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Pelvic Floor Dysfunction. OB & GYN Hospital, Fudan University Lei Yuan , MD ylronda@163.com. Questions. What does pelvic floor consist of? Where are they? (Location, Function). Pelvis. Anatomy of Pelvic floor. anal triangle urogenital triangle skin subcutaneous tissue

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pelvic floor dysfunction

Pelvic Floor Dysfunction

OB & GYN Hospital, Fudan University

Lei Yuan , MD

ylronda@163.com

questions
Questions

What does pelvic floor consist of?

Where are they?

(Location, Function)

anatomy of pelvic floor
Anatomy of Pelvic floor

anal triangleurogenital triangle

skin

subcutaneous tissue

superficial perineal fascia

bulbospongiosus m./ ischiocavernosus m./

ischiorectalfossasuperfical transverse perineal m.

Inferior fasica of UG diaphragm

deep transverse perineal m.

Superior fasica of UG diaphragm

Inferior fasica of Pelvic diaphragm

levatorani m., coccygeus m.

superior fasica of Pelvic diaphragm

pelvic diaphragm
版权所有Pelvic diaphragm

坐骨尾骨肌

髂尾肌 (Iliococcygeus)

耻尾肌 (Pubococcygeus)

耻骨直肠肌 (Puborectalis)

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Arcustendineus(white line)

盆筋膜腱弓(白线)

(Arcustendineus fasciae pelvis)

肛提肌腱弓

(Arcus tendineus levator ani)

anatomy of pelvic floor1
Anatomy of Pelvic floor

anal triangleurogenital triangle

skin

subcutaneous tissue

superficial perineal fascia

bulbospongiosus m./ ischiocavernosus m./

ischiorectalfossasuperfical transverse perineal m.

Inferior fasica of UG diaphragm

deep transverse perineal m.

Superior fasica of UG diaphragm

Inferior fasica of Pelvic diaphragm

levatorani m., coccygeus m.

superior fasica of Pelvic diaphragm

function of pelvic floor
Function of pelvic floor

Pelvic organ prolapse

Lower urinary tract disorder (SUI)

Anorectal Disorder

( fecal incontinence)

  • Supportive structure
  • Orchestrate a series of physiological function
  • Parturition
  • Micturition
  • Defecation
slide16

Integral Theory (Petros)

  • Anatomic anomaly functional abnormalities
  • Site specific defects
        • LEVEL 1 ligaments(cardinal lig. Uterosacrallig.)
        • LEVEL 2 pelvic diaphragm, muscle( levatorani.)
        • LEVEL 3 perineum & soft tissue
slide17

Integral Theory (Petros)

  • RFRF

Restoration of form(structure) leads to Restoration of function

Principles of surgery

        • Retain;
        • Reconstruction;
        • Replacement(mesh)
slide18

3 levelsof support

Delancey, 1994

slide19

Three zones (compartments )of pelvis

Anterior zone

Middle zone

Posterior zone

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

www.china-obgyn.net

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Question

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

risk factors for pfd
Risk factors for PFD

Pregnancy

Vaginal childbirth

Menopause

  Aging

Hypoestrogenism

Chronically increased intra-abdominal pressure

  Chronic obstructive pulmonary disease (COPD)

  Constipation

  Obesity

Pelvic floor trauma

Genetic factors

  Race

  Connective tissue disorders

Hysterectomy

Spina bifida

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  • Age?
  • The causes of uterine prolapse?

chronic coughing?Chronic diarrhea or constipation? Cachexia?

  • Clinical symptoms

bulge symptom; urinary and bowel symptoms; sexual symptom; pain

  • Accessory examination and history acquiring

History of pregnancy and parturition

History of DM、TB, etc

Accessory examination to exclude malignant disease and other nervous system disease

  • Previous treatment
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The complete case

  • Chief complain:

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

  • History:

Previous menstruation: regular, 7/27-32,moderate volume; dysmenorrhea(-). Natural menopause for 30 yrs and never receive HRT after menopause. No abnormal vaginal bleeding and vaginal discharge.

