Pelvik Organ Prolapsusunda Tanı ve Tedavi - www.jinekolojivegebelik.com

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Pelvik Organ Prolapsusunda Tanı ve Tedavi - www.jinekolojivegebelik.com

Pelvik Organ Prolapsusunda Tanı ve Tedavi - www.jinekolojivegebelik.com

  1. 1. Evaluation & Management of Genital Prolapse Peter K. Sand, M.D. Professor, Department of Obstetrics & Gynecology Director, Division of Urogynecology Evanston Northwestern Healthcare Northwestern University, Feinberg School of Medicine
  2. 2. Outline <ul><li>Normal uterine and vaginal support </li></ul><ul><li>Pathophysiology of pelvic organ prolapse </li></ul><ul><li>Epidemiology </li></ul><ul><li>Evaluation </li></ul><ul><ul><li>Clinical </li></ul></ul><ul><ul><li>Radiographic </li></ul></ul><ul><ul><li>Urodynamic </li></ul></ul><ul><li>Staging </li></ul><ul><li>Treatment </li></ul>
  3. 3. Normal Uterine Support <ul><li>Ligaments: </li></ul><ul><ul><li>Uterosacral </li></ul></ul><ul><ul><li>Broad </li></ul></ul><ul><ul><li>Cardinal </li></ul></ul><ul><ul><li>Round </li></ul></ul><ul><ul><li>Infundibulopelvic </li></ul></ul><ul><li>Endopelvic Connective Tissue </li></ul><ul><ul><li>Pubocervical “Fascia” </li></ul></ul>
  4. 4. Normal Uterine Support Uterosacral ligaments Cardinal ligaments Uterosacral Ligament
  5. 5. Normal Vaginal Support <ul><li>Three Levels of Support: </li></ul><ul><li>(DeLancey) </li></ul><ul><li>Level I (upper level): </li></ul><ul><ul><li>Cardinal/Uterosacral ligaments </li></ul></ul><ul><li>Level II (middle level): </li></ul><ul><ul><li>Pubocervical fascia anteriorly </li></ul></ul><ul><ul><li>Rectovaginal fascia posteriorly </li></ul></ul><ul><ul><li>Levator ani muscles (through the arcus tendineus fasciae pelvis) </li></ul></ul><ul><li>Level III (lower level): </li></ul><ul><ul><li>Perineum </li></ul></ul><ul><ul><li>Urogenital Diaphragm </li></ul></ul>
  6. 7. Pelvic Floor Structures
  7. 8. Pathophysiology of Genital Prolapse <ul><li>Neuromuscular Dysfunction </li></ul><ul><ul><li>Delayed & Weakened Levator Contraction </li></ul></ul><ul><li>Uterus: </li></ul><ul><ul><li>Weakness of the ligaments and Endopelvic Connective Tissue holding the uterus </li></ul></ul><ul><li>Vagina: </li></ul><ul><ul><li>Detachment from the Pelvic Sidewall (Paravaginal defects) </li></ul></ul><ul><ul><li>Weakness/Tears of the Endopelvic Connective Tissue (Central defects) </li></ul></ul>
  8. 9. Vaginal Prolapse: Paravaginal Defects Normal vaginal attachment to the pelvic walls Detachment of vagina from pelvic walls
  9. 10. Pelvic Organ Prolapse Epidemiology <ul><li>Common Problem in Women </li></ul><ul><ul><li>30%-40% above 40 yrs </li></ul></ul><ul><li>11% Lifetime Risk for Surgery </li></ul><ul><ul><li>Of these, 29% require repeat surgery </li></ul></ul><ul><li>5-7% Develop Post-Hysterectomy Vault Prolapse </li></ul>
  10. 11. Risk Factors <ul><li>Aging </li></ul><ul><li>Urinary and Anal Incontinence </li></ul><ul><li>Parity (Vaginal birth) </li></ul><ul><li>Occupational/recreational </li></ul><ul><li>Increased intraabdominal pressure </li></ul><ul><ul><li>Chronic cough </li></ul></ul><ul><ul><li>Pelvic/abdominal mass </li></ul></ul><ul><ul><li>Ascites </li></ul></ul><ul><li>Genetic predisposition </li></ul>
  11. 12. Age and Pelvic Organ Prolapse
  12. 13. Vaginal Birth and Pelvic Organ Prolapse <ul><li>Risk factors associated with vaginal birth </li></ul><ul><li>High birth weight </li></ul><ul><li>Instrumental delivery </li></ul><ul><li>Prolonged 2 nd stage </li></ul><ul><li>Multiparity </li></ul>
  13. 14. Vaginal Birth and Pelvic Organ Prolapse
  14. 15. Vaginal birth and pelvic floor injury
  15. 16. Parity and Pelvic Organ Prolapse
  16. 17. Uterine Prolapse
  17. 18. Anterior Vaginal Wall Prolapse (Cystocele) Cystocele
  18. 19. Posterior Vaginal Wall Prolapse (Rectocele) Rectocele
  19. 20. Small Bowel Herniation (Enterocele)
