Pelvic Floor Dysfunction - PowerPoint PPT Presentation

pelvic floor dysfunction n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Pelvic Floor Dysfunction PowerPoint Presentation
Download Presentation
Pelvic Floor Dysfunction

play fullscreen
1 / 47
Pelvic Floor Dysfunction
701 Views
Download Presentation
manju
Download Presentation

Pelvic Floor Dysfunction

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

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

  2. Questions What does pelvic floor consist of? Where are they? (Location, Function)

  3. 版权所有 Pelvis

  4. 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

  5. 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)

  6. 版权所有 Arcustendineus(white line) 盆筋膜腱弓(白线) (Arcustendineus fasciae pelvis) 肛提肌腱弓 (Arcus tendineus levator ani)

  7. 版权所有 Fascia and ligaments

  8. 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

  9. Longitudinal view

  10. 版权所有 Function of pelvic diaphragm

  11. 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

  12. 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

  13. Integral Theory (Petros) • RFRF Restoration of form(structure) leads to Restoration of function Principles of surgery • Retain; • Reconstruction; • Replacement(mesh)

  14. 3 levelsof support Delancey, 1994

  15. Three zones (compartments )of pelvis Anterior zone Middle zone Posterior zone

  16. Case discussion

  17. 版权所有 • Chief complain:feeling a ball in the vagina for 4 years and progressively worsen for the last 6 months www.china-obgyn.net

  18. 版权所有 Question What else would you like to know about the patient’s history?

  19. 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

  20. 版权所有 • 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

  21. 版权所有 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.

  22. 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.

  23. 版权所有 • 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

  24. 版权所有 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

  25. 版权所有 POP-Q

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

  27. 版权所有 Question • Next step? (Accessory examination) Urodynamics Detect blood glucose(BG), BP ECG+Holter Pulmonary function (>70ys) Echocardiography(>70ys)

  28. 版权所有 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

  29. 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

  30. Treatment principles(2) • Conservative treatment • Indication: mild-moderate prolapse • Procedures: Pessary Pelvic floor muscle exercise (Kegel exercises, biofeedback therapy)

  31. 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

  32. 版权所有 术式 • Anterior compartment • anterior colporrhaphy(repair) • If with moderate or severe SUI: TVT (Tension-Free Vaginal Tape) TVT-O • Middle compartment (uterine prolapse, vaginal vault prolapse, enterocele, Douglashernia) • Tradition:vaginal hysterectomy、Manchester surgery、 colpocleisis • Now:Pubovaginal Sling(PIVS)、Sacrospinous Ligament Fixation (SSLF) • Posterior compartment • posterior colporrhaphy(repair) • Mesh

  33. POP-Quantification

  34. STAGE 3 STAGE 2 STAGE 4

  35. 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

  36. 版权所有 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

  37. Treatment 人类站起来了, 器官却掉下去了 When human being stand up, Their organs decent…

  38. 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.

  39. Thank You !