Embed Size (px)
Citation preview
Vaumllkommen till kursen
Fraringn foumlrlossningsskada till prolaps ndashbaumlckenbottendysfunktion
genom livet Baumlckenbottencentrum vid Karolinska Universitetssjukhuset Huddinge
i samarbete med SFOG
Leonardo da Vinci
SFOG-kurs 2019
Susruta India 900-330 BC ndash smoumlr och varm mjoumllk
Cleopatra 300 BC ndash uttorkande loumlsningar vaginalt
Dicles of Carystos 350 BC ndashgranataumlpple doppat i vinaumlger
Operation av prolaps aumlr en av de aumlldsta gynekologiska operationer som
aumlr beskrivna i litteraturen
SFOG-kurs 2019
Hippocrates medicinens fader 460-370 BC
Etiologi
Varingta foumltter
Troumltthet
Fattigdom
Sexuell aktivitet
Behandling
ldquoScarificationrdquo av vaginal
slemhinnan och application av
olika medicamenter
Hippocratic Succesion
SFOG-kurs 2019
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Leonardo da Vinci
SFOG-kurs 2019
Susruta India 900-330 BC ndash smoumlr och varm mjoumllk
Cleopatra 300 BC ndash uttorkande loumlsningar vaginalt
Dicles of Carystos 350 BC ndashgranataumlpple doppat i vinaumlger
Operation av prolaps aumlr en av de aumlldsta gynekologiska operationer som
aumlr beskrivna i litteraturen
SFOG-kurs 2019
Hippocrates medicinens fader 460-370 BC
Etiologi
Varingta foumltter
Troumltthet
Fattigdom
Sexuell aktivitet
Behandling
ldquoScarificationrdquo av vaginal
slemhinnan och application av
olika medicamenter
Hippocratic Succesion
SFOG-kurs 2019
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Susruta India 900-330 BC ndash smoumlr och varm mjoumllk
Cleopatra 300 BC ndash uttorkande loumlsningar vaginalt
Dicles of Carystos 350 BC ndashgranataumlpple doppat i vinaumlger
Operation av prolaps aumlr en av de aumlldsta gynekologiska operationer som
aumlr beskrivna i litteraturen
SFOG-kurs 2019
Hippocrates medicinens fader 460-370 BC
Etiologi
Varingta foumltter
Troumltthet
Fattigdom
Sexuell aktivitet
Behandling
ldquoScarificationrdquo av vaginal
slemhinnan och application av
olika medicamenter
Hippocratic Succesion
SFOG-kurs 2019
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Hippocrates medicinens fader 460-370 BC
Etiologi
Varingta foumltter
Troumltthet
Fattigdom
Sexuell aktivitet
Behandling
ldquoScarificationrdquo av vaginal
slemhinnan och application av
olika medicamenter
Hippocratic Succesion
SFOG-kurs 2019
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Samband mellan vaginal foumlrlossning och baumlckenbottenskador
(prolaps)
Soranus (100-talet efter Kristus) - obstetrikens fader
Orsaker till livmoderframfall
Moderkakan slits ut haumlftigt
Foumlrlossning med krok
Ref Soranus rdquoKvinnolaumlrardquo om graviditet foumlrlossningskonst spaumldbarnsvaringrd och kvinnosjukdomar i oumlversaumlttning av Sylvia Toumlrnkvist och Ingrid Ursing (Paul Aringstroumlms foumlrlag)
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Anstraumlngningsinkontinens
1914 Kelly
rdquoThere is a type of urinary incontinence in women without manifest injury to the bladder and having no relation to fistula which most frequently comes on following childbirthrdquo
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Axel Westermark 1892 colporrhaphia lateralis
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Manchester skolan sent 1800-tal
Arhibald Donald WE Forhergill
Etiologi
Foumlrlossningsskada
Tungt arbete ( industriella revolutionen i norra England1760-1830)
Vaumlvnadssvaghet
Postmenopausal atrofi
Oumlkat intraabdominellt tryck
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
1909 (White)
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Baumlckenbottensvaghet ndash ett folkhaumllsoproblem
5- 6000 kvinnoraringr opereras foumlr prolaps i Sverige
I litteraturen daringligt samband mellan symtom och anatomiska fynd
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Prevalens av anatomisk prolaps
0
5
10
15
20
25
30
35
40
45
50
Stage
0
Stage I Stage
II
Stage
III
Stage
IV
Serie1
Serie2
Serie3
1 Swift SE (2000) The distribution of pelvic organ support in a population of female subjects seen
for routine gynecologic health care Am J Obstet Gynecol 183277ndash285
2Swift SE Tate SB Nichols J (2003) Correlation of symptomology with degree of pelvic organ
support in a general population of women what is pelvic organ prolapse Am J Obstet Gynecol 189
372ndash379
3Barber M Walters M Bump R Association of the magnitude of pelvic organ prolapse and
presence and severity of symptoms
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Prevalens symtomgivande prolaps Globus (Fraringgeformulaumlr)
Kumari (2000)
Indien
2990 kvinnor gt15 aringr 76
Tegerstedt (2004)
Stockholm
5489 kvinnor 30-79 aringr 83
Cooper (2014) UK
UK
1832 kvinnor gt 18 aringr 84
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Prolaps ndashriskfaktorer
Aumlrftlighet ndash Bindvaumlvsfaktorer
Vaginal foumlrlossning (stort barn bindvaumlv muskelskada
nervskada)
Hormonella faktorer
Aringlder
BMI
Livstils faktorer (motion kost)
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Tegerstedt et al SoumlS
Metod Tvaumlrsnittstudie med validerade fraringgor om symtomgivande prolaps till slumpmaumlssigt utvalda 8000 Stockholmskvinnor 30-79 aringr
Resultat Svarsfrekvens 5489 (69)
Ref Prevalence of symptomatic pelvic organ prolapse in a Swedish population Int Urogynecol J Pelvic Floor Dysfunct 2005
