Presentation is loading. Please wait.

Presentation is loading. Please wait.

Pelvic Floor Dysfunction OB & GYN Hospital, Fudan University Lei Yuan, MD

Similar presentations


Presentation on theme: "Pelvic Floor Dysfunction OB & GYN Hospital, Fudan University Lei Yuan, MD"— Presentation transcript:

1 Pelvic Floor Dysfunction OB & GYN Hospital, Fudan University Lei Yuan, MD

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./ 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., c occygeus m. superior fasica of Pelvic diaphragm

5

6

7

8 版权所 有 髂尾肌 ( Iliococcygeus) 耻尾肌 ( Pubococcygeus ) 耻骨直肠肌 ( Puborectalis) Pelvic diaphragm 坐骨尾骨肌

9

10 版权所 有 盆筋膜腱弓 ( 白线 ) ( Arcus tendineus fasciae pelvis) 肛提肌腱弓 (Arcus tendineus levator ani) Arcus tendineus ( white line )

11 版权所 有 Fascia and ligaments

12 Anatomy of Pelvic floor anal triangleurogenital 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., c occygeus m. superior fasica of Pelvic diaphragm

13 Longitudinal view

14 版权所 有 Function of pelvic diaphragm

15 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)

16  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 )

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

18 3 levels of support Delancey, 1994

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

20 Case discussion

21 版权所 有  Chief complain : feeling a ball in the vagina for 4 years and progressively worsen for the last 6 months

22 版权所 有 What else would you like to know about the patient’s history? Question

23 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

24 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

25 版权所 有  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

26 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.

27 版权所 有  Previous history: Hypertension for 1 yr, BP : /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

28 版权所 有 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

29 版权所 有 POP-Q

30 版权所 有  Initial diagnosis? 1.Pelvic floor dysfunction: Anterior III, Middle IV, Posterior III 2.II-DM 3.Chronic hypertension Question

31 版权所 有  Next step? (Accessory examination) Urodynamics Detect blood glucose(BG), BP ECG+Holter Pulmonary function (>70ys) Echocardiography(>70ys) Question

32 版权所 有  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

33 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

34 Treatment principles(2)  Conservative treatment  Indication: mild-moderate prolapse  Procedures: PessaryPessary Pelvic floor muscle exercise (Kegel exercises, biofeedback therapy)

35  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)

36 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, Douglas hernia )  Tradition : vaginal hysterectomy 、 Manchester surgery 、 colpocleisis  Now : Pubovaginal Sling ( PIVS )、 Sacrospinous Ligament Fixation ( SSLF)  Posterior compartment  posterior colporrhaphy ( repair )  Mesh

37

38

39 POP-Quantification

40

41

42 STAGE 2 STAGE 3 STAGE 4

43 Quiz: POP-Q application 版权 所有 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

44 版权所 有 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

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

46 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.

47


Download ppt "Pelvic Floor Dysfunction OB & GYN Hospital, Fudan University Lei Yuan, MD"

Similar presentations


Ads by Google