1. بِسْمِ اللهِ الرَّحْمنِ الرَّحيمِ

2. شلی های لگن و ورزش کگل دکتر آسیه السادات بنی عقیل
عضو هیات علمی دانشگاه علوم پزشکی گلستان

3. Herniation of the bladder. Also called colpocystoc ele , vesicocele
Prolapse of the anterior vaginal wall= Fallen =Bladder= Cystocele= Anterior prolapse= prolapsed bladder
Herniation of the bladder. Also called colpocystoc ele , vesicocele
Greek kystis "bladder, pouch" + kele“ tumor."  
When the bladder falls down into the vagina it is referred to as a cystocele. When the bladder prolapses, it falls towards the vagina and creates a large bulge in the front vaginal wall which may cause discomfort and difficulty emptying the bladder

4. Prolapse is the bulging or dropping of the uterus (uterine prolapse), rectum (rectocele) or bladder (cystocele) into the vagina.
Genital prolapse occurs in about 316 million women worldwide as of (9.3% of all females.

5. Uterine Prolapse = Fallen Uterus
Uterine prolapse is when the womb drops down into the vagina.

6. Vaginal vault vaginal varolapse (Fallen/Bulging Vagina) -
In women who have previously had a hysterectomy, it is still possible for the vagina itself to fall down even though the uterus is no longer present.
This is referred to as a post hysterectomy ("after hysterectomy") vaginal prolapse. 

7. Enterocele (Bulging of small bowels) - An entrocele occurs when a space between the vagina and rectum opens and small bowel bulges through.
Prolapse of the posterior (back) vaginal wall

8. Rectocele (Bulging rectum)- If the rectum falls it is called a rectocele. This condition may cause discomfort and problems with difficulty having bowel movements.

9. Normal aging
Damage to supportive tissues during pregnancy and childbirth
Effects of gravity
Loss of estrogen
Repeated straining over the years
Conditions that put pressure on the pelvic muscles, such as chronic cough and obesity
Pelvic tumor (rare)
constipation

10. Other Causes of Prolapse:
Menopause: Decreased estrogen, such as during menopause, may also contribute to pelvic organ prolapse. During menopause, estrogen levels, collagen and certain connective tissue proteins decline.
Obesity: Weight contributes to an increased pressure in the abdomen so women who are overweight often have a higher rate of pelvic organ prolapse.
Chronic cough: Chronic coughing caused by smoking, asthma or chronic bronchitis puts increased pressure on the abdomen and pelvis. Smoking alone reduces collagen and can increase the chances of a connective tissue tear.
Prior pelvic floor surgery: Prior surgery may cause damage to the support of the pelvic organs.
Neurologic diseases: Diseases affecting the nervous system such as Parkinson’s, multiple sclerosis or a spinal cord injury also increase the chances of developing pelvic organ prolapse.
Ethnicity/Race: Pelvic organ prolapse is found more often in women of Caucasian and Hispanic backgrounds

11. Physical symptoms A bulge or lump on the outside of the vagina
Feeling as though something is bulging out of the vagina, like a tampon is about to fall out
Lower back pain or increased pelvic pressure that interferes with daily activities
Irregular vaginal spotting or bleeding
Frequent urinary incontinence, urinary tract infections, difficulty urinating, frequent urination or any of the above that interfere with a daily routine
Sexual intercourse that is painful or difficult
Difficult bowel movements, constipation, liquid stools
Women with pelvic organ prolapse can experience all, some or none of the above mentioned. Each woman’s experience with prolapse depends on the type, severity and the individual herself.

12. Pressure or heaviness in the pelvis or vagina
Problems with sexual intercourse
Leaking urine or sudden urge to empty the bladder
Low backache
Uterus and cervix that bulge into the vaginal opening
Repeated bladder infections
Vaginal bleeding
Increased vaginal discharge

13. Even though more than 40% of all women experience some degree of prolapse in their lifetime, 14 million in the US alone.
the exact cause is unknown. However, risk factors include pregnancy, vaginal delivery, hysterectomy, obesity, chronic cough, chronic constipation, repetitive heavy lifting, menopause and genetic connective tissue weakness.

