{"id":172,"date":"2020-08-13T15:59:16","date_gmt":"2020-08-13T15:59:16","guid":{"rendered":"https:\/\/brooksidepress.org\/basic_obgyn\/?page_id=172"},"modified":"2021-05-09T20:47:23","modified_gmt":"2021-05-09T20:47:23","slug":"37-pelvic-floor-disorders","status":"publish","type":"page","link":"https:\/\/brooksidepress.org\/pa_obgyn\/overview\/37-pelvic-floor-disorders\/","title":{"rendered":"37. Pelvic Floor Disorders"},"content":{"rendered":"<p><iframe loading=\"lazy\" src=\"https:\/\/www.youtube.com\/embed\/nGan0kYG32Y\" width=\"560\" height=\"315\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><span data-mce-type=\"bookmark\" style=\"display: inline-block; width: 0px; overflow: hidden; line-height: 0;\" class=\"mce_SELRES_start\">\ufeff<\/span><\/iframe><\/p>\n<p>Duration = 9:52<\/p>\n<input type='hidden' bg_collapse_expand='69e9b56a5e3022083665978' value='69e9b56a5e3022083665978'><input type='hidden' id='bg-show-more-text-69e9b56a5e3022083665978' value='Show Transcript'><input type='hidden' id='bg-show-less-text-69e9b56a5e3022083665978' value='Hide Transcript'><button id='bg-showmore-action-69e9b56a5e3022083665978' class='bg-showmore-plg-button bg-blue-button  '   style=\" color:#ffffff;\">Show Transcript<\/button><div id='bg-showmore-hidden-69e9b56a5e3022083665978' ><\/p>\n<p>00:00<br \/>\nAPGO educational topic number 37 pelvic<br \/>\n00:02<br \/>\nfloor disorders welcome to another<br \/>\n00:05<br \/>\nepisode of the pelvic floor<br \/>\n00:06<br \/>\nI&#8217;m your host levator Ani I hope to<br \/>\n00:09<br \/>\nprovide important support throughout<br \/>\n00:10<br \/>\nthis video pelvic organ prolapse urinary<br \/>\n00:13<br \/>\nincontinence and anal incontinence<br \/>\n00:15<br \/>\nbecome increasingly common as women age<br \/>\n00:16<br \/>\nthese conditions can have a major impact<br \/>\n00:19<br \/>\non a woman&#8217;s daily activities sexual<br \/>\n00:21<br \/>\nfunction exercise and quality of life<br \/>\n00:24<br \/>\nthe lifetime risk up to age 84<br \/>\n00:27<br \/>\nundergoing surgery for prolapse or<br \/>\n00:29<br \/>\nurinary incontinence is 11% and the most<br \/>\n00:31<br \/>\ncommon indication for hysterectomy for<br \/>\n00:33<br \/>\nwomen age 55 and greater is prolapse the<br \/>\n00:37<br \/>\nobjectives of this video are to describe<br \/>\n00:38<br \/>\nnormal pelvic anatomy and pelvic support<br \/>\n00:40<br \/>\nlist risk factors for pelvic floor<br \/>\n00:43<br \/>\ndisorders describes signs and symptoms<br \/>\n00:45<br \/>\nof pelvic floor disorders differentiate<br \/>\n00:48<br \/>\nthe types of urinary incontinence<br \/>\n00:50<br \/>\ndiscuss the steps in the evaluation of<br \/>\n00:52<br \/>\npelvic floor disorders describe the<br \/>\n00:55<br \/>\nanatomic changes associated with pelvic<br \/>\n00:57<br \/>\nfloor disorders and lastly describe<br \/>\n00:59<br \/>\nnon-surgical and surgical management for<br \/>\n01:01<br \/>\npelvic floor disorders pelvic organ<br \/>\n01:04<br \/>\nprolapse occurs with descent of one or<br \/>\n01:06<br \/>\nmore of the pelvic structures this can<br \/>\n01:08<br \/>\nbe the anterior wall of the vagina which<br \/>\n01:10<br \/>\nis a sistah seal here is a photograph of<br \/>\n01:13<br \/>\na pronounced sistah seal the pink tissue<br \/>\n01:15<br \/>\nis the anterior wall of the vagina<br \/>\n01:17<br \/>\ndescending below the high metal ring<br \/>\n01:19<br \/>\ndescent of the posterior wall of the<br \/>\n01:21<br \/>\nvagina is a rectus seal this photograph<br \/>\n01:24<br \/>\nillustrates a rectus seal a one-sided<br \/>\n01:26<br \/>\nspeculum is retracting the anterior wall<br \/>\n01:28<br \/>\nof the vagina