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PELVIC FLOOR AND FUNCTIONAL ANATOMY. Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn. Objectives. To define Pelvic organ prolapsus To learn Risk factors for Pelvic organ prolapsus Diagnosis of the prolapsus To manage
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PELVIC FLOOR AND FUNCTIONAL ANATOMY Assoc. Prof. Gazi YILDIRIM, M.D. Yeditepe University, Medical Faculty Dept of Ob&Gyn
Objectives • To define • Pelvic organ prolapsus • Tolearn • Risk factorsforPelvic organ prolapsus • Diagnosis of theprolapsus • Tomanage • A womanwho has pelvicorgan prolapsus
Functions of Pelvic Floor 1.Supportive function Pelvic viscera 2.Sphincteric function Vagina, Urethra, Rectum 3.Sexual function Proprioseptive 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 Superficial Transverse perineus Pyramidal Fibrous Body Internal Anal Sphincter External Anal Sphincter Perineal Membrane Bulbocavernosis (urethrovaginal sphincter) Cleveland Clinic Foundation Burnett Novack’s Gynecology 2004
Sphincter urethrae externus • Bulbospongiosus • Ischiocavernosus • Transversus perinei profundus • Transversus perinei superficialis
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
Urethra Bladder Cervix
Lig. sacrouterina Lig. cardinale
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 LevelsI. 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
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 Symptomatic Prolapse Stage I Stage II Stage III Stage IV 1 cm 1cm tvl – 1 cm 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
Anterior Compartment:Abdominal Approach Bladder Ureter ATFP Paravaginal defect A Cullen Richardson
