PELVIC FLOOR AND

FUNCTIONAL ANATOMY

Assoc. Prof. Gazi YILDIRIM, M.D.

Yeditepe University, Medical Faculty Dept of Ob&Gyn

• 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

Objectives

Functions of Pelvic Floor

1.Supportive functionPelvic viscera

2.Sphincteric functionVagina, Urethra, Rectum

3.Sexual functionProprioseptive 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 Complex(Delancy level I)

Paracervical Ring

Arcus Tendineus Fascia Pelvis ATFP

Pubocervical “fascia”

Rectovaginal “fascia”

Perineal Body

Bulbocavernosis (urethrovaginal sphincter)Superficial Transverse perineusExternal Anal SphincterInternal Anal SphincterPyramidal Fibrous BodyPerineal Membrane

Cleveland Clinic FoundationBurnett Novack’s Gynecology 2004

• Sphincter urethrae externus

• Bulbospongiosus

• Ischiocavernosus

• Transversus perinei profundus

• Transversus perinei superficialis

Lets ‘create’ a woman pelvis…

Bony structures of a pelvis

Perineal muscles

Urethra

Vagina

M. ischiocavernosus

M. bulbospongiosus

M. transversus perinei superficialis

M. sphincter ani externus

Urogenital fascia

Urethra

Vagina

M. transversus perinei profundus

M. transversus perinei superficialis

M. sphincter ani externus

Pelvic floor

ATFP

Add rectum

Rectal connections

Vaginal connections

Urethra

Bladder

Cervix

lig.cardinale

Lig. cardinale

Lig. sacrouterina

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

De Lancey’s 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

1 cm 1cmtvl – 1 cm

Stage I Stage II Stage III Stage IV

Symptomatic Prolapse

Hymen

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 ön duvar prolapsusuAyırıcı tanı

Defekt türüDefekt türü ParavaParavajjinalinal ssentralentral

TanıTanı Rugae varRugae var Rugae Rugae silinmişsilinmiş

Tedavi Tedavi yöntemiyöntemi

Paravajinal Paravajinal kolpopeksikolpopeksi

Anteriör Anteriör kolporafikolporafi

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.

Pessaries

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.Abdominal1.Sacrocolpopexy2.Robotic assisted

laparoscopic sacrocolpopexy

3.Suturing the cuff to the fascia of rectus abdominis muscle (Williams Operation)

• B.Vaginal1.Posterior IVS(Intraginal slingplasty/Infracocygeal sacropexy)

2.Sacrospinous fixation3.Gynecare Prolift4.İliococygeal fixation5.Levator miyoraphy6.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.

Sacrospinous Ligament Suspension • Sacrospinous ligament fixation

entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle

Vaginal Apical Repair

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