and you can appreciate how<br \/>\n01:30<br \/>\nthe posterior wall rises up and beyond<br \/>\n01:32<br \/>\nthe high metal ring a herniation at the<br \/>\n01:34<br \/>\ntop of the vagina that allows the<br \/>\n01:36<br \/>\nperitoneum of the cul-de-sac containing<br \/>\n01:38<br \/>\nsmall bowel to herniate through is<br \/>\n01:39<br \/>\ncalled an entry seal it is important to<br \/>\n01:42<br \/>\nnote that almost 50% of all Paris women<br \/>\n01:45<br \/>\nor women who&#8217;ve had a vaginal delivery<br \/>\n01:46<br \/>\nwill have some prolapse by physical exam<br \/>\n01:49<br \/>\nbut most are not clinically affected<br \/>\n01:51<br \/>\nphysical findings may not correlate with<br \/>\n01:54<br \/>\nspecific pelvic symptoms what are some<br \/>\n01:56<br \/>\nof the symptoms that women experience<br \/>\n01:58<br \/>\nwith pelvic organ prolapse the symptoms<br \/>\n02:00<br \/>\ncan be vague and nondescript<br \/>\n02:01<br \/>\nwomen may present with vaginal pressure<br \/>\n02:03<br \/>\nor heaviness abdominal or low back pain<br \/>\n02:06<br \/>\nvaginal or perineal pain or discomfort<br \/>\n02:08<br \/>\nor a mass sensation there can also be<br \/>\n02:11<br \/>\nurinary or fecal loss or retention<br \/>\n02:13<br \/>\nsome women may experience sexual health<br \/>\n02:15<br \/>\nissues as well as anxiety or fear<br \/>\n02:17<br \/>\nrelated to this condition<br \/>\n02:19<br \/>\nlike many gynecological conditions this<br \/>\n02:21<br \/>\nwas an issue that was not openly<br \/>\n02:22<br \/>\ndiscussed in the past and many women may<br \/>\n02:24<br \/>\nfeel discomfort or embarrassment about<br \/>\n02:26<br \/>\nissues down there this photograph of a<br \/>\n02:29<br \/>\npro so densha which is when the cervix<br \/>\n02:31<br \/>\ndescends beyond the vulva illustrates<br \/>\n02:33<br \/>\nhow significantly prolapse can sometimes<br \/>\n02:35<br \/>\nsilently impact a woman&#8217;s quality of<br \/>\n02:37<br \/>\nlife yet it&#8217;s discussed very little<br \/>\n02:39<br \/>\noutside of the gynecological world we<br \/>\n02:41<br \/>\nnow have a special guest for our<br \/>\n02:43<br \/>\ndiscussion dr. procede enchi has joined<br \/>\n02:45<br \/>\nus to talk about risk factors for pelvic<br \/>\n02:47<br \/>\norgan prolapse<br \/>\n02:48<br \/>\nThanks levator let&#8217;s discuss risk<br \/>\n02:50<br \/>\nfactors parody is our first risk factor<br \/>\n02:53<br \/>\nparticularly after one or more vaginal<br \/>\n02:54<br \/>\nbirths are there other risk factors<br \/>\n02:57<br \/>\nother than pregnancy yes genetic<br \/>\n03:00<br \/>\npredisposition menopause advancing age<br \/>\n03:02<br \/>\nprior pelvic surgery connective tissue<br \/>\n03:04<br \/>\ndisorders and factors associated with<br \/>\n03:06<br \/>\nelevated intra-abdominal pressure<br \/>\n03:08<br \/>\nnotably including obesity and chronic<br \/>\n03:10<br \/>\nconstipation with excessive straining<br \/>\n03:12<br \/>\nThank You dr. Percy densha it&#8217;s always<br \/>\n03:15<br \/>\nspecial to be able to hang out with you<br \/>\n03:17<br \/>\nlet&#8217;s now move to the anatomy lab for<br \/>\n03:19<br \/>\ndiscussion of the complex interactions<br \/>\n03:21<br \/>\ninvolved in pelvic organs support pelvic<br \/>\n03:24<br \/>\norgans support is accomplished by a<br \/>\n03:25<br \/>\ncomplex interaction of levator Ani<br \/>\n03:27<br \/>\nmuscles fashio from the urogenital<br \/>\n03:29<br \/>\ndiaphragm and endo pelvic fascia and the<br \/>\n03:31<br \/>\nuterus sacral and Cardinal ligaments we<br \/>\n03:34<br \/>\nare just beginning to understand these<br \/>\n03:35<br \/>\nrelationships and how they contribute