The document provides an overview of pelvic floor anatomy and pelvic organ prolapse. It discusses the structures that support the pelvic organs, including the levator ani muscles, endopelvic fascia, and pelvic ligaments. Common types of pelvic organ prolapse are described such as cystocele, rectocele, and uterine prolapse. The document outlines how these defects are evaluated based on their location and stage. Treatment options are also summarized, including pelvic floor muscle exercises, pessaries, and various surgical repair techniques aimed at reconstructing the pelvic floor.

1. Pelvic Floor Anatomy and
Pelvic Organ Prolapse
Tevfik Yoldemir, MD BSc MA PhD
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2. Abdomino-pelvic cavity
• Respiratory diaphragm
• Vertebral column
• Abdominal muscles
• Pelvic floor
• Intra-abdominal pressure
• Visceral weight & Gravity in erect body
• Maintain visceral function

3. Genital Support
• Pelvic floor- Pelvic visceral attachment to
pelvic walls through endopelvic fascia
• Levator ani muscles- a pelvic diaphragm
with a cleft in anterior portion
• Urogenital diaphragm connects perineal
body to ischiopubic rami
• Bulocavernous, ischiocavernous,
sup.transverse perineal, anal sphincter m.

4. Levator ani muscles
• Pelvic diaphragm composed of levator ani,
coccygeus, obturator internus, and
piriformis muscles
• Levator ani consists of medial
pubococcygeus and lateral iliococcygeus
muscles
• Pelvic diaphragm composed of levator ani,
coccygeus, obturator

5. The Pelvic Diaphragm

6. The Urogenital Diaphragm

7. The Function of Pelvic Floor
• Support pelvic and abdominal organs
during stress of increased abdominal
pressure
• Allow for opening of the pelvic floor to
accommodate excretory functions and
parturition
• Endopelvic fascia and visceral ligaments
contains smooth muscles

8. 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

9. Prevention of Prolapse

10. Attachments of Pelvic Floor
• Tendinous arch of pelvic fascia-
pubocervical fascia arises
• Tendinous arch of levator ani- levator ani
muscles arise
• Pubourethral ligaments
• Pubovesical ligaments

11. Attachments of Pelvic Floor

12. Pelvic Floor Dysfunction
• A variety of fascial and anatomic defects
• Cystocele, rectocele, uterine prolapse,
enterocele, vault prolapse
• Adequate diagnosis and staging of pelvic
floor dysfunction is essential

13. Diagnosis of
Pelvic Floor Dysfunction
• Detailed physical examination
• Pelvic ultrasound
• Fluoroscopy of rectum & bladder
• Magnetic resonance imaging (MRI)

14. Normal Anatomy

15. The axes of pelvic support
• Three support axes
• Upper vertical axis (cardinal-uterosacral
ligament complex)
• Horizontal axis leads to lateral and
paravaginal supports
– Two platforms pubocervical fascia and
rectovaginal septum
• Lower vertical axis supports the lower third
of the vagina, urethra and anal canal

16. 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

17. Normal anterior anatomy

18. Anterior compartment defects
• Urethral hypermobility
– Distal 4 cm of anterior vaginal wall
– Cotton swab test
– If describes an arc greater than 30 degrees
from horizontal with valsalva
– Results in genuine stress incontinence
• Cystocele

19. Cystocele
• Main support of urethra and bladder is the pubo-vesical-
cervical fascia
• Essentially a hernia in the anterior vaginal wall due to
weakness or defect in this fascia
– Midline weakness allows bladder to descend causing central
cystocele
– Tearing of endopelvic fascial connections from lateral sulci to
arcus tendinii causes lateral or displacement cystocele
– Detachment of pubocervical fascia from pericervical ring causes
a transverse or apical cystocele
• Symptoms include pelvic pressure and bulge or mass in
the vagina

20. Cystocele
• Classified as Grade I, II, or III
• Grade III is prolapse outside the introitus
• Surgical repair is treatment of choice
– Anterior Colporrhaphy
– Paravaginal repair
– Colpocleisis
• Vaginal pessary

21. Evaluation of a cystourethrocele

22. Anterior defect

23. Cystocele

24. Bladder neck descent

25. Bladder neck descent

26. Cystocele
• Most Gr 1 and 2 cystoceles are
asymptomatic
• High grade cystoceles are associated with
vaginal buldging, vaginal pressure,
dyspareunia, UTI, obstructive voiding,
urinary retention
• A high grade cystocele may mask urethral
hypermobility and stress incontinence

27. Physical examination of
Cystocele

28. Enterocele
• Simple enterocele
• Complex enterocele- associated with vault
prolapse and anterior or posterior vaginal
prolapse
• Cause vaginal pressure, dyspareunia, low
back pain, constipation, symptoms of
bowel obstruction

