapse Procedures: Pessary

Pelvic floor muscle exercise

(Kegel exercises, biofeedback therapy)

Surgical treatment Indication: severe prolapse(>III),

fail of conservative treatment

Procedures: Obliterative procedures (Lefort colpocleisis; complete colpocleisis)

Reconstructive procedures (depend on different compartments)

• If with concurrent SUI, midurethral sling is recommended

Treatment principles(3)

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术式 Anterior compartment

anterior colporrhaphy （ repair ） If with moderate or severe SUI ： TVT （ Tension-Free Vaginal

Tape ） TVT-O

Middle compartment （ uterine prolapse, vaginal vault prolapse, enterocele, Douglas hernia） Tradition ： vaginal hysterectomy 、 Manchester surgery 、 colpocleisis Now ： Pubovaginal Sling （ PIVS ）、 Sacrospinous Ligament

Fixation （ SSLF)

Posterior compartment posterior colporrhaphy （ repair ） Mesh

POP-Quantification

STAGE 2

STAGE 3

STAGE 4

Quiz: POP-Q application

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1. POP-Q score ？Anterior ： III°(Ba+6)

Posterior ： I°(Bp-2)

Middle(vaginal vault) ： I° （ C-2 ）

2.Management阴道前壁修补术经阴道阴道旁修补术TVT-O

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1. POP-Q score ？

Posterior ： III °(Bp+5)

Middle(vaginal vault) ： I° （ C-6 ）

2.Management

经阴道后路悬吊带术（ p-IVS ）

骶棘韧带固定术（ SSLF ）

Posterior colporrhaphy

Quiz: POP-Q application

Treatment

人类站起来了，

器官却掉下去了

When human being stand up,

Their organs decent…

Take home message

Understand the anatomy of pelvic floor and etiology of pelvic floor dysfunction.

Understand definition and types of pelvic organ prolapse and principle of treatment.

Understand definition and types of lower urinary tract disorders and principle of treatment.