Pelvic Floor Dysfunction

Pelvic Organ Prolapse Lower Urinary Tract disorder Anorectal Disorder

Not life threatening But life quality worsening

Pelvic Floor

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

Pelvic Organ Prolapse

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

Pathophysiology attenuation of the supportive structures endopelvic connective tissue levator ani muscular support by actual tears or “breaks” by neuromuscular dysfunction

Definitions Rectocele Enterocele Cystocele Uterine prolapse Procidentia

Definitions

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

Symptoms

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

Pelvic Organ Prolapse Quantitation System

Pelvic Organ Prolapse Quantitation System

Pelvic Organ Prolapse Quantitation System

Pelvic Muscle Function Assessment Bladder Evaluation

Treatment Nonsurgical Therapy Mild to moderate prolapse Desire future childbearing Not suitable or desire surgery

Conservative Management pelvic floor muscle training (PFMT) Lifestyle intervention weight loss reduction of activities that increase intra–abdominal pressure Mechanical Devices

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

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.

Lower Urinary Tract Disorders

Normal Urethral Closure

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

Mixed Incontinence have symptoms of both stress and urge urinary incontinence in older women mixed and urge incontinence is predominate

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

Nonsurgical treatment Lifestyle Changes Weight loss Postural change Decrease caffeine intake Physical Therapy pelvic floor muscle training Behavioral Therapy and Bladder Training

Vaginal and Urethral Devices

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

Surgical Treatment for Stress incontinence TVT/SPARC 32

TVT/SPARC 33

Key Points

Thank you !