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APGO educational topic number 37 pelvic
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floor disorders welcome to another
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episode of the pelvic floor
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I’m your host levator Ani I hope to
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provide important support throughout
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this video pelvic organ prolapse urinary
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incontinence and anal incontinence
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become increasingly common as women age
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these conditions can have a major impact
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on a woman’s daily activities sexual
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function exercise and quality of life
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the lifetime risk up to age 84
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undergoing surgery for prolapse or
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urinary incontinence is 11% and the most
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common indication for hysterectomy for
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women age 55 and greater is prolapse the
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objectives of this video are to describe
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normal pelvic anatomy and pelvic support
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list risk factors for pelvic floor
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disorders describes signs and symptoms
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of pelvic floor disorders differentiate
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the types of urinary incontinence
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discuss the steps in the evaluation of
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pelvic floor disorders describe the
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anatomic changes associated with pelvic
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floor disorders and lastly describe
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non-surgical and surgical management for
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pelvic floor disorders pelvic organ
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prolapse occurs with descent of one or
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more of the pelvic structures this can
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be the anterior wall of the vagina which
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is a sistah seal here is a photograph of
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a pronounced sistah seal the pink tissue
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is the anterior wall of the vagina
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descending below the high metal ring
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descent of the posterior wall of the
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vagina is a rectus seal this photograph
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illustrates a rectus seal a one-sided
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speculum is retracting the anterior wall
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of the vagina and you can appreciate how
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the posterior wall rises up and beyond
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the high metal ring a herniation at the
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top of the vagina that allows the
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peritoneum of the cul-de-sac containing
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small bowel to herniate through is
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called an entry seal it is important to
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note that almost 50% of all Paris women
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or women who’ve had a vaginal delivery
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will have some prolapse by physical exam
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but most are not clinically affected
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physical findings may not correlate with
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specific pelvic symptoms what are some
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of the symptoms that women experience
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with pelvic organ prolapse the symptoms
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can be vague and nondescript
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women may present with vaginal pressure
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or heaviness abdominal or low back pain
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vaginal or perineal pain or discomfort
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or a mass sensation there can also be
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urinary or fecal loss or retention
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some women may experience sexual health
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issues as well as anxiety or fear
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related to this condition
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like many gynecological conditions this
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was an issue that was not openly
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discussed in the past and many women may
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feel discomfort or embarrassment about
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issues down there this photograph of a
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pro so densha which is when the cervix
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descends beyond the vulva illustrates
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how significantly prolapse can sometimes
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silently impact a woman’s quality of
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life yet it’s discussed very little
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outside of the gynecological world we
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now have a special guest for our
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discussion dr. procede enchi has joined
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us to talk about risk factors for pelvic
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organ prolapse
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Thanks levator let’s discuss risk
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factors parody is our first risk factor
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particularly after one or more vaginal
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births are there other risk factors
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other than pregnancy yes genetic
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predisposition menopause advancing age
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prior pelvic surgery connective tissue
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disorders and factors associated with
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elevated intra-abdominal pressure
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notably including obesity and chronic
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constipation with excessive straining
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Thank You dr. Percy densha it’s always
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special to be able to hang out with you
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let’s now move to the anatomy lab for
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discussion of the complex interactions
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involved in pelvic organs support pelvic
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organs support is accomplished by a
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complex interaction of levator Ani
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muscles fashio from the urogenital
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diaphragm and endo pelvic fascia and the
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uterus sacral and Cardinal ligaments we
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are just beginning to understand these
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relationships and how they contribute to
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pelvic organ prolapse let’s take a
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moment to look at a very helpful diagram
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courtesy of dr. John de Lancie this is a
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view of the pelvis from above here is
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the pubic symphysis and the vesicle neck
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from the bladder which has been removed
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in the illustration here is the cervix
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the Cardinal and uterus sacral ligaments
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are now illustrated in red and attached
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the cervix to the pelvic sidewalls these
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ligaments provide the apical support for
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the cervix the vagina is the trapezoid
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shape in blue and is supported laterally
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by a structure called the arcus and
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aeneas fasciae pelvis there is thus both
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apical and vaginal support for the
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cervix as we discussed earlier these
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muscles and support structures can
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become weaker with age or secondary to
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genetic predisposition or a connective
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tissue disorders the mechanism by which
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vaginal birth disrupts these mas
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is still in the process of becoming
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understood we are beginning to
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understand that there are likely breaks
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or tears and specific connective tissues
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during birth that result in identifiable
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and atomic defects and pelvic support
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the evaluation of pelvic organ prolapse
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involves a comprehensive exam that
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defines the severity of the prolapse the
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pelvic organ prolapse quantification
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examination or pop Q measures six
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specific points in the vagina relative
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to the hymen stage zero is defined as no
