Obstetrics & Gynecology Hospital Fudan University Pelvic Floor Dysfunction.

transcript

Obstetrics & Gynecology Hospital

Fudan University

Pelvic Floor Dysfunction

Fudan University

• Pelvic Organ Prolapse• Lower Urinary Tract

disorder• Anorectal Disorder

Fudan University

• Not life threatening

• But life quality worsening

Fudan University

Pelvic Floor

Fudan University

Pelvic FloorPelvic 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

Fudan University

Pelvic Organ Prolapse

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

Fudan University

Pathophysiology

• attenuation of the supportive structures – endopelvic connective

tissue– levator ani muscular

support by actual tears or

“breaks” by neuromuscular

dysfunction

Fudan University

Definitions• Rectocele• Enterocele• Cystocele• Uterine prolapse

– Procidentia

Fudan University

Definitions

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

Fudan University

Symptoms

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

Fudan University

Pelvic Organ Prolapse Quantitation System

Fudan University

• Pelvic Muscle Function Assessment• Bladder Evaluation

Fudan University

Treatment• Nonsurgical Therapy

– Mild to moderate prolapse– Desire future childbearing– Not suitable or desire surgery

Fudan University

Conservative Management• pelvic floor muscle training (PFMT)• Lifestyle intervention

– weight loss – reduction of activities that increase intra–

abdominal pressure

Mechanical Devices

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

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.

Fudan University

Lower Urinary Tract Disorders

Fudan University

Normal Urethral Closure

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

Fudan University

• Mixed Incontinence

• have symptoms of both stress and urge urinary incontinence

• in older women mixed and urge incontinence is predominate

Fudan University

Evaluation• Q–tip test• Voiding Diary• Urinalysis• Postvoid Residual Volume• Cough Stress Test• Pad Tests• Urodynamics

Fudan University

Nonsurgical treatment

Lifestyle Changes• Weight loss• Postural change• Decrease caffeine intakePhysical Therapy• pelvic floor muscle trainingBehavioral Therapy and Bladder

Training

Fudan University

Vaginal and Urethral Devices

Fudan University

Medications• Stress incontinence

– α– adrenergic activity

• Urge Incontinence and Overactive Bladder– anticholinergic agents

Fudan University

Surgical Treatment for Stress incontinence

TVT/SPARC

Fudan University

TVT/SPARC

Fudan University

Key Points

Fudan University

Thank you !

Obstetrics & Gynecology Hospital Fudan University Pelvic Floor Dysfunction.

Documents