29. Physical examination of
Vaginal Cuff Prolapse

30. Posterior compartment defects
• Rectocele
• Perineal deficiency
– Bulbocavernous and superficial transverse
muscle heads retracted
• Perineal descent
– Sagging and funneling of the levator ani
around the perineum such that anus becomes
most dependent
– Difficulty with defecation

31. Rectocele
• Chiefly a hernia in the posterior vaginal
wall secondary to weakness or defect in
the rectovaginal septum or fascia of
Denonvilliers
• Symptoms include difficulty evacuating
stool, a vaginal mass, and fullness
sensation
• Rectovaginal exam confirms diagnosis

32. Rectocele
• Damage generally due to excessive
pushing in childbirth or chronic
constipation
• Surgical treatment if symptomatic
– Posterior Colporrhaphy
– Laxatives and stool softeners
• Temporary relief
• Pessary not helpful

33. Evaluation of a rectocele

34. Rectocele
• Defect of prerectal and pararectal
fascia,and rectovaginal septum
• Present in 80% asymptomatic patients
• Vaginal mass,vaginal pressure,
dyspareunia,constipation

35. Physical examination of
Rectocele

36. Uterine Prolapse
• Laxity of uterosacral ligaments
• May present with vaginal mass,
dyspareunia, urinary retention, back pain
• Grade 4 prolapse is associated with
ureteral obstruction

37. Physical examination of
Uterine Prolapse

38. Complete Uterovaginal
procidentia

39. Bladder descent

40. Apical defect

41. Pelvic Floor Relaxation
• Associated with damage to
pubococcygeus muscle
• The muscle is lax, atrophied, poor tone
• Urinary stress incontinence
• Genital prolapse
• Sexual Problem
• Rectal stasis

42. 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

43. The Structures supporting
Bladder and Urethra
• Arcus tendineus fascia pelvis
• Levator ani (pubococcygeus muscles)
• Pubovesical muscles or ligaments
• Vaginal muscle attachments to fascia and
levator ani

44. Physical examination of Pelvic
Floor Dysfunction
• General examination- cancer screen, stool
OB, urinalysis, physical examination
• Neurological examination- paresthesia of
dermatome, bulbocavernous reflex,
voluntary contraction of anal sphincter
• Pelvic examination- cystocele,
rectocele,uterine prolapse, vault prolapse
• Urinary incontinence by Valsalva
maneuver or coughing

45. Patient position for evaluating
pelvic floor defects

47. Staging of Pelvic Organ
Prolapse
• Stage 0 - no prolapse
• Stage I - the most distal portion is >1cm above
level of hymen
• Stage II - The most distal portion is <1cm
proximal or distal to plane of hymen
• Stage III - The most distal portion is >1cm below
plane of hymen, but < total vaginal length - 2 cm
• Stage IV - complete eversion of total length of
lower genital tract, the distal portion is > TVL-2
cm, i.e. cervix or vaginal cuff

48. Evaluation of
Pelvic Floor Muscle Function
• Assessing patient’s ability to contract and
relax pelvic muscles separately
• Measuring the force of contraction
• Palpation of thickness of pelvic floor
musculatures
• Electromyography
• Pressure recording

49. Measurement of Bladder Base
Descent (The Q-tip Test)

50. Lower Urinary Tract Symptoms
caused by Pelvic Organ Prolapse
• Stress incontinence
• Frequency, urgency, urge incontinence
• Hesitancy, weak stream, incomplete
empty
• Manual reduction of prolapse for voiding
• Positional change to start or complete
voiding

51. Incontinence Assesment

53. Bowel Symptoms caused by
Pelvic Organ Prolapse
• Difficulty with defecation
• Incontinence of flatus
• Incontinence of liquid stool
• Incontinence of solid stool
• Fecal staining of underwear
• Digital manipulation to complete defecation
• Feeling of incomplete evacuation
• Rectal protrusion during or after defecation

54. Sexual symptoms caused by
Pelvic Organ Prolapse
• Vaginal coitus?
• Frequency of vaginal coitus?
• Painful coitus?
• Satisfaction with sexual activity?
• Change in orgasm?
• Incontinence experienced during sexual
activity?

55. Local symptoms caused by
Pelvic Organ Prolapse
• Vaginal pressure or heaviness
• Vaginal or perineal pain
• Sensation or awareness of tissue
protrusion from vagina
• Low back pain
• Abdominal pressure or pain
• Observation or palpation of a mass

56. Principles of reconstructive
pelvic surgery
• Site-specific repair
• Rebuild weakened endopelvic fascia,
repair fascial tears, and reattach prolapsed
tissues to stronger sites
• Goal is a vagina of normal depth, width
and axis
• Denervation or muscle trauma cannot be
corrected surgically

57. Cystocele Repair

58. Cystocele Repair

59. Burch

60. Lateral defects

61. PVR

62. Burch + PDR

63. Colposuspension

68. Rectocele

69. Rectocele

70. Rectocele

71. Pelvic Muscle Exercises

72. Medications

73. Pessaries