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Presentation on theme: "PELVIC FLOOR AND FUNCTIONAL ANATOMY"— Presentation transcript:

Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn

2 Objectives To define To learn To manage Pelvic organ prolapsus
Risk factors for Pelvic organ prolapsus Diagnosis of the prolapsus To manage A woman who has pelvic organ prolapsus

3 Functions of Pelvic Floor
1.Supportive function Pelvic viscera 2.Sphincteric function Vagina, Urethra, Rectum 3.Sexual function Proprioseptive sensation

4 Elements comprising the Pelvis
Bones Ilium, ischium and pubis fusion Ligaments Muscles Obturator internis muscle Arcus tendineus levator ani or white line Levator ani muscles Urethral and anal sphincter muscles

5 “Ligaments and Fascia”
Cardinal/Uterosacral Complex (Delancy level I) Paracervical Ring Arcus Tendineus Fascia Pelvis ATFP Pubocervical “fascia” Rectovaginal “fascia”

6 Perineal Body Bulbocavernosis (urethrovaginal sphincter)
Superficial Transverse perineus Pyramidal Fibrous Body Internal Anal Sphincter External Anal Sphincter Perineal Membrane Cleveland Clinic Foundation Burnett Novack’s Gynecology 2004

7 Sphincter urethrae externus
Bulbospongiosus Ischiocavernosus Transversus perinei profundus Transversus perinei superficialis

8 Lets ‘create’ a woman pelvis…

9 Bony structures of a pelvis

10 Perineal muscles Urethra M. ischiocavernosus Vagina
M. bulbospongiosus M. transversus perinei superficialis M. sphincter ani externus Urethra Vagina

11 Urogenital fascia Urethra Vagina M. transversus perinei profundus
M. transversus perinei superficialis M. sphincter ani externus

12 Pelvic floor ATFP

13 Add rectum

14 Rectal connections

15 Vaginal connections

16 Urethra Bladder Cervix

17 lig.cardinale

18 Lig. sacrouterina Lig. cardinale


20 DeLancey’s three levels of vaginal support
Apical suspension Upper paracolpium suspends apex to pelvic walls and sacrum Damage results in prolapse of vaginal apex Midvaginal lateral attachment Vaginal attachment to arcus tendineus fascia and levator ani muscle fascia Pubocervical and rectovaginal fasciae support bladder and anterior rectum Avulsion results in cystocele or rectocele Distal perineal fusion Fusion of vagina to perineal membrane, body and levators Damage results in deficient perineal body or urethrocele

21 De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III
De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III. Perineal membrane and perineal body

22 Factors associated with pelvic floor prolapse
age parity big babies menopause obesity occupation home delivery family history

23 Pathogenesis childbirth connective tissue disorders menopause
chronic intra-abdominal pressure iatrogenic (hysterectomy)

24 Factors promoting prolapse
Erect posture causes increased stress on muscles, nerves and connective tissue Acute and chronic trauma of vaginal delivery Aging Estrogen deprivation Intrinsic collagen abnormalities Chronic increase in intraabdominal pressure heavy lifting coughing constipation

25 Pelvic Organ Prolapse

26 POP-Q (Pelvic Organ Prolapse Quantitation)
International Continence Society American Urogynecologic Society Society of Gynecologic Surgeons Pelvic Organ Prolapse Definicition Quantitation Staging Objective Defect specific Bump RC. Am J Obstet Gynecol, 1996

27 Pelvic Organ Prolapse Quantitation
Symptomatic Prolapse Stage I Stage II Stage III Stage IV 1 cm 1cm tvl – 1 cm Hymen

28 Pelvic Relaxation Cystocele Stress urinary incontinence Rectocele
Enterocele Uterine and vaginal prolapse Result of weakness or defect in supporting tissues - endopelvic fascia and neuromuscular damage

