This document discusses pelvic floor dysfunction and pelvic organ prolapse. It begins by describing normal pelvic anatomy including ligaments, tendons, fascia and muscles that provide support. Three levels of vaginal support are identified. Pelvic organ prolapse is then defined as the protrusion of pelvic organs into or outside the vaginal canal. Etiology and risk factors for pelvic organ prolapse are outlined. Assessment, symptoms, and conservative and surgical management options are reviewed for anterior, posterior, and apical prolapse. Surgical procedures including anterior and posterior colporrhaphy, paravaginal repair, and abdominal, laparoscopic and vaginal vault suspension techniques are described.

1. Pelvic Floor Dysfunction
Khalid Sait FRCSC
Professor
( Gynecological Oncology)
Faculty of Medicine
King Abdulaziz University

2. Normal Pelvic Anatomy

4. Pelvic anatomy
n Ligament: connect two bone
n Tendon: connect bone to muscle
n Mesentery: fold of peritoneum contain
vessels, nerve and lymphatic
n Fascia: connective tissue surround two
muscles
n Pelvic bone: fixed landmark

5. Pelvic floor Support
n Passive Support:
Pelvic Bone
Endo pelvic fascia
n Active Support:
Pelvic muscle

8. Endopelvic fascia
n Uterosacral ligament
n Pubocervical fascia
n Rectovaginal fascia
n Urogenital diaphragm

9. Pubocervical fascia
n Extend between the two
isch spine at level of
cervical ring and laterally
inserted at the white line
which is the arcus
tendenus

10. Rectovaginal fascia
n Extend between the two
isch spine at level of
cervical ring and laterally
inserted at the white line
which is the arcus
tendenus

11. Uterosacral ligament
n From S1and S4 to the
back of cervix at level
of cervical ring

12. White Line
arcus tendenus
n Is condensation of fascia
at the lavator ani muscaly
that extend from isch
spine to the back of
sympesis pubis at the
level of pubic tubercal
n Its detachment cause
paravaginal defect

13. Urogenital diaphragm
n Condensation of the
fascia of:
n Ischiocavernosus
n Bulbocavernosus
n Deep transverse
pernieal muscle

14. Pelvic floor Muscle
n Levator ani
muscle
1- Pubovisceral muscle
Hammock muscle
( u shape muscle) sling
like arrangement
Include puboccygeous
and puborectalis
2- Iliococcygeous
muscle
Triangle muscle
n Coccygeus

18. Pelvic support
n Not important in pelvic support:
Urogenital diaphragm
Superficial perineal muscle
Bulbocavernosus muscle
Round ligament
Broad ligament

19. DeLancey levels of vaginal support
n Level I suspension:
uterus and vagina vault
utrerosacral
n loss of this support result in vaginal
and uterine prolapse
n Level II: attachment
bladder and rectum
pubocervical and rectovaginal fascia)
(loss of this support result in cystocele
and rectocele
n Level III Fusion
diffuse to perineal body

20. Pelvic Organ Prolapse (POP)
Protrusion of the pelvic organs into, or
out of, the vaginal canal

22. Pelvic Organ Prolapse (POP)
n Central/Apical: Uterine /Vault Prolapse
n Anterior: Cystocele / Urethrocele
n Posterior: Rectocele/Enterocele

25. Pubo-cervical fascial defect
Richardson

34. Uterine prolapse
n First degree:
descend below ischial spine not reach
introits
n Second degree :
cervix visible at introits
n Third degree:
procidentia
the whole uterus is out side the introits

35. Tetralogy of “Fall-out”

36. Assessment
Bump 1998

38. Epidemiology of POP
n Life time risk of developing POP: 11.1%
n 13% of hysterectomies in all ages
n Most common reason for hysterectomy in
women > 50
Olsen 1997, Allard 1991

39. Epidemiology of POP
Post-hysterectomy vault prolapse (PHVP):
n 11.6%: hysterectomy for pelvic prolapse
n 1.8%: hysterectomy for other benign
disease
Marchionni 1999

40. Etiology & Contributing Factors

41. Etiology & Contributing Factors
n Childbirth
n Congenital weakness of fibro muscular support
( white > black)
n Aging / Estrogen deficiency
n Increased intra-abdominal pressure
n Repetitive pelvic pressure (Lifting or Coughing)
n Neurological disease (eg. Spina bifida)
n Connective tissue ( eg. Ehlers-Danlos syndrome)

42. Damage to pelvic support
n Neuromuscular damage
n Connective tissue damage

43. Symptoms and Signs
n A symptomatic
n Heaviness / full feeling in the pelvis
n Some thing coming down
n Lump in vagina
n Urinary symptoms( up to anuria)
n Difficult in defection
n Difficulty in walking
n Vaginal discharge and bleeding
n Dysparonia ( the muscle are slack)
n Vagina flatus ( whoopee cushion)

44. Management of POP

46. Management
n Treat underlying cause
n Conservative: Kegal /Passaries
n Surgical

47. Kegal Exercise
n Find the right muscle:
Lavator ani muscle
(Hammock muscle/Triangle muscle)
1- stop the flow of urine
2- stop passing gas
3- squeezes your finger in vagina
n How frequent you do
n Repeat but don't overdo it

50. 1. Obliterative (colpocleisis)
2. Reconstructive
Ø Abdominal/laparoscopic:
o Para-vaginal repair
Ø Vaginal:
o Anterior colporrhaphy
o Graft interposition
o Para-vaginal repair
Ant. POP: Surgical management

51. Anterior colporrhaphy: Procedure

52. Paravaginal repair: Procedure

53. 1. Obliterative (colpocleisis)
2. Reconstructive (vaginal):
n Posterior colporrhaphy
(+/- perineorrhaphy)
n Graft interposition
n Site-specific repair
Post POP: Surgical management

56. 1. Obliterative (colpocleisis)
2. Reconstructive
Ø Abdominal/laparoscopic
n Colpo-sacropexy
n Uterosacral suspension
Ø Vaginal:
o Sacro-spinous vault suspension
o Iliococcygeus suspension
o Mayo/McCall culdoplasty
Apical POP: Surgical Management

57. Principal of repair

59. CULDOPLASTY

61. Lefort