14. Emotional symptoms May feel alone, isolated, and depressed.
may feel embarrassed by this condition, their body
and choose to hide their condition from their partners leading to reduced intimate contact.

16. Pelvic Organ Prolapse Quantification System (POP-Q)
Stage
description
No prolapse anterior and posterior points are all -3 cm, and C or D is between -TVL and -(TVL-2) cm. 1
The criteria for stage 0 are not met, and the most distal prolapse is more than 1 cm above the level of the hymen (less than -1 cm). 2
The most distal prolapse if between 1 cm above and 1 cm below the hymen (at least one point is -1, 0, or +1). 3
The most distal prolapse is more than 1 cm below the hymen but no further than 2 cm less than TVL. 4
Represents complete procidentia or vault eversion; the most distal prolapse protrudes to at least (TVL-2) cm.

17. posterior urethral descent, lowest part other sites
Baden-Walker System
Baden-Walker System for the Evaluation of Pelvic Organ Prolapse on Physical Examination
Grade
posterior urethral descent, lowest part other sites
normal position for each respective site 1
descent halfway to the hymen 2
descent to the hymen 3
descent halfway past the hymen 4
maximum possible descent for each site

18. LIFESTYLE CHANGES Lose weight if you are obese.
Avoid heavy lifting or straining (pushing).
Get treated for a chronic cough.
If you cough is due to smoking, try to quit.

19. VAGINAL PESSARY
Your doctor may recommend placing a rubber or plastic donut-shaped device, into the vagina.This is called a pessary. This device holds the uterus in place.
The pessary may be used for short-term or long-term. The device is fitted for your vagina. Some pessaries are similar to a diaphragm used for birth control.
Pessaries must be cleaned regularly. Sometimes they need to be cleaned by the doctor or nurse. Many women can be taught how to insert, clean, and remove a pessary.
Side effects of pessaries include:
Foul smelling discharge from the vagina
Irritation of the lining of the vagina
Ulcers in the vagina
Problems with normal sexual intercourse

20. Pelvic organ prolapse occurs when one or more of the pelvic organs (bladder, uterus, vagina, and rectum) fall downward and bulge out through the opening of the vagina.

21. Pelvic floor muscle training exercises
are a series of exercises designed to strengthen the muscles of the pelvic floor.
Pelvic floor muscle training exercises are recommended for People who have:
urinary stress incontinence
fecal incontinence

22. What are the pelvic floor muscles?
a group of muscles that wrap around the underside of the bladder and rectum. 

23. Levatorani divided into three parts: iliococcygeus muscle
Pubococcygeus muscle (pc muscle)
Puborectalis muscle
It supports the viscera in pelvic cavity, and surrounds the various structures that pass through it.
In combination with the coccygeus muscle, it forms the pelvic floor also called the pelvic diaphragm.

24. pubococcygeus muscle (PC muscle)
hammock-like muscle
controls urine flow
contracts during orgasm
aids in childbirth
core stability (maintenance of good posture)

25. Kegel exercises
The Kegel exercises are a series of voluntary contractions of all the perineal muscles.
Such movement is done in an effort to strengthen all the striated muscles in the perineum's area.
They are often referred to simply as "kegels", named after their founder, Dr. Arnold Kegel.

26. First, exercise increases the strength of your pelvic floor muscles, so that they will be strong enough to prevent urine leakage.
Second, through repeated practice you gain control over these muscles. Then you can use them quickly to prevent urine loss or to decrease the urge feeling.

27. Leak a few drops of urine while sneezing, laughing or coughing
Have a strong, sudden urge to urinate just before losing a large amount of urine (urinary incontinence)
Leak stool (fecal incontinence)

28. Because Kegels improve circulation to your rectal and vaginal area,
they may help keep hemorrhoids possibly speed healing after an episiotomy or tear during childbirth.
making sex more enjoyable.

