Pelvic Floor Dysfunction Chen Xiaojun Ob&Gyn Hospital Fudan Uniiversity

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

Pelvic Organ Prolapse Lower Urinary Tract disorder Anorectal Disorder

Pelvic floor dysfunction Not life threatening But life quality worsening

Pelvic Floor

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

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

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

--------------------球海绵体肌bulbocavernosus 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。 355A

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。 356A

Strongest support of pelvic floor 女性骨盆横膈:俯视图 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 337A 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。

Levator ani Support pelvic organs Inforce sphincters

The hammock hypothesis

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

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

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.

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

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%

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

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

Definitions Rectocele Enterocele Cystocele Uterine prolapse Procidentia

Definitions

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

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 >1

Pelvic Muscle Function Assessment Bladder Evaluation

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

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

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.

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.

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.

LOWER URINARY TRACT DISORDERS

Normal Urethral Closure

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

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

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

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

Risk factors Age Obesity Functional impairment Cognitive impairment Pregnancy and delivery

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

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

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

Vaginal and Urethral Devices

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

Surgical Treatment for Stress incontinence TVT/SPARC 51

Key Points

Anorectal Dysfunction

Clasification Defecatory dysfunction --- constipation Infrequent stools, typically fewer than three bowel movements per week. Fecal Incontinence

Key points Defecatory dysfunction and fecal incontinence are common conditions that have tremendous psychosocial and economic implications. The differential diagnosis for anorectal dysfunction is broad and can be classified into systemic factors, anatomic and structural abnormalities, and functional disorders. A thorough history and physical examination is critical for the evaluation of fecal incontinence and defecatory dysfunction, as well as appropriate ancillary testing.

Key points Treatment of anorectal dysfunction should focus on treatment of the underlying condition with nonsurgical management attempted before surgery. Overlapping sphincteroplasty is the procedure of choice for fecal incontinence caused by a disrupted anal sphincter.

Questions Which structure is the strongest support of the pelvic floor? The types of pelvic organ prolapse and their definition. The principle of treatment of pelvic organ prolapse. Types of urinary incontinence and their definition.

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