pelvic floor and functional anatomy assoc. prof. gazi yildirim, m.d. yeditepe university, medical...
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PELVIC FLOOR AND
FUNCTIONAL ANATOMY
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty Dept of Ob&Gyn
• To define– Pelvic organ prolapsus
• To learn– Risk factors for Pelvic organ prolapsus– Diagnosis of the prolapsus
• To manage – A woman who has pelvic organ prolapsus
Objectives
Functions of Pelvic Floor
1.Supportive functionPelvic viscera
2.Sphincteric functionVagina, Urethra, Rectum
3.Sexual functionProprioseptive 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 perineusExternal Anal SphincterInternal Anal SphincterPyramidal Fibrous BodyPerineal Membrane
Cleveland Clinic FoundationBurnett 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
Vagina
M. ischiocavernosus
M. bulbospongiosus
M. transversus perinei superficialis
M. sphincter ani externus
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. cardinale
Lig. sacrouterina
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. 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
1 cm 1cmtvl – 1 cm
Stage I Stage II Stage III Stage IV
Symptomatic Prolapse
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 prolapsusuAyırıcı tanı
Defekt türüDefekt türü ParavaParavajjinalinal ssentralentral
TanıTanı Rugae varRugae var Rugae Rugae silinmişsilinmiş
Tedavi Tedavi yöntemiyöntemi
Paravajinal Paravajinal kolpopeksikolpopeksi
Anteriör Anteriör kolporafikolporafi
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)
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).
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.Abdominal1.Sacrocolpopexy2.Robotic assisted
laparoscopic sacrocolpopexy
3.Suturing the cuff to the fascia of rectus abdominis muscle (Williams Operation)
• B.Vaginal1.Posterior IVS(Intraginal slingplasty/Infracocygeal sacropexy)
2.Sacrospinous fixation3.Gynecare Prolift4.İliococygeal fixation5.Levator miyoraphy6.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 • Sacrospinous ligament fixation
entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle
Vaginal Apical Repair
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