pelvic floor dysfunction ob & gyn hospital, fudan university lei yuan, md [email protected]
TRANSCRIPT
Questions
What does pelvic floor consist of?
Where are they?(Location, Function)
Pelvis
Anatomy of Pelvic flooranal triangle urogenital triangle
skin
subcutaneous tissue
superficial perineal fascia
bulbospongiosus m./ ischiocavernosus m./
ischiorectal fossa superfical transverse perineal m.
Inferior fasica of UG diaphragm
deep transverse perineal m.
Superior fasica of UG diaphragm
Inferior fasica of Pelvic diaphragm
levator ani m., coccygeus m.
superior fasica of Pelvic diaphragm
髂尾肌 (Iliococcygeus)
耻尾肌 (Pubococcygeus)
耻骨直肠肌 (Puborectalis)
Pelvic diaphragm
坐骨尾骨肌
盆筋膜腱弓 ( 白线 )
(Arcus tendineus fasciae pelvis)
肛提肌腱弓 (Arcus tendineus levator ani)
Arcus tendineus（white line）
Fascia and ligaments
Anatomy of Pelvic flooranal triangle urogenital triangle
skin
subcutaneous tissue
superficial perineal fascia
bulbospongiosus m./ ischiocavernosus m./
ischiorectal fossa superfical transverse perineal m.
Inferior fasica of UG diaphragm
deep transverse perineal m.
Superior fasica of UG diaphragm
Inferior fasica of Pelvic diaphragm
levator ani m., coccygeus m.
superior fasica of Pelvic diaphragm
Longitudinal view
Function of pelvic diaphragm
Function of pelvic floor
Supportive structure
Orchestrate a series of physiological function
Parturition Micturition Defecation
Pelvic organ prolapse
Lower urinary tract disorder (SUI)
Anorectal Disorder ( fecal incontinence)
Anatomic anomaly functional
abnormalities
Site specific defects LEVEL 1 ligaments(cardinal lig. Uterosacral lig.) LEVEL 2 pelvic diaphragm, muscle( levator ani.) LEVEL 3 perineum & soft tissue
Integral Theory (Petros）
RFRFRestoration of form(structure) leads to Restoration of function
Principles of surgery Retain; Reconstruction; Replacement(mesh)
Integral Theory (Petros）
3 levels of support
Delancey, 1994
Three zones (compartments )of pelvis
Anterior zone
Middle zone
Posterior zone
Case discussion
Chief complain： feeling a ball in the
vagina for 4 years and progressively worsen for the last 6 months
www.china-obgyn.net
What else would you like to know about the patient’s history?
Question
Risk factors for PFD
Pregnancy
Vaginal childbirth
Menopause
Aging
Hypoestrogenism
Chronically increased intra-abdominal pressure
Chronic obstructive pulmonary disease (COPD)
Constipation
Obesity
Pelvic floor trauma
Genetic factors
Race
Connective tissue disorders
Hysterectomy
Spina bifida
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Age?
The causes of uterine prolapse?chronic coughing? Chronic diarrhea or constipation? Cachexia?
Clinical symptomsbulge symptom; urinary and bowel symptoms; sexual symptom; pain
Accessory examination and history acquiringHistory of pregnancy and parturitionHistory of DM 、 TB, etcAccessory examination to exclude malignant disease and other nervous system disease
Previous treatment
Chief complain:feeling a ball in the vagina for 4 years and progressively worsen for the last 6 months
History:Previous menstruation: regular, 7/27-32 ， moderate volume; dysmenorrhea(-). Natural menopause for 30 yrs and never receive HRT after menopause. No abnormal vaginal bleeding and vaginal discharge.Sensation of a vaginal protrusion 4 yrs ago and the size was the same like a bean, the symptom was deteriorated when standing or pelvic pressure increased while alleviated after lying down. Pessary use was recommended 1 yr ago, however, the patient didn’t use it because of the difficulty of removing the pessary.
