PELVIC FLOOR DYSFUNCTION

Edwin Armawan
Divisi Uroginekologi Rekonstruksi
Dept/SMF Ob&Gyn
RS dr Hasan Sadikin
Universitas Padjadjaran
Learning Objective
What you need to know

Anatomy of pelvic floor and etiology of pelvic

floor dysfunction
Definition and major types of pelvic organ
prolapse
Principle of treatment
Types of urinary incontinence
Pelvic Organ Prolapse
Lower Urinary Tract disorder
Anorectal Disorder
Pelvic floor dysfunction

Not life threatening

But life quality worsening

Pelvic Floor
Pelvic floor

Pelvic outlet

Anterior
pubic symphysis
Posterior
apex of coccys
Bilateral
descending ramus of pubis
ascending ramus of ischium
ischial tuberosity
ischial spine
Pelvic floor
Pelvic Supports

Muscle

Fasciae and ligament
Pelvic Floor

Pelvic diaphragm
Funnel-shaped fibromuscular
partition
Forms the primary supporting
structure for the pelvic contents
Composition
Levator ani
Coccygeus muscles
their superior and inferior fasciae
Forms the ceiling of the
ischiorectal fossa
 clitoris-------------------------------
---------------------------
External urethral orific
---------------------------
Vaginal orific
---------------------ischocavernosus
--------------------bulbocavernosus
---------------superficial transverse perineal muscle
------------------External anal sphincter
 --------------------- urethral sphincter
Inferior fascia of urogenital
diaphragm ---------------- ----------------Superior fascia of
urogenital diaphragm

Deep transverse perineal muscle

 Levator ani
Strongest support of pelvic
floor

------------------- Pubovaginal muscle

--------------------- Puborectal muscle

----------------------- Pubococcygeal muscle

Tendinous fascia pelvis
the white line Iliaccoccygeal muscle
ischiococcygeus
 Levator ani

Support pelvic organs

Inforce sphincters
The hammock hypothesis
 3 levels of support
Level 1 - Apical Support
Superior suspension of the vagina to the cardinal-uterosacral
complex

Level 2Lateral Support

Lateral attachment of the upper 2/3 of the vagina

Level 3 distal support

Fusion of the vagina into the urogenital diaphragm and perineal
body
Pelvic floor 3 compartments

Anterior compartment (bladder and urethra)

Middle compartment (vagina and uterus)
Posterior compartment (anorectus)
Integral theory
Prolapse and most pelvic floor symptoms such as urinary stress,
urge, abnormal bowel and bladder emptying, and some forms of
pelvic pain, mainly arise, for different reasons, from laxity in the
vagina or its supporting ligaments, a result of altered connective
tissue.
 Pelvic floor dysfunction
Level 1 prolapse of the uterus or anterior vaginal vault
Level2/3 prolapse of anterior or posterior vaginal wall

Anterior compartment
lower urethral tract dysfunction
Middle compartment
Enterocele
Cystocele
Uterine prolapse
Posterior compartment
Rectocele
Anorectal dysfunction
PELVIC ORGAN PROLAPSE
Pelvic Organ Prolapse (POP)

Bulge or protrusion of pelvic organs and their

associated vaginal segments into or through
the vagina
Incidence increases with aging
anterior pelvic organ prolapse 34.3%
posterior wall prolapse 18.6%
uterine prolapse in 14.3%
Pelvic Organ Prolapse (POP)

Vaginal delivery as a significant risk factor

History of hysterectomy; obesity ; history of previous
prolapse operations; race
Optional surgical treatment remains elusive
 Pathophysiology
Attenuation of the supportive
structures
endopelvic connective tissue
levator ani muscular support
by actual tears or breaks
by neuromuscular
dysfunction
Continuous abdominal pressure
Definitions
Rectocele
Enterocele
Cystocele
Uterine prolapse
Procidentia
Definitions
Symptoms
Pelvic organ prolapse
Symptoms of voiding dysfunction
Urinary incontinence
Urinary urgency and frequency
Obstructive voiding symptoms
Urinary retention and upper renal compromise
Defecatory problems (e.g., constipation, diarrhea, tenesmus, fecal incontinence)
Pelvic pain
Back and flank pain
Overall pelvic discomfort
Dyspareunia
Symptoms
Physical examination
Divide the pelvis into compartments
Apical compartment ---- Graves speculum or Baden retractor
The anterior and posterior compartments ---- univalve or Sims'
speculum
Rectovaginal examination ---- distinguish a posterior vaginal
wall defect from a dissecting apical enterocele
Anterior lateral detachment defect----Baden retractor
Valsalva is encouraged
Standing straining examination
Pelvic Organ Prolapse Quantitation System
Pelvic Organ Prolapse Quantitation System
Pelvic Organ Prolapse Quantitation System

>1
 Pelvic Muscle Function Assessment
Bladder Evaluation
Treatment

Nonsurgical Therapy
Mild to moderate prolapse
Desire future childbearing
Not suitable or desiring surgery

Always conservative therapy first!!!