  20. 21. Pelvic Organ Prolapse - Symptoms <ul><li>Lump </li></ul><ul><ul><li>Discomfort </li></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Irritation/abrasion/ulcers </li></ul></ul><ul><li>Urinary symptoms </li></ul><ul><ul><li>Retention </li></ul></ul><ul><ul><li>Detrusor overactivity </li></ul></ul><ul><ul><li>Ureteral obstruction </li></ul></ul><ul><li>GI symptoms </li></ul><ul><ul><li>Constipation </li></ul></ul><ul><ul><li>Anal Incontinence </li></ul></ul>
  21. 23. History <ul><li>Medical history (chronic cough) </li></ul><ul><li>Obstetric history </li></ul><ul><li>Occupation/recreation (heavy weight lifting) </li></ul><ul><li>Previous treatments </li></ul><ul><ul><li>Pessaries </li></ul></ul><ul><ul><li>Surgeries </li></ul></ul><ul><li>Incontinence history </li></ul><ul><ul><li>Stress symptoms </li></ul></ul><ul><ul><li>Urge symptoms </li></ul></ul>
  22. 24. Rectovaginal Exam <ul><li>Each Compartment Should be Examined </li></ul><ul><li>Separately: </li></ul><ul><li>Anterior vaginal wall </li></ul><ul><li>Posterior vaginal wall </li></ul><ul><li>Uterus </li></ul><ul><li>Vaginal apex </li></ul><ul><li>Perineum </li></ul>
  23. 25. Anterior Vaginal Wall Central Cystocele Paravaginal Defect
  24. 26. Posterior Vaginal Wall Rectocele Enterocele
  25. 27. Vaginal Apex
  26. 28. Perineum
  27. 29. Uterine Prolapse
  28. 30. Cystocele (Central)
  29. 31. Cystocele (Paravaginal)
  30. 32. Enterocele
  31. 33. Vaginal Vault Prolapse
  32. 34. Rectocele + Enterocele Rectocele Enterocele
  33. 36. Anatomic Outcome <ul><li> Site Specific Post. Colp. P </li></ul><ul><li> (n = 124) (n=183) </li></ul><ul><li> </li></ul><ul><li>Rectocele recurrence </li></ul><ul><li>2 nd degree 41 (33%) 26 (14%) 0.001* </li></ul><ul><li>≥ 3 rd degree 14 (11%) 7 (4%) 0.02* </li></ul><ul><li>Mean Bp Point (cm) -2.2 ± 0.3 -2.7 ± 0.4 0.001* </li></ul>
  34. 37. Functional Outcome <ul><li>. </li></ul><ul><li> Site-Specific Post. Colp. P </li></ul><ul><li> (n = 124) (n=183) </li></ul><ul><li> . </li></ul><ul><li>Symptomatic 14 (11) 7 (4) 0.02* </li></ul><ul><li>bulge </li></ul><ul><li>Dyspareunia 24 (19) 27 (15) 0.51 </li></ul><ul><li>Constipation 46 (37) 62 (37) 0.56 </li></ul><ul><li>Fecal Incont. 24 (19) 28 (15) 0.49 </li></ul>
  35. 38. Staging Systems <ul><li>Baden Walker Halfway system </li></ul><ul><ul><li>1 st degree: prolapse up to the midvaginal plane </li></ul></ul><ul><ul><li>2 nd degree: prolapse beyond the midvaginal plane, up to the hymenal ring </li></ul></ul><ul><ul><li>3 rd degree: prolapse beyond the hymenal ring and up to halfway outside of the vagina </li></ul></ul><ul><ul><li>4 th degree: prolapse of more than halfway outside of the vagina </li></ul></ul>
  36. 39. Pelvic Organ Prolapse Quantification (POP-Q) System
  37. 40. Vaginal Dimensions
  38. 41. Perineal Dimensions
  39. 43. Cystography - Cystocele
  40. 44. MRI: Cystocele
  41. 45. MRI: Uterine Prolapse
  42. 46. Summary <ul><li>Uterovaginal prolapse is a common problem </li></ul><ul><li>Pathophysiology: </li></ul><ul><ul><li>Detachment from pelvic walls </li></ul></ul><ul><ul><li>Fascial defects (pubocervical, rectovaginal) </li></ul></ul><ul><ul><li>Failure of ligament support (uterus, vaginal apex) </li></ul></ul><ul><li>Risk factors: </li></ul><ul><ul><li>Aging </li></ul></ul><ul><ul><li>Parity </li></ul></ul><ul><ul><li>Increased Intraabdominal Pressure </li></ul></ul><ul><ul><li>Genetic Predisposition </li></ul></ul><ul><li>Evaluation: </li></ul><ul><ul><li>History </li></ul></ul><ul><ul><li>Pelvic exam (compartment specific): Staging systems </li></ul></ul><ul><ul><li>Additional tests: Cystogram, MRI, Ultrasound </li></ul></ul>
  43. 47. Treatment of Pelvic Organ Prolapse <ul><li>Conservative </li></ul><ul><ul><li>Vaginal Pessaries </li></ul></ul><ul><ul><li>Intravaginal Devices </li></ul></ul><ul><li>Surgical </li></ul>
  44. 48. Vaginal Pessaries <ul><li>Rubber/silicone devices </li></ul><ul><li>Provide mechanical support to the vaginal walls </li></ul><ul><li>Patient is fitted with the appropriate type/size </li></ul><ul><li>Optimally, patient should handle the pessary on her own </li></ul><ul><ul><li>Frequent removal and cleaning (q 1-3 days) </li></ul></ul><ul><ul><li>Topical estrogen cream </li></ul></ul>
