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Obstetrics & Gynecology Hospital
Fudan University
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 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
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 intakePhysical Therapy• pelvic floor muscle trainingBehavioral 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 !