Conservative Management
Pelvic floor muscle training (PFMT)
Lifestyle intervention
weight loss
reduction of activities that increase intraabdominal pressure
Mechanical Devices
Pessary
Surgical Management

OPTIONAL!!!
Relieve symptoms
Restore vaginal anatomy
Vaginal, abdominal, and laparoscopic routes
Involve a combination of repairs directed to the anterior vagina,
vaginal apex, posterior vagina, and perineum
NONE IS PERFECT!
 Surgical Management

Procedures
Restorative: use the patient's endogenous support structures
Compensatory: replace deficient support with permanent graft
material
Obliterative: close or partially close the vagina.
 Key points

With the aging of the population, pelvic organ prolapse is an increasingly common
condition seen in women.

Causes of pelvic organ prolapse are multifactorial and result in weakening of the pelvic
support connective tissue and muscles as well as nerve damage.

Patients may be asymptomatic or have significant symptoms such as those relating to the
lower urinary tract, pelvic pain, defecatory problems, fecal incontinence, back pain, and
dyspareunia.

Physical examination includes thoughtful attention to all parts of the vagina, including the
anterior, apical, and posterior compartments, levator muscle, and anal sphincter complex.
Key points

Nonsurgical treatment options include pelvic floor muscle training and the
use of intravaginal devices.

Surgical treatment involves an individualized, multicompartmental approach

consistent with the patients previous treatment attempts, activity level, and
health status.
LOWER URINARY TRACT DISORDERS
Normal Urethral Closure
Urinary incontinence

Stress Urinary Incontinence

Most common type of urinary continence in women
Leaking when sneezing, coughing, or exercise
Urethral sphincter defect and/or urethral hypermobility
Urge Urinary Incontinence and Overactive Bladder
Most common form of incontinence in older women
Involuntary leakage of urine accompanied by or immediately
preceded by urgency
May or may not be caused by detrusor overactivity
 Urinary incontinence
Mixed Incontinence
Have symptoms of both stress and urge urinary incontinence
In older women mixed and urge incontinence is predominate
Stress urinary incontinence

Incidence
US 15-35 %
Korea 50%
China 18.9 %

Age
Postmenopausal women 17%.
Affects 50 million people in the world.
Pathophysiology

Stress urinary incontinence

Incontinence caused by anatomic hypermobility of the urethra
Incontinence caused by intrinsic sphincteric weakness or deficiency

Urgent urinary incontinence

Bladder
Innervation
Risk factors

Age
Obesity
Functional impairment
Cognitive impairment
Pregnancy and delivery
Evaluation

History (medications, operations...)

Quality of life measures
Physical examination (Qtip test)
Primary care level tests
Voiding Diary
Urinalysis
Postvoid Residual Volume
Cough Stress Test
Pad Tests
Evaluation

Advanced testing
Urodynamics
Uroflowmetry
Filling cystometry
Voiding cystometrography
Imaging tests
Neurophysiological tests
.
Nonsurgical treatment

Lifestyle Changes
Weight loss
Postural change
Decrease caffeine intake
Physical Therapy -- SUI
Pelvic floor muscle training
Behavioral Therapy and Bladder Training UI & OAB
Vaginal and urethral devices --SUI
Vaginal and Urethral Devices
Medications
Stress incontinence
adrenergic activity

Urge Incontinence and Overactive Bladder

anticholinergic agents
Surgical Treatment for Stress incontinence

TVT/SPARC
Key Points
Anorectal Dysfunction
Clasification

Defecatory dysfunction --- constipation

Infrequent stools, typically fewer than three bowel

movements per week.

Fecal Incontinence
Key points

Defecatory dysfunction and fecal incontinence are common conditions that

have tremendous psychosocial and economic implications.

The differential diagnosis for anorectal dysfunction is broad and can be

classified into systemic factors, anatomic and structural abnormalities, and
functional disorders.

A thorough history and physical examination is critical for the evaluation of

fecal incontinence and defecatory dysfunction, as well as appropriate ancillary
testing.
Key points

Treatment of anorectal dysfunction should focus on treatment of

the underlying condition with nonsurgical management attempted
before surgery.

