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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 A woman who has pelvic organ 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 Comple (Delancy level I) Paracervical Ring Arcus Tendineus Fascia Pelvis AT

Pubocervical fascia Rectovaginal fascia Perineal Body Perineal Membrane

Superficial Pyramidal Internal External Transverse Anal Anal

Fibrous Sphincter Sphincter perineus Body sphincter) Bulbocavernosis (urethrovaginal

Cleveland Clinic Foundation Burnett Novacks Gynecology 20 Sphincter urethrae

externus Bulbospongiosus

Ischiocavernosus Transversus perinei profundus

Transversus perinei superficialis

Lets create a woman pelvis Bony structures of a pelvis M.

Urethra ischiocavernosus M. bulbospongiosus

M. transversus perinei superficialis Perineal muscles

M. sphincter ani externus Vagina Urethra

Vagina M. transversus perinei profundus Urogenital fascia

M. transversus perinei superficialis M. sphincter ani externus

ATFP Pelvic floor Add

rectum Rectal connections Vaginal connections

Urethra Bladder Cervix lig.cardinale

Lig. sacrouterina Lig. cardinale DeLanceys 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 Lanceys 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 Symptomatic Prolapse Stage I

Stage II 1 cm Stage III

Stage IV 1cm Hymen tvl 1 cm

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 n duvar prolapsusu Ayrc tan Defekt tr Paravajinal

sentral Tan Rugae var

Rugae silinmi Tedavi yntemi Paravajinal

kolpopeksi Anterir kolporafi 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. Pessarie s 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.Abdominal 1.Sacrocolpopexy 2.Robotic assisted laparoscopic sacrocolpopexy

3.Suturing the cuff to the fascia of rectus abdominis muscle (Williams Operation) B.Vaginal 1.Posterior IVS

(Intraginal slingplasty/Infracocygeal sacropexy) 2.Sacrospinous fixation 3.Gynecare Prolift 4.liococygeal fixation 5.Levator miyoraphy 6.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. Vaginal Apical

Repair Sacrospinous Ligament Suspension Sacrospinous ligament fixation entails attachment of the vaginal

apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle 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

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