The document discusses pelvic organ prolapse from an anatomical perspective. It describes the layers of fascia and muscles that provide support to the pelvic organs. Damage to the fascia can result in cystocele, rectocele, or uterine prolapse as the pelvic organs lose support and protrude into the vaginal canal. The document outlines the components of the pelvic floor according to the Integral Theory and how dysfunction, such as stress urinary incontinence, can arise from weakness or damage in specific areas. Assessment tools like the Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire are also mentioned for evaluating patients.

1. Pelvic Organ Prolapse
Anatomical Perspectives
TEVFİK YOLDEMİR MD. BSc. MA. PhD.
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profdrdryoldemir

2. Stress Incontinence symptoms
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

3. Urge symptoms
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

4. The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

5. Closure at Rest and Effort
• Closure at rest results from inherent
elasticity and slow-twitch muscle
contraction.
• The bladder neck area of vagina must be
elastic to allow the anterior and posterior
muscle forces to function separately.
• This is called the ‘ zone of critical elasticity’
(ZCE).
• The ZCE extends between midurethra and
bladder base, and is stretched during
effort and micturition.
• During effort, the fast-twitch muscle fibres
of all three muscles are recruited to close
the system further.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

6. Normal Micturition – A Controlled Temporary
Unbalancing of the Closure System
Micturition – a controlled temporary
unbalancing of the closure system
Stress incontinence – lax PUL fails to anchor the
urethra and weakens the force of PCM contraction,
so LP and LMA pull open the urethra during effort.

7. The components of urethral closure.
Perspective: vagina at midurethra
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

8. The Role of Connective Tissue Damage in the
Causation of Abnormal Bladder Emptying
• Abnormal bladder emptying - inability to activate
the external opening mechanism. A lax USL may
inactivate the LMA contraction required to stretch
open the outflow tract. A cystocoele may inactivate
LP contraction.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

9. The three zone structure of the pelvic floor
according to the Integral Theory
The dotted lines represent the pelvic brim.
PCM = anterior portion of pubococcygeus muscle;
LP = levator plate;
LMA = longitudinal muscle of the anus;
PRM = puborectalis muscle;
EAS = external anal sphincter.
‘ZCE’ = ‘Tethered vagina’ - excessive tightness caused by
previous surgery.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

10. The Pictorial Diagnostic Algorithm
The Female Pelvic Floor. Function,
Dysfunction and Management According
to the Integral Theory. Second Edition

11. The area of the symptom rectangles
indicates the estimated frequency
of symptom causation occurring in
each zone
The Female Pelvic Floor. Function,
Dysfunction and Management According
to the Integral Theory. Second Edition

12. Clinical
Examination
Sheet
The Female Pelvic Floor. Function,
Dysfunction and Management
According to the Integral Theory.
Second Edition

13. The ‘Simulated
Operations’
Validation Table
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

14. The pubocervical fascia (PCF)
The fibromuscular layer of the vaginal wall (PCF) is
attached laterally (L) to arcus tendineus fascia pelvis (ATFP)
and posteriorly (P) to the cervical ring by collagenous
tissue (yellow).
Dislocation of ‘L’ may cause a paravaginal defect and of ‘P’,
a high cystocoele.
Muscle contractions (arrows) stretch the pubocervical
fascia (PCF) to support the bladder base
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

15. Potential sites of damage
1. Midline defect (central part of PCF);
2. 2. Paravaginal defect (collagenous ‘glue’ and ATFP);
3. High cystocoele (attachment of PCF to cervical ring,
‘transverse defect’.
Schematic 2D view from below.
Perspective: looking into the anterior wall of the vagina.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

16. ‘lumps’ in the vagina
The structural differences between midline (cystocoele), lateral
(paravaginal) and cervical ring (high cystocoele) defects.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

17. Damage to fascia may cause a central
or cervical ring defect
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

18. Thinning of the pubocervical fascia
(PCF) causes prolapse of the bladder base
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

19. Co-existence of central and lateral defects
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

20. Cervical ring extension
The cervical ring (r) extends laterally to the cardinal ligament
(CL). A break in the cervical ring may cause prolapse of the
puboservical fascia (PCF) or uterine
prolapse due to lateral displacement of CL
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

21. The fibromuscular supports of the vagina
Note the dense fibrous tissue at the distal 2-3 cm of the
vagina, urethra and anus. Superior to this area there is
less collagen, and more smooth muscle and elastin
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

22. Ligamentous support of the cervix.
F = force of gravity;
CL = cardinal ligament;
USL = uterosacral ligament.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

23. Interconnectedness of pelvic fascia
All fascial and ligamentous structures
insert directly or indirectly
into the cervical ring
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

24. Rectovaginal fascia (RVF) extension (fascia of
Denonvilliers) to levator plate (LP)
PB= perineal body;
CX = cervix;
P of D = Pouch of Douglas; UT =
uterus;
V = vagina;
R = rectum;
EAS = external anal sphincter
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

25. Prolapsed Vagina
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

26. Fascial support for the vaginal vault in a normal
patient
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

27. Uterine prolapse may be caused by laxity of CL, USL
and adjoining fascia.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

28. The lateral displacement of rectovaginal fascia (RVF)
and perineal body (PB)
The lateral displacement of rectovaginal fascia (RVF) and
perineal body (PB) allows protrusion of a rectocoele into the
vaginal cavity.
Damage to apical fascia may cause enterocoele.
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

29. Superolateral displacement of rectocoele
Rectocoele may eliminate the rectovaginal
space (RVS) and displace laterally causing
adhesions between vagina and rectum
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

30. A high rectocoele (RVF fascial defect)
OR enterocoele (apical defect)
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

31. Pelvic Floor Distress Inventory Questionanaire SF20

32. Pelvic Floor Impact Questionnaire PFIQ-7

35. Take away notes -1

36. Take away notes -2
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

37. Take away notes -3
The Female Pelvic Floor. Function, Dysfunction and Management
According to the Integral Theory. Second Edition

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