Pelvic Floor Dysfunction

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)

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

Longitudinal view

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

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

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

3 levelsof support Delancey, 1994

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

Case discussion

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

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

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.

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.

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

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

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

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)

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

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

POP-Quantification

STAGE 3 STAGE 2 STAGE 4

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.

Thank You !

Pelvic Floor Dysfunction