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. Pelvis
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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

8. Pelvic diaphragm 耻尾肌 (Pubococcygeus) 耻骨直肠肌 (Puborectalis) 坐骨尾骨肌
髂尾肌 (Iliococcygeus)
耻尾肌 (Pubococcygeus)
耻骨直肠肌 (Puborectalis)
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10. Arcus tendineus（white line）
盆筋膜腱弓(白线)
(Arcus tendineus fasciae pelvis)
肛提肌腱弓
(Arcus tendineus levator ani)
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11. Fascia and ligaments
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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

13. Longitudinal view

14. Function of pelvic diaphragm
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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. Integral Theory (Petros）
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

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

18. 3 levels of support
Delancey, 1994

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

20. Case discussion

21. Chief complain：feeling a ball in the vagina for 4 years and progressively worsen for the last 6 months
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22. Question What else would you like to know about the patient’s history?
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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. The causes of uterine prolapse?
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
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25. 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.
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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.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
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28. Cervix: atrophy, decent totally beyond the hymen
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
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29. POP-Q +3 +5 4 2 7 +6
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30. Question Initial diagnosis?
Pelvic floor dysfunction: Anterior III, Middle IV, Posterior III
II-DM
Chronic hypertension
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31. Question Next step? (Accessory examination) Urodynamics
Detect blood glucose(BG), BP
ECG+Holter
Pulmonary function (>70ys)
Echocardiography(>70ys)
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32. 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
手术方式，针对不同compartment的手术方式不同
Individulized therapy
治疗分：Conservative and surgical
保守性治疗中又分：pelvic floor muscle training (PFMT).（有Kegal 训练及生物电刺激 ）及Mechnical treatment（子宫托）
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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: Pessary
Pelvic floor muscle exercise
(Kegel exercises, biofeedback therapy)

35. Treatment principles(3)
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

36. 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
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39. POP-Quantification

42. STAGE 3
STAGE 2
STAGE 4

43. Quiz: POP-Q application
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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44. Quiz: POP-Q application
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
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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 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. Thank You !