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Riskfaktorer foumlr symtomgivande framfall
Resultat (Multivariat modell)
Oumlkad risk med stigande aringlder med houmlgsta prevalensen vid 50-59
aringrs aringlder
Ingen foumlrlossning1 foumlrlossning OR 39
Stigande antal foumlrlossningar gt 4 barn OR 107
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Obstetriska riskfaktorer foumlr symtomgivande framfall
Tegerstedt 2006
Metod Retrospektiv fall kontroll-studie 454 testpositiva kvinnor foumlr symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller
Aringlder paritet klipp och eller bristning (analsfinkterskada eller stor vaginal bristning) oumlkade risken foumlr symtomgivande framfall
Ref Obstetrisk riskfactors for prolaps- - A population approach
Am J Obst Gyn 2006
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Andra riskfaktorer (ej obstetriska) foumlr symtomgivande framfall
Miedel et alSoumlS
Metod Retrospektiv fallkontroll-studie 454 testpositiva kvinnor foumlr
symtomgivande framfall =fall 405 testnegativa kvinnor =kontroller 72
fraringgor om taumlnkbara riskfaktorer
Resultat 655 (762 ) besvarade enkaumlten
Ref Nonobstetrisk riskfactors for symptomatic pelvic organ prolaps-
Obstet Gynecol 2009
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Resultat
Hereditet- (kvinnor med syster eller mamma opererad foumlr urininkontinens eller prolaps) - OR 33
Tunga lyft(gt 5kg) - OR 20
Anamnes med annan bindvaumlvssjd (varicierbraringckhemorrojder) - OR 19
Oumlvervikt ndashBMI oumlver 25 ndash OR 19
Tarmtoumlmningsvaringrigheter o obstipation ndashOR 21
Baumlckenbottentraumlning skyddar ej
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Patofysiologi
Foumlrlust av baumlckenbottens stoumldfunktioner
ndash Vaginal foumlrlossning ndash direkt skada av endopelvina fascian eller indirekt skada paring muskler och nerver
Oumlkat tryck
ndash Trycket av den gravida livmodern och moderns oumlkade kroppsvikt paringverkar baumlckenbotten
ndash Oumlkat intraabdominellt buktryck tex oumlvervikt kan ofta leda till prolaps och urinlaumlckage
ndash Obstipation aumlr en viktig faktor vid patogenes av bakvaumlggsdefekt
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Patofysiologi
Kollagen och hormoner
ndash Maringnga studier har rapporterat en minskning av kollagen hos kvinnor med prolaps och urininkontinens
ndash Studier har paringvisat att det finns receptorer foumlr oumlstrogen och progesteron i baumlckenbottens muskler och ligament Minskade hormonhalter efter menopaus kan resultera i minska elasticitet
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Vaginas upphaumlngning
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Whats new in the functional anatomy of pelvic organ
prolapse
Delancey 2016
ldquoThe longest-running debate about the etiology of pelvic organ
prolapse concerns whether muscle or connective tissue is the
most critical element in pelvic organ support
The hypothesis that levator ani muscle injury is an important
cause of pelvic organ prolapse put forth by Halban and Tandler in
1907 is now provenrdquo
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Delancey 2016
ldquoMajor levator injury (injury affecting more than half of the muscle
bulk) is found in 16 of women with normal pelvic organ support
but in between 34 and 55 of women with prolapse thus proving
the association between levator ani muscle injury and pelvic
organ prolapse This injury specifically involves the pubovisceral
portion of the muscle but does not involve the puborectal portion
a point made somewhat confusing because some authors have
used the term puborectal for the injured portion of the muscle
before this distinction was clarifiedrdquo
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
SFOG-kurs 2019
Diagrammatic representation of interactions between levator ani muscle anterior vaginal wall
prolapse and cardinaluterosacral ligament suspension With normal levator function (a) the
vaginal walls are in apposition and anterior and posterior pressures are balanced Levator
damage (b) results in hiatal opening and the vagina becomes exposed to a pressure differential
between abdominal and atmospheric pressures This pressure differential (c) creates a traction
force on the cardinal ligament (CL) and uterosacral ligament (USL) Modified from DeLancey
2012 copy DeLancey
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Vilken betydelse har en levatorskada
bullStoumlrre hiatus oumlppning
bullMinskad muskelstyrka vid kontraktion
bullTidig utveckling av framfall
bullOumlkad risk foumlr recidiv av framfall efter operation
Adekanmi O Int Urogyn J Pelvic floor dys 2009
Model et al Eur J Obstet Gynecol Rep Bio 2010
Weemhoff et al Int Urogynecol J 2012
Dietz et al Ultra Obstet Gynecol 2010
Delancey et al 2010
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
Riskfaktorer foumlr levatorskada
Laringg BMI hos modern(Ref 1-2)
Stort barnhuvud
Assisterad foumlrlossning taringng och VE
Snabb foumlrlossning
Vaumlltraumlnad mamma
1Levator ani defects and the severity of symptoms in women with anterior compartment pelvic
organ prolapse
Oversand et al Int Urogynecol J 2017 Jun 15
2Can pelvic floor trauma be perdikted antenatally
Cauwell-Hall J et al Acta Obstet Gynecol Scand 2018 Feb 2
SFOG-kurs 2019