29 Apical Prolapse (Uterus)

30 Apical Prolapse (Uterus)

31 Apical Prolapse (Uterus)

32 Apical Prolapse (Uterus)

33 Apical Prolapse (Uterus)

34 Apical Prolapse (Uterus)

35 Complete Uterovaginal procidentia

36 Anterior Prolapse

37 Anterior Prolapse

38 Anterior Prolapse

39 Anterior Prolapse

40 Anterior Prolapse

41 Anterior Prolapse

42 Anterior Prolapse

43 Anterior Compartment: Abdominal Approach
Bladder Ureter ATFP Paravaginal defect A Cullen Richardson

44 Vajen ön duvar prolapsusu Ayırıcı tanı
Defekt türü Paravajinal sentral Tanı Rugae var Rugae silinmiş Tedavi yöntemi Paravajinal kolpopeksi Anteriör kolporafi




48 Posterior Prolapse

49 Posterior Prolapse

50 Posterior Prolapse

51 Posterior Prolapse

52 Posterior Prolapse

53 Posterior Prolapse

54 Posterior Prolapse

55 Apical Prolapse (vault)

56 Apical Prolapse (vault)

57 Apical Prolapse (vault)

58 Apical Prolapse (vault)

59 Apical Prolapse (vault)

60 Apical Prolapse (vault)

61 Apical Prolapse (vault)

62 Apical Prolapse (vault)

63 Apical Prolapse (vault)

64 Apical Prolapse (vault)

65 No data supporting their use to prevent prolapse progression.
Are effective non-surgical treatments available for women with pelvic organ prolapse Pessary. Pelvic Floor Muscle Rehabilitation. Symptom-Directed Therapy No data supporting their use to prevent prolapse progression.

66 Pessaries

67 Nonsurgical Management

68 Nonsurgical Management

69 Surgical Procedures for Female Genital Prolapse
Anterior vaginal wall: Anterior colporrhaphy. Paravaginal repair (vaginal, laparotomy, laparoscopic). Posterior vaginal wall: Posterior colporrhaphy. Site specific rectocele repair. Enterocele repair (vaginal, laparotomy, laparoscopic). Apical suspension: Sacrospinous suspension, Uterosacral ligament suspension (mc call), Iliococcygeal suspension. Sacrocolpopexy (vaginal, laparotomy, laparoscopic). Anterior enterocele repair by laparotomy or laparoscopically. Dysparuenia is the main concern with traditional post colporrhaphy, especially with plication of levator ani plus overzealous perineorrhaphy, or the combinations of procedures that alter normal vaginal contouirs. e.g. Burch plus post. Colporrhaphy. Concommitantly 38% of pts developed p.o dysparunia after combine Burch plus posterior colporrhaphy ( persistent one year or more after surgery.). .Using permanent sutures for site specific posterior. Repair? Sacrocolpopexy –Apex to anterior longitudinal ligament of sacrum. 69

70 What to do to prevent vaginal vault prolapse during abdominal hysterectomy?
Plication of the uterosacral ligaments *Ureter complication!!!

71 What to do to prevent vaginal vault prolapse during vaginal hysterectomy?
McCall Culdoplasty

72 Surgical techniques in vault prolapse
A.Abdominal 1.Sacrocolpopexy 2.Robotic assisted laparoscopic sacrocolpopexy 3.Suturing the cuff to the fascia of rectus abdominis muscle (Williams Operation) B.Vaginal 1.Posterior IVS (Intraginal slingplasty/Infracocygeal sacropexy) 2.Sacrospinous fixation 3.Gynecare Prolift 4.İliococygeal fixation 5.Levator miyoraphy 6.Colpocleisis (Le Fort Operation)

73 Sacrocolpopexy Timmons’ procedure
A polypropylene synyhetic mesh is placed between the vaginal vault and sacrum (anterior longitudinal ligaments) so that the vault is hanged to the sacral bone. Burch colposuspension is a concomitant procedure. If necessary, colporaphy posterior is performed.

74 Sacrospinous Ligament Suspension
Vaginal Apical Repair Sacrospinous Ligament Suspension Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle

75 Paravaginal defects -Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop)

76 Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage


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