PELVIC FLOOR AND FUNCTIONAL ANATOMY Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn
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
Functions of Pelvic Floor 1.Supportive function Pelvic viscera 2.Sphincteric function Vagina, Urethra, Rectum 3.Sexual function Proprioseptive sensation
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
“Ligaments and Fascia” Cardinal/Uterosacral Complex (Delancy level I) Paracervical Ring Arcus Tendineus Fascia Pelvis ATFP Pubocervical “fascia” Rectovaginal “fascia”
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
Sphincter urethrae externus Bulbospongiosus Ischiocavernosus Transversus perinei profundus Transversus perinei superficialis
Lets ‘create’ a woman pelvis…
Bony structures of a pelvis
Perineal muscles Urethra M. ischiocavernosus Vagina M. bulbospongiosus M. transversus perinei superficialis M. sphincter ani externus Urethra Vagina
Urogenital fascia Urethra Vagina M. transversus perinei profundus M. transversus perinei superficialis M. sphincter ani externus
Pelvic floor ATFP
Add rectum
Rectal connections
Vaginal connections
Urethra Bladder Cervix
lig.cardinale
Lig. sacrouterina Lig. cardinale
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
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
Factors associated with pelvic floor prolapse age parity big babies menopause obesity occupation home delivery family history
Pathogenesis childbirth connective tissue disorders menopause chronic intra-abdominal pressure iatrogenic (hysterectomy)
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
Pelvic Organ Prolapse
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
Pelvic Organ Prolapse Quantitation Symptomatic Prolapse Stage I Stage II Stage III Stage IV 1 cm 1cm tvl – 1 cm Hymen
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
Apical Prolapse (Uterus)
Apical Prolapse (Uterus)
Apical Prolapse (Uterus)
Apical Prolapse (Uterus)
Apical Prolapse (Uterus)
Apical Prolapse (Uterus)
Complete Uterovaginal procidentia
Anterior Prolapse
Anterior Prolapse
Anterior Prolapse
Anterior Prolapse
Anterior Prolapse
Anterior Prolapse
Anterior Prolapse
Anterior Compartment: Abdominal Approach Bladder Ureter ATFP Paravaginal defect A Cullen Richardson
Vajen ön duvar prolapsusu Ayırıcı tanı Defekt türü Paravajinal sentral Tanı Rugae var Rugae silinmiş Tedavi yöntemi Paravajinal kolpopeksi Anteriör kolporafi
Posterior Prolapse
Posterior Prolapse
Posterior Prolapse
Posterior Prolapse
Posterior Prolapse
Posterior Prolapse
Posterior Prolapse
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
Apical Prolapse (vault)
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.
Pessaries
Nonsurgical Management
Nonsurgical Management
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
What to do to prevent vaginal vault prolapse during abdominal hysterectomy? Plication of the uterosacral ligaments *Ureter complication!!!
What to do to prevent vaginal vault prolapse during vaginal hysterectomy? McCall Culdoplasty
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)
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.
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
Paravaginal defects -Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop)
Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage