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Pelvic Floor Dysfunction Obstetrics & Gynecology Hospital Fudan University • Pelvic Organ Prolapse • Lower Urinary Tract disorder • Anorectal Disorder Obstetrics & Gynecology Hospital Fudan University • Not life threatening • But life quality worsening Obstetrics & Gynecology Hospital Fudan University Pelvic Floor Obstetrics & Gynecology Hospital Fudan University Pelvic Floor Pelvic diaphragm • Funnel-shaped fibromuscular partition • Forms the primary supporting structure for the pelvic contents • Composition – – – • Levator ani Coccygeus muscles their superior and inferior fasciae Forms the ceiling of the ischiorectal fossa Obstetrics & Gynecology Hospital Fudan University Obstetrics & Gynecology Hospital Fudan University Pelvic Organ Prolapse Obstetrics & Gynecology Hospital Fudan University Pelvic Organ Prolapse (POP) • bulge or protrusion of pelvic organs and their associated vaginal segments into or through the vagina • Incidence increases with aging – anterior pelvic organ prolapse 34.3% – posterior wall prolapse 18.6% – uterine prolapse in 14.3% • Vaginal delivery as a significant risk factor • history of hysterectomy; obesity ; history of previous prolapse operations; race • Optical surgical treatment remains elusive Obstetrics & Gynecology Hospital Fudan University Pathophysiology • attenuation of the supportive structures – endopelvic connective tissue – levator ani muscular support by actual tears or “breaks” by neuromuscular dysfunction Obstetrics & Gynecology Hospital Fudan University Definitions • • • • Rectocele Enterocele Cystocele Uterine prolapse – Procidentia Obstetrics & Gynecology Hospital Fudan University Definitions Obstetrics & Gynecology Hospital Fudan University Symptoms • Pelvic organ prolapse • Symptoms of voiding dysfunction – – – – Urinary incontinence Obstructive voiding symptoms Urinary urgency and frequency Urinary retention and upper renal compromise • Defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence) • Pelvic pain • Back and flank pain • Overall pelvic discomfort • Dyspareunia Obstetrics & Gynecology Hospital Fudan University Symptoms Obstetrics & Gynecology Hospital Fudan University Physical examination • Divide the pelvis into compartments • Apical compartment ---- Graves speculum or Baden retractor • The anterior and posterior compartments ---univalve or Sims' speculum • Rectovaginal examination ---- distinguish a posterior vaginal wall defect from a dissecting apical enterocele • Anterior lateral detachment defect----Baden retractor • Valsalva is encouraged • standing straining examination Obstetrics & Gynecology Hospital Fudan University Pelvic Organ Prolapse Quantitation System Obstetrics & Gynecology Hospital Fudan University Pelvic Organ Prolapse Quantitation System Obstetrics & Gynecology Hospital Fudan University Pelvic Organ Prolapse Quantitation System Obstetrics & Gynecology Hospital Fudan University • Pelvic Muscle Function Assessment • Bladder Evaluation Obstetrics & Gynecology Hospital Fudan University Treatment • Nonsurgical Therapy – Mild to moderate prolapse – Desire future childbearing – Not suitable or desire surgery Obstetrics & Gynecology Hospital Fudan University Conservative Management • pelvic floor muscle training (PFMT) • Lifestyle intervention – weight loss – reduction of activities that increase intra–abdominal pressure Mechanical Devices Obstetrics & Gynecology Hospital Fudan University Surgical Management • • • • OPTIONAL!!! relieve symptoms restore vaginal anatomy vaginal, abdominal, and laparoscopic routes • involve a combination of repairs directed to the anterior vagina, vaginal apex, posterior vagina, and perineum • None is perfect Obstetrics & Gynecology Hospital Fudan University Surgical Management Procedures • Restorative: use the patient's endogenous support structures • Compensatory: replace deficient support with permanent graft material • Obliterative: close or partially close the vagina. Obstetrics & Gynecology Hospital Fudan University Obstetrics & Gynecology Hospital Fudan University Lower Urinary Tract Disorders Obstetrics & Gynecology Hospital Fudan University Normal Urethral Closure Obstetrics & Gynecology Hospital Fudan University • Stress Urinary Incontinence • • • Most common type of urinary continence in women Leaking when sneezing, coughing, or exercise Urethral sphincter defect and/or urethral hypermobility • Urge Urinary Incontinence and Overactive Bladder • most common form of incontinence in older women • involuntary leakage of urine accompanied by or immediately preceded by urgency • may or may not be caused by detrusor overactivity Obstetrics & Gynecology Hospital Fudan University • Mixed Incontinence • have symptoms of both stress and urge urinary incontinence • in older women mixed and urge incontinence is predominate Obstetrics & Gynecology Hospital Fudan University Evaluation • • • • • • • Q–tip test Voiding Diary Urinalysis Postvoid Residual Volume Cough Stress Test Pad Tests Urodynamics Obstetrics & Gynecology Hospital Fudan University Nonsurgical treatment Lifestyle Changes • Weight loss • Postural change • Decrease caffeine intake Physical Therapy • pelvic floor muscle training Behavioral Therapy and Bladder Training Obstetrics & Gynecology Hospital Fudan University Vaginal and Urethral Devices Obstetrics & Gynecology Hospital Fudan University Medications • Stress incontinence – α– adrenergic activity • Urge Incontinence and Overactive Bladder – anticholinergic agents Obstetrics & Gynecology Hospital Fudan University Surgical Treatment for Stress incontinence TVT/SPARC Obstetrics & Gynecology Hospital Fudan University TVT/SPARC Obstetrics & Gynecology Hospital Fudan University Key Points Obstetrics & Gynecology Hospital Fudan University Thank you ! Obstetrics & Gynecology Hospital Fudan University
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