Overlapping sphincteroplasty is the procedure of choice for fecal

incontinence caused by a disrupted anal sphincter.
Questions

Which structure is the strongest support of the pelvic floor?

The types of pelvic organ prolapse and their definition.
The principle of treatment of pelvic organ prolapse.
Types of urinary incontinence and their definition.
 8TH EDITION APGO
OBJECTIVES FOR MEDICAL
STUDENTS
Pelvic Relaxation and Urinary Incontinence
Rationale

Patients with conditions of pelvic relaxation and urinary incontinence present in a

variety of ways. The physician should be familiar with the types of pelvic
relaxation and incontinence and the approach to management of these patients.
Objectives

The student will demonstrate knowledge of the following:

Predisposing factors for pelvic organ prolapse and urinary incontinence
Anatomic changes, fascial defects and neuromuscular pathophysiology
Signs and symptoms of pelvic organ prolapse
Physical exam
Cystocele
Rectocele
Enterocele
Vaginal vault or uterine prolapse
Risk factors

Vaginal delivery
Large baby
Prolonged 2nd stage of labor
Forceps
Multiparous
Risk factors

Increased abdominal pressure

Obesity
Chronic constipation
Chronic lung disease
Risk factors

Altered nerve function or tissue strength

Diabetes
Neurologic diseases
Aging
Collagen disorders
Hypoestrogenism
Pelvic surgery
Anatomy

Basic
Levator ani muscles
Pubococcygeuas
Puborectalis
Iliococcygeus
Viscerofascial layer
Endopelvic fascia - attaches uterus and vagina to pelvic wall
Parametria - cardinal and uterosacral ligaments
Fascial defects
Neuromuscular pathophysiology
Signs and symptoms of pelvic organ
prolapse
Symptoms - prolapse
Asymptomatic
Vaginal pressure heaviness (>90%)
Vaginal pain
Sensation of tissue protruding from the vagina (>90%)
Abdominal pain
Low back pain
Dyspareunia/impaired coitus (37%)
Vaginal dryness
Ulceration
Bleeding
Urinary incontinence (33%)
Signs and symptoms of pelvic organ
prolapse
Symptoms - urinary incontinence - unexpected loss of urine
Stress incontinence - involuntary loss of urine with increased abdominal
pressure (valsalva, cough, laugh, sneeze)
Urge incontinence - involuntary loss of urine associated with overwhelming urge
to void
Physical exam (definitions)

Cystocele
Defect where the bladder and anterior vaginal wall protrudes through the
vaginal introitus
Secondary to attenuation or rupture of the pubovesical cervical fascia
Note anterior relaxation with urethral inclination
Mobility of bladder base and urethra with valsalva maneuver
Physical exam (definitions)

Rectocele
Protrusion of posterior vaginal wall and anterior rectal wall
Look for bulging of posterior vaginal wall with valsalva maneuver
Insert a finger in rectum and, if vaginal and rectal tissue are jauxtaposed =
rectocele
Physical exam (definitions)

Enterocele
Elongation of posterior cul-de-sac along rectovaginal septum
50% are diagnosed intraoperatively
Physical exam (patient standing) - palpate enterocele sac and small bowel
Physical exam (definitions)

Uterine/vaginal vault prolapse

Uterine - descent of uterus and cervix into the vaginal canal
Exam - patient upright, valsalva
Look and fell for prolapse
Grade based on location from hymeneal ring
Vaginal vault - loss of support of vagina beginning at apex
Methods of diagnosis

Urine culture
Rule out urinary tract infection
> 105 organisms
Voiding diary
Normal bladder capacity (up to 60cc)
Normal frequency (<8 voids/day)
Accidents/leaking with physical activity
Amount and type of intake
Methods of diagnosis

Standing stress test - note urine loss with cough or valsalva

Q-tip test
Looks for hypermobility of the urethrovesical junction
Resting position -30o or a change of greater than 30o is hypermobile
Methods of diagnosis

Filling cystometrogram - examines the bladder during filling and storage

Post-void residual < 100cc
First urge - 100 - 200 mL
Maximum capacity - 400 - 500 mL
Resting bladder pressure < 10 - 15 cm of H2O
Cystoscopy
Nonsurgical and surgical treatments

Pessary
Oldest effective treatment
If pelvic floor muscle damaged, they cannot be held in place
Adjunctive treatment - estrogen
Nonsurgical and surgical treatments