to<br \/>\n03:37<br \/>\npelvic organ prolapse let&#8217;s take a<br \/>\n03:39<br \/>\nmoment to look at a very helpful diagram<br \/>\n03:41<br \/>\ncourtesy of dr. John de Lancie this is a<br \/>\n03:43<br \/>\nview of the pelvis from above here is<br \/>\n03:45<br \/>\nthe pubic symphysis and the vesicle neck<br \/>\n03:48<br \/>\nfrom the bladder which has been removed<br \/>\n03:49<br \/>\nin the illustration here is the cervix<br \/>\n03:51<br \/>\nthe Cardinal and uterus sacral ligaments<br \/>\n03:54<br \/>\nare now illustrated in red and attached<br \/>\n03:56<br \/>\nthe cervix to the pelvic sidewalls these<br \/>\n03:59<br \/>\nligaments provide the apical support for<br \/>\n04:01<br \/>\nthe cervix the vagina is the trapezoid<br \/>\n04:04<br \/>\nshape in blue and is supported laterally<br \/>\n04:06<br \/>\nby a structure called the arcus and<br \/>\n04:08<br \/>\naeneas fasciae pelvis there is thus both<br \/>\n04:11<br \/>\napical and vaginal support for the<br \/>\n04:13<br \/>\ncervix as we discussed earlier these<br \/>\n04:16<br \/>\nmuscles and support structures can<br \/>\n04:17<br \/>\nbecome weaker with age or secondary to<br \/>\n04:19<br \/>\ngenetic predisposition or a connective<br \/>\n04:22<br \/>\ntissue disorders the mechanism by which<br \/>\n04:24<br \/>\nvaginal birth disrupts these mas<br \/>\n04:26<br \/>\nis still in the process of becoming<br \/>\n04:28<br \/>\nunderstood we are beginning to<br \/>\n04:31<br \/>\nunderstand that there are likely breaks<br \/>\n04:33<br \/>\nor tears and specific connective tissues<br \/>\n04:35<br \/>\nduring birth that result in identifiable<br \/>\n04:38<br \/>\nand atomic defects and pelvic support<br \/>\n04:40<br \/>\nthe evaluation of pelvic organ prolapse<br \/>\n04:42<br \/>\ninvolves a comprehensive exam that<br \/>\n04:45<br \/>\ndefines the severity of the prolapse the<br \/>\n04:47<br \/>\npelvic organ prolapse quantification<br \/>\n04:49<br \/>\nexamination or pop Q measures six<br \/>\n04:51<br \/>\nspecific points in the vagina relative<br \/>\n04:53<br \/>\nto the hymen stage zero is defined as no<br \/>\n04:56<br \/>\nprolapse the cervix or vaginal cuff is<br \/>\n04:58<br \/>\nat the top of the vagina in stage one<br \/>\n05:01<br \/>\nthe leading part of the prolapse is more<br \/>\n05:03<br \/>\nthan one centimeter above the hymen in<br \/>\n05:05<br \/>\nstage two the leading part of the<br \/>\n05:07<br \/>\nprolapse is less than or equal to one<br \/>\n05:09<br \/>\ncentimeter above or below the hymen in<br \/>\n05:12<br \/>\nstage three the leading edge is more<br \/>\n05:14<br \/>\nthan one centimeter beyond the hymen but<br \/>\n05:16<br \/>\nless than or equal to the total vaginal<br \/>\n05:18<br \/>\nlength and lastly stage four is defined<br \/>\n05:21<br \/>\nas complete aversion treatments for<br \/>\n05:24<br \/>\npelvic organ prolapse depend on how much<br \/>\n05:25<br \/>\nthe symptoms are affecting the patient&#8217;s<br \/>\n05:27<br \/>\nquality of life if the patient is<br \/>\n05:29<br \/>\nsymptomatic then there are surgical and<br \/>\n05:31<br \/>\nnon-surgical options pessaries are<br \/>\n05:34<br \/>\nremovable rubber plastic or silicone<br \/>\n05:36<br \/>\ndevices that can be fitted in most women<br \/>\n05:38<br \/>\nwith prolapse pessaries are used by 75%<br \/>\n05:41<br \/>\nof urogynecologist<br \/>\n05:42<br \/>\nas first-line therapy for prolapse they<br \/>\n05:45<br \/>\ncan be classified as supportive such as<br \/>\n05:47<br \/>\nthis ring pessary that can be used for<br \/>\n05:48<br \/>\nmild prolapse space-occupying pessaries<br \/>\n05:51<br \/>\nsuch as this Gellhorn and q pessary are<br \/>\n05:53<br \/>\nutilized for higher degree prolapses or<br \/>\n05:56<br \/>\nfor presidencia surgical options for<br \/>\n05:58<br \/>\nprolapse often involve a hysterectomy<br \/>\n06:00<br \/>\nhere is another cross sectional drawing<br \/>\n06:02<br \/>\nwith the uterus bladder and vaginal apex<br \/>\n06:04<br \/>\nit&#8217;s not enough simply to remove the<br \/>\n06:06<br \/>\nuterus apical support has to be<br \/>\n06:09<br \/>\naddressed as well vaginally this can be<br \/>\n06:11<br \/>\nperformed with a uterus sacral ligament<br \/>\n06:13<br \/>\nsuspension or sacral spinous ligament<br \/>\n06:15<br \/>\nsuspension these procedures involves<br \/>\n06:17<br \/>\nsuspending the vaginal apex to either<br \/>\n06:19<br \/>\nthe uterus sacral or say Chris &#8211;<br \/>\n06:20<br \/>\nligament an abdominal sacral cocapec C<br \/>\n06:24<br \/>\ninvolves using a mesh to suspend the<br \/>\n06:26<br \/>\nvaginal apex to the sacrum a copal<br \/>\n06:29<br \/>\nclassist involves the complete<br \/>\n06:30<br \/>\nobliteration of the vaginal lumen and is<br \/>\n06:32<br \/>\na procedure for women who do not desire<br \/>\n06:33<br \/>\nfuture vaginal intercourse and who are<br \/>\n06:35<br \/>\nat high risk for complications from<br \/>\n06:37<br \/>\nsurgery it is also important to discuss<br \/>\n06:40<br \/>\nan<br \/>\n06:40<br \/>\nask about urinary incontinence and women<br \/>\n06:42<br \/>\nleakage of urine can affect women social<br \/>\n06:44<br \/>\nclinical and psychological well-being<br \/>\n06:46<br \/>\nless than 1\/2 of all incontinent women<br \/>\n06:49<br \/>\nseek medical care even though the<br \/>\n06:51<br \/>\ncondition can often be treated let&#8217;s<br \/>\n06:53<br \/>\nstart with stress incontinence patients<br \/>\n06:56<br \/>\nwill describe leakage of urine with<br \/>\n06:57<br \/>\nactivities that increase intra-abdominal<br \/>\n06:59<br \/>\npressure such as coughing jumping<br \/>\n07:01<br \/>\nsneezing or laughing this is the most<br \/>\n07:05<br \/>\ncommon type of incontinence among<br \/>\n07:07<br \/>\nambulatory women with incontinence<br \/>\n07:08<br \/>\nrepresenting 20 to 75 percent of cases<br \/>\n07:11<br \/>\nit&#8217;s also important to note that<br \/>\n07:12<br \/>\napproximately 25 percent of women will<br \/>\n07:15<br \/>\nhave stress urinary incontinence for the<br \/>\n07:16<br \/>\nfirst 4 to 6 months after a vaginal<br \/>\n07:18<br \/>\ndelivery the etiology of stress<br \/>\n07:21<br \/>\nincontinence is often related to<br \/>\n07:22<br \/>\nurethral hypermobility<br \/>\n07:23<br \/>\nhere is a cross sectional drawing of the<br \/>\n07:26<br \/>\nbladder and the urethra the urethra can<br \/>\n07:29<br \/>\nbecome hyper mobile if there has been<br \/>\n07:30<br \/>\nloss of integrity of the underlying<br \/>\n07:32<br \/>\npelvic floor muscles stress incontinence<br \/>\n07:35<br \/>\ncan also result from intrinsic sphincter<br \/>\n07:37<br \/>\ndeficiency which is weakness of the<br \/>\n07:39<br \/>\nurethral sphincter itself treatment for<br \/>\n07:42<br \/>\nstress incontinence can be pelvic floor<br \/>\n07:44<br \/>\nexercises known as Kegel exercises to<br \/>\n07:46<br \/>\nstrengthen the para urethral and peri<br \/>\n07:48<br \/>\nvaginal muscles surgical treatment is<br \/>\n07:51<br \/>\nindicated when conservative treatments<br \/>\n07:52<br \/>\nhave failed to satisfactorily relieve<br \/>\n07:54<br \/>\nthe symptoms and the patient wishes<br \/>\n07:55<br \/>\nfurther treatment in an effort to<br \/>\n07:57<br \/>\nachieve continence surgical treatment<br \/>\n07:59<br \/>\nfor stress incontinence has evolved over<br \/>\n08:01<br \/>\nrecent years and at this time the most<br \/>\n08:03<br \/>\ncommonly utilized procedure is the<br \/>\n08:04<br \/>\ntension free vaginal tape a narrow strip<br \/>\n08:07<br \/>\nof polypropylene mesh is vaginally<br \/>\n08:10<br \/>\nplaced at the mid urethra level to<br \/>\n08:11<br \/>\ncompensate for the inefficiency for<br \/>\n08:13<br \/>\nintrinsic sphincter deficiency bulking<br \/>\n08:16<br \/>\nagents are injected transurethral II to<br \/>\n08:18<br \/>\nprovide a washer effect around the<br \/>\n08:19<br \/>\nproximal urethra and bladder neck this<br \/>\n08:21<br \/>\nis second line therapy after surgery has<br \/>\n08:23<br \/>\nfailed for stress incontinence or among<br \/>\n08:26<br \/>\nolder a debilitating woman for whom<br \/>\n08:28<br \/>\noperative treatments may be hazardous<br \/>\n08:29<br \/>\nurge incontinence occurs with detrusor<br \/>\n08:32<br \/>\nmuscle \/ activity normally the detrusor<br \/>\n08:34<br \/>\nmuscle allows the bladder to fill in a<br \/>\n08:36<br \/>\nlow resistance setting the volume may<br \/>\n08:39<br \/>\nincrease but the pressure within the<br \/>\n08:41<br \/>\nbladder remains low patients with urgent<br \/>\n08:43<br \/>\ncontinents will have detrusor muscle<br \/>\n08:45<br \/>\ncontractions that cause the bladder<br \/>\n08:46<br \/>\npressure to rise and patients will often<br \/>\n08:48<br \/>\nfeel they must run to the bathroom<br \/>\n08:50<br \/>\nfrequently and urgently patients often<br \/>\n08:52<br \/>\ndescribe almost making it to the<br \/>\n08:54<br \/>\nor having their hand on the bathroom<br \/>\n08:56<br \/>\ndoor handle when there is inappropriate<br \/>\n08:57<br \/>\ndetrusor muscle contraction with<br \/>\n08:59<br \/>\nsubsequent leakage of urine treatment<br \/>\n09:02<br \/>\noptions for urge incontinence can be<br \/>\n09:03<br \/>\nbehavioral therapy including bladder<br \/>\n09:05<br \/>\ntraining and prompted voiding<br \/>\n09:07<br \/>\nanticholinergic agents especially<br \/>\n09:09<br \/>\noxybutynin until Tara dawn may also have<br \/>\n09:11<br \/>\na small beneficial effect in improving<br \/>\n09:13<br \/>\nsymptoms of detrusor \/ activity other<br \/>\n09:16<br \/>\ntypes of incontinence include mixed<br \/>\n09:18<br \/>\noverflow and possibly from a fistula if<br \/>\n09:20<br \/>\nshe recently has had a pelvic surgery<br \/>\n09:22<br \/>\nradiation or delivery this concludes the<br \/>\n09:25<br \/>\naapko video on pelvic floor disorders we<br \/>\n09:27<br \/>\nhave reviewed normal pelvic Anatomy<br \/>\n09:29<br \/>\ncommon risk factors for prolapse and<br \/>\n09:31<br \/>\nincontinence and reviewed surgical and<br \/>\n09:33<br \/>\nnon-surgical options for these common<br \/>\n09:34<br \/>\ndisorders in women<br \/>\n09:36<br \/>\n[Music]<br \/>\n09:46<br \/>\nyou<br \/>\n09:48<br \/>\n[Music]<\/p>\n<p><\/div>\n<hr \/>\n","protected":false},"excerpt":{"rendered":"<p>\ufeff Duration = 9:52<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":46,"menu_order":37,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-172","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/172","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/comments?post=172"}],"version-history":[{"count":1,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/172\/revisions"}],"predecessor-version":[{"id":2843,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/172\/revisions\/2843"}],"up":[{"embeddable":true,"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/pages\/46"}],"wp:attachment":[{"href":"https:\/\/brooksidepress.org\/pa_obgyn\/wp-json\/wp\/v2\/media?parent=172"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}