4 Anatomy of Pelvic floor anal 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
12 Anatomy of Pelvic floor anal 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
15 Function of pelvic floor Supportive structureOrchestrate a series of physiological functionParturitionMicturitionDefecationPelvic organ prolapseLower urinary tract disorder (SUI)Anorectal Disorder( fecal incontinence)
16 Integral Theory (Petros） Anatomic anomaly functional abnormalitiesSite specific defectsLEVEL 1 ligaments(cardinal lig. Uterosacral lig.)LEVEL 2 pelvic diaphragm, muscle( levator ani.)LEVEL 3 perineum & soft tissue
17 Integral Theory (Petros） RFRFRestoration of form(structure) leads to Restoration of functionPrinciples of surgeryRetain;Reconstruction;Replacement(mesh)
24 The causes of uterine prolapse? Age?The causes of uterine prolapse?chronic coughing? Chronic diarrhea or constipation? Cachexia?Clinical symptomsbulge symptom; urinary and bowel symptoms; sexual symptom; painAccessory examination and history acquiringHistory of pregnancy and parturitionHistory of DM、TB, etcAccessory examination to exclude malignant disease and other nervous system diseasePrevious treatment版权所有
25 The complete case Chief complain: feeling a ball in the vagina for 4 years and progressively worsen for the last 6 monthsHistory: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.版权所有
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 Marital and Fertile History: Previous history:Hypertension for 1 yr, BP： /50-60mmHg,maxium: 180/80mmHg. Current treatment: Levamlodipine Beslate p.oDM for 6-7yrs， Current treatment: Insulin 14u(am), 0u(noon), 5u(pm), s.c; Acarbose: 1# tid, p.oNo previous surgeryMarital and Fertile History:G2P2，1963，1966 vaginal delivery，fetal birth weight :3kgNo dystocia history版权所有
28 Cervix: atrophy, decent totally beyond the hymen Pelvic examinationVagina: no congestionCervix: atrophy, decent totally beyond the hymenUterus: decent totally beyond the hymen, atrophy, unfixed, no tendernessAdnexal: normalVagino-recto-abdominal examination: normalValsalva maneuver版权所有
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
35 Treatment principles(3) Surgical treatmentIndication: severe prolapse(>III),fail of conservative treatmentProcedures: Obliterative procedures (Lefort colpocleisis; complete colpocleisis)Reconstructive procedures (depend on different compartments)If with concurrent SUI, midurethral sling is recommended
36 术式 Anterior compartment anterior colporrhaphy（repair）If with moderate or severe SUI： TVT （Tension-Free Vaginal Tape） TVT-OMiddle compartment （uterine prolapse, vaginal vault prolapse, enterocele, Douglas hernia）Tradition：vaginal hysterectomy、Manchester surgery、colpocleisisNow：Pubovaginal Sling（PIVS）、Sacrospinous Ligament Fixation （SSLF)Posterior compartmentposterior colporrhaphy（repair）Mesh版权所有
45 人类站起来了， 器官却掉下去了 Treatment When human being stand up, Their organs decent…
46 Take home messageUnderstand 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.