1. PELVIC FLOOR AND FUNCTIONAL ANATOMY
Assoc. Prof. Gazi YILDIRIM, M.D.
Yeditepe University, Medical Faculty
Dept of Ob&Gyn

2. Objectives To define To learn To manage Pelvic organ prolapsus
Risk factors for Pelvic organ prolapsus
Diagnosis of the prolapsus
To manage
A woman who has pelvic organ prolapsus

3. Functions of Pelvic Floor
1.Supportive function
Pelvic viscera
2.Sphincteric function
Vagina, Urethra, Rectum
3.Sexual function
Proprioseptive sensation

4. 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

5. “Ligaments and Fascia”
Cardinal/Uterosacral Complex
(Delancy level I)
Paracervical Ring
Arcus Tendineus Fascia Pelvis ATFP
Pubocervical “fascia”
Rectovaginal “fascia”

6. Perineal Body Bulbocavernosis (urethrovaginal sphincter)
Superficial Transverse perineus
Pyramidal Fibrous Body
Internal Anal Sphincter
External Anal Sphincter
Perineal Membrane
Cleveland Clinic Foundation
Burnett Novack’s Gynecology 2004

7. Sphincter urethrae externus
Bulbospongiosus
Ischiocavernosus
Transversus perinei profundus
Transversus perinei superficialis

8. Lets ‘create’ a woman pelvis…

9. Bony structures of a pelvis

10. Perineal muscles Urethra M. ischiocavernosus Vagina
M. bulbospongiosus
M. transversus perinei superficialis
M. sphincter ani externus
Urethra
Vagina

11. Urogenital fascia Urethra Vagina M. transversus perinei profundus
M. transversus perinei superficialis
M. sphincter ani externus

12. Pelvic floor
ATFP

13. Add rectum

14. Rectal connections

15. Vaginal connections

16. Urethra
Bladder
Cervix

17. lig.cardinale

18. Lig. sacrouterina
Lig. cardinale

20. 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

21. De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III
De Lancey’s Levels I. Uterosacral cardinal ligament II. ATFP III. Perineal membrane and perineal body

22. Factors associated with pelvic floor prolapse
age
parity
big babies
menopause
obesity
occupation
home delivery
family history

23. Pathogenesis childbirth connective tissue disorders menopause
chronic intra-abdominal pressure
iatrogenic (hysterectomy)

24. 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

25. Pelvic Organ Prolapse

26. 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

27. Pelvic Organ Prolapse Quantitation
Symptomatic Prolapse
Stage I
Stage II
Stage III
Stage IV
1 cm
1cm
tvl – 1 cm
Hymen

28. 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

29. Apical Prolapse (Uterus)

30. Apical Prolapse (Uterus)

31. Apical Prolapse (Uterus)

32. Apical Prolapse (Uterus)

33. Apical Prolapse (Uterus)

34. Apical Prolapse (Uterus)

35. Complete Uterovaginal procidentia

36. Anterior Prolapse

37. Anterior Prolapse

38. Anterior Prolapse

39. Anterior Prolapse

40. Anterior Prolapse

41. Anterior Prolapse

42. Anterior Prolapse

43. Anterior Compartment: Abdominal Approach
Bladder
Ureter
ATFP
Paravaginal defect
A Cullen Richardson

44. Vajen ön duvar prolapsusu Ayırıcı tanı
Defekt türü
Paravajinal
sentral
Tanı
Rugae var
Rugae silinmiş
Tedavi yöntemi
Paravajinal kolpopeksi
Anteriör kolporafi

48. Posterior Prolapse

49. Posterior Prolapse

50. Posterior Prolapse

51. Posterior Prolapse

52. Posterior Prolapse

53. Posterior Prolapse

54. Posterior Prolapse

55. Apical Prolapse (vault)

56. Apical Prolapse (vault)

57. Apical Prolapse (vault)

58. Apical Prolapse (vault)

59. Apical Prolapse (vault)

60. Apical Prolapse (vault)

61. Apical Prolapse (vault)

62. Apical Prolapse (vault)

63. Apical Prolapse (vault)

64. Apical Prolapse (vault)

65. No data supporting their use to prevent prolapse progression.
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.

66. Pessaries

67. Nonsurgical Management

68. Nonsurgical Management

69. 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).
Anterior enterocele repair by laparotomy or laparoscopically. Dysparuenia is the main concern with traditional post colporrhaphy, especially with plication of levator ani plus overzealous perineorrhaphy, or the combinations of procedures that alter normal vaginal contouirs. e.g. Burch plus post. Colporrhaphy. Concommitantly 38% of pts developed p.o dysparunia after combine Burch plus posterior colporrhaphy ( persistent one year or more after surgery.). .Using permanent sutures for site specific posterior. Repair? Sacrocolpopexy –Apex to anterior longitudinal ligament of sacrum. 69

70. What to do to prevent vaginal vault prolapse during abdominal hysterectomy?
Plication of the uterosacral ligaments
*Ureter complication!!!

71. What to do to prevent vaginal vault prolapse during vaginal hysterectomy?
McCall Culdoplasty

72. 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.İliococygeal fixation
5.Levator miyoraphy
6.Colpocleisis (Le Fort Operation)

73. 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.

74. Sacrospinous Ligament Suspension
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

75. Paravaginal defects -Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop)

76. Burch Urethroplexy - Supporting the vagina (pubocervical fascia) beside the urethra is one of the two best cures for stress or activity related urine leakage