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prolapse the cervix or vaginal cuff is
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at the top of the vagina in stage one
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the leading part of the prolapse is more
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than one centimeter above the hymen in
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stage two the leading part of the
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prolapse is less than or equal to one
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centimeter above or below the hymen in
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stage three the leading edge is more
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than one centimeter beyond the hymen but
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less than or equal to the total vaginal
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length and lastly stage four is defined
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as complete aversion treatments for
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pelvic organ prolapse depend on how much
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the symptoms are affecting the patient’s
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quality of life if the patient is
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symptomatic then there are surgical and
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non-surgical options pessaries are
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removable rubber plastic or silicone
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devices that can be fitted in most women
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with prolapse pessaries are used by 75%
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of urogynecologist
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as first-line therapy for prolapse they
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can be classified as supportive such as
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this ring pessary that can be used for
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mild prolapse space-occupying pessaries
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such as this Gellhorn and q pessary are
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utilized for higher degree prolapses or
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for presidencia surgical options for
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prolapse often involve a hysterectomy
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here is another cross sectional drawing
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with the uterus bladder and vaginal apex
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it’s not enough simply to remove the
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uterus apical support has to be
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addressed as well vaginally this can be
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performed with a uterus sacral ligament
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suspension or sacral spinous ligament
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suspension these procedures involves
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suspending the vaginal apex to either
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the uterus sacral or say Chris –
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ligament an abdominal sacral cocapec C
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involves using a mesh to suspend the
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vaginal apex to the sacrum a copal
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classist involves the complete
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obliteration of the vaginal lumen and is
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a procedure for women who do not desire
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future vaginal intercourse and who are
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at high risk for complications from
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surgery it is also important to discuss
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an
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ask about urinary incontinence and women
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leakage of urine can affect women social
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clinical and psychological well-being
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less than 1/2 of all incontinent women
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seek medical care even though the
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condition can often be treated let’s
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start with stress incontinence patients
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will describe leakage of urine with
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activities that increase intra-abdominal
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pressure such as coughing jumping
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sneezing or laughing this is the most
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common type of incontinence among
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ambulatory women with incontinence
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representing 20 to 75 percent of cases
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it’s also important to note that
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approximately 25 percent of women will
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have stress urinary incontinence for the
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first 4 to 6 months after a vaginal
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delivery the etiology of stress
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incontinence is often related to
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urethral hypermobility
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here is a cross sectional drawing of the
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bladder and the urethra the urethra can
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become hyper mobile if there has been
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loss of integrity of the underlying
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pelvic floor muscles stress incontinence
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can also result from intrinsic sphincter
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deficiency which is weakness of the
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urethral sphincter itself treatment for
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stress incontinence can be pelvic floor
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exercises known as Kegel exercises to
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strengthen the para urethral and peri
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vaginal muscles surgical treatment is
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indicated when conservative treatments
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have failed to satisfactorily relieve
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the symptoms and the patient wishes
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further treatment in an effort to
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achieve continence surgical treatment
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for stress incontinence has evolved over
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recent years and at this time the most
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commonly utilized procedure is the
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tension free vaginal tape a narrow strip
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of polypropylene mesh is vaginally
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placed at the mid urethra level to
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compensate for the inefficiency for
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intrinsic sphincter deficiency bulking
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agents are injected transurethral II to
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provide a washer effect around the
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proximal urethra and bladder neck this
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is second line therapy after surgery has
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failed for stress incontinence or among
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older a debilitating woman for whom
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operative treatments may be hazardous
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urge incontinence occurs with detrusor
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muscle / activity normally the detrusor
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muscle allows the bladder to fill in a
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low resistance setting the volume may
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increase but the pressure within the
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bladder remains low patients with urgent
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continents will have detrusor muscle
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contractions that cause the bladder
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pressure to rise and patients will often
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feel they must run to the bathroom
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frequently and urgently patients often
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describe almost making it to the
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or having their hand on the bathroom
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door handle when there is inappropriate
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detrusor muscle contraction with
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subsequent leakage of urine treatment
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options for urge incontinence can be
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behavioral therapy including bladder
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training and prompted voiding
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anticholinergic agents especially
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oxybutynin until Tara dawn may also have
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a small beneficial effect in improving
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symptoms of detrusor / activity other
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types of incontinence include mixed
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overflow and possibly from a fistula if
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she recently has had a pelvic surgery
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radiation or delivery this concludes the
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aapko video on pelvic floor disorders we
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have reviewed normal pelvic Anatomy
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common risk factors for prolapse and
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incontinence and reviewed surgical and
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non-surgical options for these common
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disorders in women
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[Music]
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you
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[Music]