Sensation of a vaginal protrusion 4 yrs ago and the size was the same like a bean, the symptom was deteriorated when standing or pelvic pressure increased while alleviated after lying down. Pessary use was recommended 1 yr ago, however, the patient didn’t use it because of the difficulty of removing the pessary.

slide26

The symptom was deteriorated in the last 6 months with the egg-like ball bulged totally from the vagina when walking and only part of it can be returned to the vagina after lying down. However, the protrusion can be totally returned to the vagina by hand. No concurrent urinary frequency, urinary urgency, seldom complain of voiding dysfunction but didn’t receive any treatment. Good control of urination and never had involuntary leakage of urine with coughing.

  • No abdominal pain or low back pain, no abnormal vaginal discharge. No change in appetite or sleep pattern, no cachexia, complain of constipation in recent months.
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  • Previous history:

Hypertension for 1 yr, BP:130-140/50-60mmHg,maxium: 180/80mmHg. Current treatment: LevamlodipineBeslatep.o

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

No previous surgery

  • Marital and Fertile History:

G2P2,1963,1966vaginal delivery,fetal birth weight :3kg

No dystocia history

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Valsalva maneuver

Pelvic examination

  • Vagina: no congestion
  • Cervix: atrophy, decent totally beyond the hymen
  • Uterus: decent totally beyond the hymen, atrophy, unfixed, no tenderness
  • Adnexal: normal
  • Vagino-recto-abdominal examination: normal
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Question

  • Initial diagnosis?
  • Pelvic floor dysfunction: Anterior III, Middle IV, Posterior III
  • II-DM
  • Chronic hypertension
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Question

  • Next step? (Accessory examination)

Urodynamics

Detect blood glucose(BG), BP

ECG+Holter

Pulmonary function (>70ys)

Echocardiography(>70ys)

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Question

  • Treatment( Principle? Option?)
  • Pessary
  • Laprotomy
  • Laproscopy
  • Vaginal surgery
    • Transvaginal hysterectomy +Pelvic floor reconstruction(Total prolift)
    • Transvaginal hysterectomy + anteriorand posterior vaginal wall repair
    • Transvaginal hysterectomy + Sacrospinous Ligament Fixation
    • + Midurethral Slings (tension free vaginal tape , TVT)
    • Transvaginal hysterectomy +Lefort surgery
    • Lefort surgery
treatment principles 1
Treatment principles(1)

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

treatment principles 2
Treatment principles(2)
  • Conservative treatment
    • Indication: mild-moderate prolapse
    • Procedures: Pessary

Pelvic floor muscle exercise

(Kegel exercises, biofeedback therapy)

treatment principles 3
Treatment principles(3)
  • Surgical treatment
    • Indication: severe prolapse(>III),

fail of conservative treatment

    • Procedures: Obliterative procedures (Lefortcolpocleisis; complete colpocleisis)

Reconstructive procedures (depend on different compartments)

    • If with concurrent SUI, midurethral sling is recommended
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  • Anterior compartment
    • anterior colporrhaphy(repair)
    • If with moderate or severe SUI: TVT (Tension-Free Vaginal Tape) TVT-O
  • Middle compartment (uterine prolapse, vaginal vault prolapse, enterocele, Douglashernia)
    • Tradition:vaginal hysterectomy、Manchester surgery、

colpocleisis

    • Now:Pubovaginal Sling(PIVS)、Sacrospinous Ligament Fixation (SSLF)
  • Posterior compartment
    • posterior colporrhaphy(repair)
    • Mesh
slide42

STAGE 3

STAGE 2

STAGE 4

quiz pop q application
版权所有 Quiz: POP-Qapplication

1. POP-Qscore?

Anterior:III°(Ba+6)

Posterior:I°(Bp-2)

Middle(vaginal vault):I°(C-2)

2.Management

阴道前壁修补术

经阴道阴道旁修补术

TVT-O

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Quiz: POP-Qapplication

  • POP-Q score?
  • Posterior:III°(Bp+5)
  • Middle(vaginal vault):I°(C-6)
  • 2.Management
  • 经阴道后路悬吊带术(p-IVS)
  • 骶棘韧带固定术(SSLF)
  • Posterior colporrhaphy
treatment
Treatment

人类站起来了,

器官却掉下去了

When human being stand up,

Their organs decent…

take home message
Take home message
  • Understand the anatomy of pelvic floor and etiology of pelvic floor dysfunction.
  • Understand definition and types of pelvic organ prolapse and principle of treatment.
  • Understand definition and types of lower urinary tract disorders and principle of treatment.