29. How to do Kegel exercises Don't Exercise the Wrong Muscles!
It takes diligence to identify your pelvic floor muscles and learn how to contract and relax them.
Find the right muscles. To identify your pelvic floor muscles, stop urination in midstream. If you succeed, you've got the right muscles. OR
Imagine that you're trying to stop yourself from passing gas and trying to stop the flow of urine midstream at the same time.
The feeling is one of "squeeze and lift" – a closing and drawing up of the front and back passages. Lift them UP inside. You should have a sense of “lift” each time you squeeze your pelvic floor muscles.

30. Perfect your technique:
Once you've identified your pelvic floor muscles, empty your bladder and lie on your back.
Tighten your pelvic floor muscles, hold the contraction for five seconds, and then relax for five seconds. each squeeze and relaxation counts as one exercise.
Try it four or five times in a row. Repeat 3 to 5 times a day. 
When you first start doing Kegel exercises, tense the muscles in your pelvic floor for a count of three, then relax them for a count of three.
Work up to keeping the muscles contracted for 10 seconds at a time, relaxing for 10 seconds between contractions.
Aim for at least three sets of 10 repetitions a day.

31. Using Your Pelvic Muscle to Control the "Urge"
Many people think that the only way to relieve the uncomfortable sudden feeling of urgency is to empty the bladder, but this is not so. Urges can come and go without you emptying the bladder; they are simply messages telling you that eventually you will need to urinate. In someone with overactive bladder , the urges are often false messages that you need to go now. Urges, however, should not be commands. They should function as an early warning system, getting you ready to find a place to urinate—after you have relaxed and suppressed the urge.

32. To reduce or eliminate the urge to urinate, you will use your pelvic floor muscles.
Remember to squeeze your pelvic floor muscles quickly several times when you get the urge feeling.
To do this, tighten/squeeze and relax the pelvic muscle as rapidly as possible.
Do not relax fully in between squeezes.
Squeezing your pelvic floor muscles in this way sends a message to your nervous system and back to your bladder to stop contracting.
As your bladder stops contracting and starts relaxing, the urge feeling subsides.
Then, once the urge to urinate has subsided, you have a safe period when the bladder is calm. .

33. You can do these exercises at any time and any place.
Most people prefer to do the exercises while lying down or sitting in a chair. After 4 to 6 weeks, most people notice some improvement.
It may take as long as 3 months to see a major change (12 weeks) .
They also work differently for each person.
Kegels may prevent your condition from getting worse.

34. A word of caution
Some people feel that they can speed up the progress by increasing the number of repetitions and the frequency of exercises.
However, over-exercising can instead cause muscle fatigue and increase urine leakage.
t is common for most people not to take the time to relax between squeezes. You must allow the muscles to relax between squeezes so that your muscles can rest before squeezing again.

35. Maintain your focus.
For best results, focus on tightening only your pelvic floor muscles.
Be careful not to flex the muscles in your abdomen, thighs or buttocks. stomach or chest.
It is best just to relax your body as much as possible and concentrate on your pelvic floor muscles.
Avoid holding your breath. Instead, breathe freely during the exercises.
It might help to place a hand on your belly while you're doing your Kegels to make sure that it stays relaxed.

36. Be sure that you do not feel
any movement of your belly and stomach.
holding your breath
 your body is moving up and down slightly (also using your buttock muscles)

37. If you get back pain or stomach pain after you exercise, you are probably trying too hard and using your stomach muscles.
If you experience headaches, then you are also tensing your chest muscles and probably holding your breath.

38. When to do your Kegels
Make Kegel exercises part of your daily routine.
You can do Kegel exercises discreetly just about anytime, whether you're sitting at your desk or relaxing on the couch.
You might make a practice of fitting in a set every time you do a routine task, such as checking .
At the beginning private place to sit or to lie down before doing your exercises. As you practice, you will find you can do them anywhere.

39. If you are still not sure whether you are tightening the right muscles,
Insert a finger into your vagina. Tighten the muscles as if you are holding in your urine, then let go.
 tightening your vaginal muscles around your finger.
You should feel the muscles tighten and move up and down.

40. t is very important that you keep the following muscles relaxed while doing pelvic floor muscle training exercises:
Abdominal
Buttocks (the deeper, anal sphincter muscle should contract)
Thigh