Pelvic Floor Dysfunction

1. Pelvic Floor Dysfunction Chen Xiaojun Ob&Gyn Hospital Fudan Uniiversity

2. What you need to know • Anatomy of pelvic floor and etiology of pelvic floor dysfunction • Definition and major types of pelvic organ prolapse • Principle of treatment • Types of urinary incontinence

3. Pelvic Organ Prolapse Lower Urinary Tract disorder Anorectal Disorder

4. Pelvic floor dysfunction • Not life threatening • But life quality worsening

5. Pelvic Floor

6. Pelvic floor Pelvic outlet Anterior pubic symphysis Posterior apex of coccys Bilateral descending ramus of pubis ascending ramus of ischium ischial tuberosity ischial spine

7. 神经支配； Pelvic Supports Pelvic floor Muscle Fasciae and ligament

8. 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

9. 女性会阴.浅表分割 阴蒂clitoris------------------------------- ---------------------坐骨海绵体肌 ischocavernosus 尿道外口--------------------------- External urethral orific --------------------球海绵体肌bulbocavernosus 阴道口--------------------------- Vaginal orific ---------------会阴浅横肌 superficial transverse perineal muscle -----------------------肛门外括约肌 External anal sphincter 外层　由会阴浅筋膜与肌肉组成， 包括会阴浅横肌、球海绵体肌、坐骨海绵体肌和肛门外括约肌。

10. 女性会阴和尿生殖膈 ---------------------尿道括约肌 urethral sphincter 尿生殖膈下筋膜---------------- Inferior fascia of urogenital diaphragm ----------------尿生殖膈上筋膜 Superior fascia of urogenital diaphragm 会阴深横肌 Deep transverse perineal muscle 中层　为尿生殖膈，由上、下两层坚韧筋膜及一层薄肌肉组成。 覆盖在耻骨弓及两坐骨结节间所形成的骨盆出口前部的三角平面上。 包括会阴深横肌及尿道括约肌。

11. Levator ani Strongest support of pelvic floor 女性骨盆横膈:俯视图 ----------------------耻骨阴道肌 Pubovaginal muscle ---------------------耻骨直肠肌 Puborectal muscle -----------------------耻骨尾骨肌 Pubococcygeal muscle Tendinous fascia pelvis “the white line” 髂骨尾骨肌 Iliaccoccygeal muscle 坐骨尾骨肌 ischiococcygeus 内层　称为盆膈，为盆底最里层，最坚韧的组织。 由肛提肌、盆筋膜组成，有尿道、阴道、直肠贯穿其中。

12. Levator ani • Support pelvic organs • Inforce sphincters

13. The hammock hypothesis

14. 3 levels of support • Level 1 - Apical Support Superior suspension of the vagina to the cardinal-uterosacral complex • Level 2—Lateral Support Lateral attachment of the upper 2/3 of the vagina • Level 3 – distal support Fusion of the vagina into the urogenital diaphragm and perineal body

16. Pelvic floor 3 compartments • Anterior compartment (bladder and urethra) • Middle compartment (vagina and uterus) • Posterior compartment (anorectus)

17. Integral theory Prolapse and most pelvic floor symptoms such as urinary stress, urge, abnormal bowel and bladder emptying, and some forms of pelvic pain, mainly arise, for different reasons, from laxity in the vagina or its supporting ligaments, a result of altered connective tissue.

18. Pelvic floor dysfunction • Level 1 – prolapse of the uterus or anterior vaginal vault • Level2/3 – prolapse of anterior or posterior vaginal wall • Anterior compartment – • lower urethral tract dysfunction • Middle compartment – • Enterocele • Cystocele • Uterine prolapse • Posterior compartment • Rectocele • Anorectal dysfunction

19. Pelvic Organ Prolapse

20. 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% • uterineprolapse in 14.3%

21. Pelvic Organ Prolapse (POP) • Vaginal delivery as a significant risk factor • History of hysterectomy; obesity ; history of previous prolapse operations; race • Optional surgical treatment remains elusive

22. Pathophysiology • Attenuation of the supportive structures • endopelvic connective tissue • levator ani muscular support • by actual tears or “breaks” • by neuromuscular dysfunction • Continuous abdominal pressure

23. Definitions • Rectocele • Enterocele • Cystocele • Uterine prolapse • Procidentia

24. Definitions

25. Symptoms • Pelvic organ prolapse • Symptoms of voiding dysfunction • Urinary incontinence • Urinary urgency and frequency • Obstructive voiding symptoms • 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

26. Symptoms

27. 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

28. Pelvic Organ Prolapse Quantitation System

29. Pelvic Organ Prolapse Quantitation System

30. Pelvic Organ Prolapse Quantitation System >1

31. Pelvic Muscle Function Assessment • Bladder Evaluation

32. Treatment • Nonsurgical Therapy • Mild to moderate prolapse • Desire future childbearing • Not suitable or desiring surgery Always conservative therapy first!!!

33. Conservative Management • Pelvic floor muscle training (PFMT) • Lifestyle intervention • weight loss • reduction of activities that increase intra–abdominal pressure • Mechanical Devices • Pessary

34. 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!

35. 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.

37. Key points • With the aging of the population, pelvic organ prolapse is an increasingly common condition seen in women. • Causes of pelvic organ prolapse are multifactorial and result in weakening of the pelvic support connective tissue and muscles as well as nerve damage. • Patients may be asymptomatic or have significant symptoms such as those relating to the lower urinary tract, pelvic pain, defecatory problems, fecal incontinence, back pain, and dyspareunia. • Physical examination includes thoughtful attention to all parts of the vagina, including the anterior, apical, and posterior compartments, levator muscle, and anal sphincter complex.

38. Key points • Nonsurgical treatment options include pelvic floor muscle training and the use of intravaginal devices. • Surgical treatment involves an individualized, multicompartmental approach consistent with the patient‘s previous treatment attempts, activity level, and health status.

39. LOWER URINARY TRACT DISORDERS

40. Normal Urethral Closure

41. Urinary incontinence • 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

42. Urinary incontinence • Mixed Incontinence • Have symptoms of both stress and urge urinary incontinence • In older women mixed and urge incontinence is predominate

43. Stress urinary incontinence • Incidence US 15-35 % Korea 50% China 18.9 % • Age Postmenopausal women 17%. Affects 50 million people in the world.

44. Pathophysiology • Stress urinary incontinence • Incontinence caused by anatomic hypermobility of the urethra • Incontinence caused by intrinsic sphincteric weakness or deficiency • Urgent urinary incontinence • Bladder • Innervation

45. Risk factors • Age • Obesity • Functional impairment • Cognitive impairment • Pregnancy and delivery

46. Evaluation • Hisotory (medications, operations...) • Quality of life measures • Physical examination (Q–tip test) • Primary care level tests • Voiding Diary • Urinalysis • Postvoid Residual Volume • Cough Stress Test • Pad Tests

47. Evaluation • Advanced testing • Urodynamics • Uroflowmetry • Filling cystometry • Voiding cystometrography • Imaging tests • Neurophysiological tests • …….

48. Nonsurgical treatment • Lifestyle Changes • Weight loss • Postural change • Decrease caffeine intake • Physical Therapy -- SUI • Pelvic floor muscle training • Behavioral Therapy and Bladder Training – UI & OAB • Vaginal and urethral devices --SUI

49. Vaginal and Urethral Devices

50. Medications • Stress incontinence • α– adrenergic activity • Urge Incontinence and Overactive Bladder • anticholinergic agents