  45. 49. Pessary <ul><li>Advantages </li></ul><ul><ul><li>Non invasive (non surgical) </li></ul></ul><ul><ul><li>Appropriate for: </li></ul></ul><ul><ul><ul><li>Elderly patients </li></ul></ul></ul><ul><ul><ul><li>Patients at high operative/anesthetic risk </li></ul></ul></ul><ul><ul><li>May also treat incontinence (continence pessaries) </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Require constant handling (removal/cleaning/replacement) </li></ul></ul><ul><ul><li>Risk for vaginal abrasion/ulceration/fistula formation >> mandates routine pelvic exams (q 8-12 weeks) and topical estrogen cream </li></ul></ul>
  46. 50. Vaginal Pessaries <ul><li>Various types of pessaries: (A) Ring, (B) Shaatz, (C) Gellhorn, (D) Gellhorn, (E) Ring with support, (F) Gellhorn, (G) Risser, (H) Smith, (I) Tandem cube, (J) Cube, (K) Hodge with knob, (L) Hodge, (M) Gehrung, (N) Incontinence dish with support, (O) Donut, (P) Incontinence ring, (Q) Incontinence dish, (R) Hodge with support, (S) Inflatoball (latex). </li></ul>
  47. 51. Ring Pessary Ring With Support
  48. 52. Ring Pessary Placement
  49. 53. Ring/Ring With Support Pessary <ul><li>Usually the first choice </li></ul><ul><li>Easy to manipulate </li></ul><ul><li>Easy patient handling </li></ul><ul><li>Require adequate levator and perineal support </li></ul>
  50. 54. Gellhorn Pessary
  51. 55. Gellhorn Pessary <ul><li>Usually second line </li></ul><ul><li>Efficient in patients with poor perineal support but good levator ani tone </li></ul><ul><li>Excellent for Apical Prolapse </li></ul><ul><li>More difficult to manipulate </li></ul><ul><li>More difficult patient handling </li></ul>
  52. 56. Cube Pessary
  53. 57. Cube Pessary <ul><li>Usually third line </li></ul><ul><li>Attaches to the vagina through vacuum </li></ul><ul><li>Does not require perineal or levator support </li></ul><ul><li>Excellent for Gaping Introitus </li></ul><ul><li>Higher risk for vaginal ulceration/fistula formation </li></ul>
  54. 58. Donut Pessaries
  55. 59. Inflatoball Pessary
  56. 60. Continence Pessaries
  57. 61. Colpexin ™ Sphere <ul><li>New Intravaginal Device (IVD) </li></ul><ul><li>Available in 5 sizes: 44, 42, 39, 36, & 32 mm </li></ul><ul><li>Allows for prolapse elevation while uniquely facilitating the performance of concomitant PFM exercises </li></ul>
  58. 62. Cystocele With and Without Colpexin TM Sphere
  59. 63. Summary <ul><li>77% (20/26) of women had improvement of straining Q-tip angles </li></ul><ul><li>75% (15/20) of women reported improvement in their continence status </li></ul><ul><li>Significant improvement noted in 4/6 parameters of the UDI-6 </li></ul><ul><li>No deterioration found on IIQ-7 subscales </li></ul><ul><li>Majority of subjects reported device was beneficial, easy to use, and well tolerated </li></ul>
  60. 64. Colpexin Sphere: Effect on Pelvic Floor Muscles <ul><li>81.5% (22/27) of subjects showed improvement in at least 1 vaginal segment at 16 weeks </li></ul><ul><li>63% (17/27) of subjects showed increased muscle function on digital examination </li></ul><ul><li>Statistically significant improvement ( P = 0.029) in pelvic floor muscle contraction strength compared to baseline (Colpexin Pull Test) </li></ul><ul><ul><li>1.84 + 1.04 lb (baseline) vs 2.14 + 1.26 lb (16 weeks) </li></ul></ul><ul><li>No significant improvement observed in resting pelvic floor tone at 16 weeks compared to baseline </li></ul>Lukban JC et al. Int Urogynecol J. Epub; November 19, 2005.
  61. 65. Colpexin Sphere: Effect on Colpexin Pull Test Lukban JC et al. Int Urogynecol J. Epub; November 19, 2005. +0.30 ( P = 0.029) +0.12 ( P = 0.23)
  62. 66. Conclusions <ul><li>Colpexin Sphere allows for active exercise of the levator ani musculature </li></ul><ul><li>Colpexin Sphere subjectively improves continence status and urethral hypermobility, without any change in voiding function </li></ul><ul><li>Colpexin Sphere in conjunction with PFME may provide a new management option for women with genital prolapse and urinary symptoms </li></ul>

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