The complete case
The symptom was deteriorated in the last 6 months with the egg-like ball bulged totally from the vagina when walking and only part of it can be returned to the vagina after lying down. However, the protrusion can be totally returned to the vagina by hand. No concurrent urinary frequency, urinary urgency, seldom complain of voiding dysfunction but didn’t receive any treatment. Good control of urination and never had involuntary leakage of urine with coughing.No abdominal pain or low back pain, no abnormal vaginal discharge. No change in appetite or sleep pattern, no cachexia, complain of constipation in recent months.
Previous history: Hypertension for 1 yr, BP ： 130-140/50-60mmHg,maxium:
180/80mmHg. Current treatment: Levamlodipine Beslate p.o DM for 6-7yrs ， Current treatment: Insulin 14u(am), 0u(noon), 5u(pm), s.c; Acarbose: 1# tid, p.o
No previous surgery
Marital and Fertile History: G2P2 ， 1963 ， 1966 vaginal delivery ， fetal birth weight :3kg
No dystocia history
Pelvic examination – Vagina: no congestion– Cervix: atrophy, decent totally beyond the hymen– Uterus: decent totally beyond the hymen, atrophy,
unfixed, no tenderness– Adnexal: normal– Vagino-recto-abdominal examination: normal
Valsalva maneuver
+3 +5 +5
4 2 7
+3 +5 +6
POP-Q
Initial diagnosis? 1. Pelvic floor dysfunction: Anterior III, Middle
IV, Posterior III
2. II-DM
3. Chronic hypertension
Question
Next step? (Accessory examination)
UrodynamicsDetect blood glucose(BG), BP
ECG+Holter Pulmonary function (>70ys) Echocardiography(>70ys)
Question
Treatment( Principle? Option?) Pessary Laprotomy Laproscopy Vaginal surgery
Transvaginal hysterectomy +Pelvic floor reconstruction(Total prolift)
Transvaginal hysterectomy + anterior and posterior vaginal wall repair
Transvaginal hysterectomy + Sacrospinous Ligament Fixation + Midurethral Slings (tension free vaginal tape , TVT) Transvaginal hysterectomy +Lefort surgery Lefort surgery
Question
Treatment principles（ 1）
Treatment choice depends on the type and severity of symptoms, age and medical co-morbidities, desire for future sexual function and/or fertility, and risk factors for recurrence
Treatment principles(2)
Conservative treatment Indication: mild-moderate prolapse Procedures: Pessary
Pelvic floor muscle exercise
(Kegel exercises, biofeedback therapy)
Surgical treatment Indication: severe prolapse(>III),
fail of conservative treatment
Procedures: Obliterative procedures (Lefort colpocleisis; complete colpocleisis)
Reconstructive procedures (depend on different compartments)
• If with concurrent SUI, midurethral sling is recommended
Treatment principles(3)
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术式 Anterior compartment
anterior colporrhaphy （ repair ） If with moderate or severe SUI ： TVT （ Tension-Free Vaginal
Tape ） TVT-O
Middle compartment （ uterine prolapse, vaginal vault prolapse, enterocele, Douglas hernia） Tradition ： vaginal hysterectomy 、 Manchester surgery 、 colpocleisis Now ： Pubovaginal Sling （ PIVS ）、 Sacrospinous Ligament
Fixation （ SSLF)
Posterior compartment posterior colporrhaphy （ repair ） Mesh
POP-Quantification
STAGE 2
STAGE 3
STAGE 4
Quiz: POP-Q application
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1. POP-Q score ？Anterior ： III°(Ba+6)
Posterior ： I°(Bp-2)
Middle(vaginal vault) ： I° （ C-2 ）
2.Management阴道前壁修补术经阴道阴道旁修补术TVT-O
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1. POP-Q score ？
Posterior ： III °(Bp+5)
Middle(vaginal vault) ： I° （ C-6 ）
2.Management
经阴道后路悬吊带术（ p-IVS ）
骶棘韧带固定术（ SSLF ）
Posterior colporrhaphy
Quiz: POP-Q application
Treatment
人类站起来了，
器官却掉下去了
When human being stand up,
Their organs decent…
Take home message
Understand the anatomy of pelvic floor and etiology of pelvic floor dysfunction.
Understand definition and types of pelvic organ prolapse and principle of treatment.
Understand definition and types of lower urinary tract disorders and principle of treatment.
