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Il pavimento pelvico come unità morfo funzionale meschia

Il pavimento pelvico come unità morfo funzionale meschia



GLUP_Gardone_Il pavimento pelvico come unità morfo-funzionale – M. Meschia

GLUP_Gardone_Il pavimento pelvico come unità morfo-funzionale – M. Meschia



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    Il pavimento pelvico come unità morfo funzionale meschia Il pavimento pelvico come unità morfo funzionale meschia Presentation Transcript

    • Il pavimento pelvico come unità morfo-funzionale Michele Meschia U.O. Ostetricia e Ginecologia Magenta In God we trust All others must use data!!
    • The Pelvic Floor
      • Support pelvic and abdominal organs during stress of increased abdominal pressure
      • Contribute to maintenance of continence
      • Allow for opening of the pelvic floor to accommodate excretory functions and parturition
      A muscolo-tendinous complex
    • Pelvic organs support
      • Pelvic side walls
      • Endopelvic fascia
      • Levator ani muscles
      • Perineal membrane
    • The Pelvic Floor Attachments
      • Pelvic floor support depends on its connection to the pelvic bones
      • An evolutionary solution for support of visceral organs
      • Pelvic floor muscles oppose gravity and increased abdominal pressures
    • La fascia endopelvica
    • Le connessioni muscolo-fasciali
    • I muscoli del pavimento pelvico
    • The Urogenital Diaphragm
    • Pelvic floor actions
      • Constriction – levator ani muscles constrict lumen of vagina
      • Suspension –cardinal ligaments & uterosacral ligaments, pubocervical fascia act to suspend cervix and vagina
      • Flap valve mechanism- anterior traction of levator ani m. and suspension of vagina in posterior pelvis
    • A = rest B = increases abdominal pressure Relationship between pelvic viscera and levator ani muscle
    • Muscular Component of Pubococcygeus muscle
      • Large diameter slow twitch type I fibers predominant- provide static visceral support
      • Fast twitch type II fibers- assists in active closure of pelvic visceral organs
      • 40% of women have lost function or coordination of this muscle
    • Il muscolo pubo-rettale
    • Puborectalis
      • U-shaped, medial most located levator ani muscle
      • Pulls the anorectal junction anteriorly, forming the anorectal angle
      • Pelvic floor muscle vs. sphincter muscle?
    • Il supporto pelvico
    • Pelvic floor dysfunction
      • Pelvic organ prolapse
      • Stress urinary incontinence
      • Anal incontinence
      Clinical signs
    • Major Levator Ani Defects : Case-Control Study of Pelvic Organ Prolapse Prolapse N=151 Normal N=134 Levator Ani Defects OR 7.3 DeLancey, et al. 2002, 2007
    • Effect of Levator ani relaxation
    • Levels of support DeLancey 1988 Endopelvic fascia
    • Defects in the apical support
      • Include
      • The loss of cardinal/uterosacral support with resultant uterine or vaginal cuff descent
      • The detachment of the fibromuscular vagina from the anterior rectum with resultant enterocele
    • Defects in the anterior compartment (level II)
      • Tears or attenuation of the vaginal fibromuscular wall
      • Detachment from the pelvic side walls, the cervix or cardinal ligament complex, or from the pubis
      • Specific sites of fibromuscular tears are frequently difficult to recognize (lateral,apex, or central)
    • Defects in the posterior compartment (level II)
      • Discrete tears in the recto-vaginal fascia at its lateral, apical and perineal attachments and centrally within the fascia itself
    • Defects in the anterior compartment (level III) The vaginal hammock
    • Anatomical relationship between anterior vaginal and apical supports Cervix Arcus Tendineus -Fascia Pelvis -Levator Ani Apical Supports Vaginal Wall
    • DeLancey JO. Am J Obstet Gynecol. 2002;187:93-8 Association between cystocele and apical prolapse
    • Bladder Descent Cervical (Apical) Descent Bladder Prolapse versus Uterine Prolapse Summers et al, Obstet Gynecol 2006 60% of bladder descent explained by apical descent
      • Cohort study of 325 patients
      • Strong correlation between anterior (Ba point)
      • and apical (C point) support (Spearman’s p=0.835 )
      • Mild correlation between anterior (Ba point)
      • and posterior (Bp point) support (Spearman’s p=0.556)
      Rooney K & Brubaker L Am J Obstet Gynecol. 2006;195:1837-40 Anterior vaginal wall prolapse is highly correlated with apical prolapse If cystocele ≥ +2cm Apical defect ≥ -2cm in 80% cases
    • CL AVW Rectum ATFP US LA 3 D model
    • Findings of Simulations
    • Conclusions
      • Apical much more than paravaginal failure influence cystocele size
      • Combined defects (connective and muscular) cause larger cystocele
    • Pelvic floor defects
      • Childbirth
      • Connective tissue
      • Genetic factors
      • Pelvic neuropathies
      • Congenital factors
      • Other factors
      Contributing factors
    • Childbirth
    • Connective tissue
      •  mumber of fibroblast in women undergoing surgery for POP (Makinen,1986)
      • 30% decrease of collagen content in women with SUI (Falconer,1994)
      • Reduction in collagen quantity and changes in organization of collagen fibers was found in women with SUI & POP (Liapis,2004)
      •  prevalence of POP in women with Ehlers-Danlos syndrome (Carley,2000) or joint hypermobility (Norton,1995)
      • Recent evidence suggests that genital prolapse has a certain genetic component.
      • The importance of genetics is suggested by the high prevalence of POP in patients affected by disorders of type I/III collagen such as the Ehlers-Danlos and the Marfan syndromes.
      • It has been demonstrated that some polymorphisms in genes involved in collagen metabolism may influence the quantity and quality of body collagen.
    • Genetics familiar transmission Pifarotti, IUGA 2008 Controls 90 Cases 124 P OR (CI) Mothers with POP (n/%) 12 (13%) 31 (25%) 0.039 2.2 (1.0-4.5) Sisters with POP (n/%) 3 (3%) 21 (17%) 0.002 5.9(1.7-20.5) All relatives with POP (n/%) 14 (16%) 43 (35%) 0.002 2.9 (1.5-5.7)
    • Pelvic neuropathies
      • Descending perineum syndrome
      • Partial denervation with advancing age
      Congenital factors
      • Spina bifida
      • Muscular dystrophy
      • Myelodysplasia
      • Bladder exstrophy
    • Factors contributing to POP
      • Chronic respiratory conditions (Bump,1992)
      • Obesity (Bump,1992)
      • Occupational and recreational activities (Jorgensen,1994)
    • Conclusion Pelvic floor dysfunction, is a multifactorial and extremely common disorder in which genetic, endocrine and environmental factors may predispose to different clinical conditions including urinary incontinence, anal incontinence and pelvic organ prolapse.