Medications
Stress incontinence
Antagonist to increase smooth muscle tone (phenylpropanolamine)
Estrogen to increase urethral resistance
Urge incontinence - anticholinergics to decrease spasm of the detrusor muscle
(oxybutynin, tolterodine)
Nonsurgical and surgical treatments

Pelvic floor muscle exercises

Kegels - voluntary contraction of the pelvic floor
Vaginal cones
Electrical stimulation
Nonsurgical and surgical treatments

Surgery
Hysterectomy - vaginal or abdominal (route depends on other surgical
interventions)
For anterior wall prolapse (cystocele)
Vaginal approach
Anterior colporrhaphy (central defect)
Paravaginal repair (lateral defect)
Abdominal approach - paravaginal repair
Nonsurgical and surgical treatments

Surgery
For apical defect
Vaginal approach
Sacrospinous ligament fixation
Uterosacral colposuspension
Abdominal approach
Abdominal sacrocolpopexy
Uterosacral colposuspension
Nonsurgical and surgical treatments

Surgery
For posterior defect - posterior colporraphy
For enterocele
Obliterate cul-de-sac with purse string suture in endopelvic fascia
McCall culdoplasty
Colpocleisis (LeFort procedure)
Nonsurgical and surgical treatments

Surgery
For stress incontinence
Vaginal approach
Pereyra
Raz
Stamey
Tensionless vaginal tape (TVT)
Nonsurgical and surgical treatments

Surgery
For stress incontinence
Abdominal approach
Marshall-Marchetti-Krantz (MMK)
Burch colposuspension
 Nonsurgical and surgical treatments

Surgery
For stress incontinence
Intrinsic urethral sphincter dysfunction
Suburethral sling
Bulking injections (with collagen) to improve urethral coaptation (for patients without
urethrovesical junction hypermobility)
Artificial sphincter
References

American College of Obstetricians and Gynecologists Technical Bulletin

#214. Pelvic Organ Prolapse. ACOG: Washington DC 1995.
American College of Obstetricians and Gynecologists Technical Bulletin
#213. Urinary Incontinence. ACOG: Washington DC 1995.
Mischel DR, ed., Comprehensive Gynecology 3rd ed., Mosby, St. Louis,
MO, 1997.
Adapted from Association of Professors of Gynecology and Obstetrics
Medical Student Educational Objectives, 7th edition, copyright 1997
CLINICAL CASE
Pelvic Relaxation and Urinary Incontinence
Patient presentation

A 75-year-old woman G5P5 presents complaining of fullness in the vaginal area.

The symptom is more noticeable when she is standing for a long period of time.
She does not complain of urinary or fecal incontinence. She has no other
urinary or gastrointestinal symptoms. There has been no vaginal bleeding. Her
past medical history is significant for well-controlled hypertension and chronic
bronchitis. She has never had surgery.
Patient presentation

Physical exam
Pelvic exam reveals normal appearing external genitalia except for generalized
atrophic changes. The vagina and cervix are without lesions. A second-degree
cystocele and rectocele are noted. The cervix descends to introitus with the
patient in an erect position. No rectal masses are noted. Rectal sphincter tone is
slightly decreased. Uterus is normal size. Right and left ovaries are not
palpable.
Labs or Studies
None
Diagnosis
Pelvic organ prolapse
Management plan

Management Plan
Patient prefers non-surgical option
Pessary placed and vaginal estrogen used to address atrophic changes
Teaching points

1. The patients multiple vaginal deliveries, age and chronic bronchitis places her
at risk for pelvic organ prolapse.
2. Patients commonly present with a feeling of fullness or are able to touch
vaginal or cervical tissue protruding through the introitus. They may or may
not experience urinary incontinence.
Teaching points

3. In addition to pelvic muscle exercises, non-surgical management of pelvic

organ prolapse mainly involves fitting the patient with a vaginal pessary. There
are numerous vaginal pessaries designed to support specific types of pelvic
organ prolapse. Pessaries press against the walls of the vagina and are
retained within the vagina by the tissues of the vaginal outlet.
Teaching points

4. Pessaries may cause vaginal irritation and ulceration. They are better
tolerated when the vaginal epithelium is well estrogenized; exogenous
estrogen may be required in the hypoestrogenic patient. Periodically, vaginal
pessaries should be removed, cleaned and reinserted. Failure to do so may
result in serious consequences, including fistula formation.
Teaching points

5. Patients may be managed successfully with a pessary for years. Indications

for surgery include the desire for definitive surgical correction, recurrent
vaginal ulcerations with a pessary or stress incontinence that the patient finds
unacceptable.
THANK YOU !