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Pelvic Organs Prolapse? Undergraduate Pelvic organs prolapse? undergraduate Ahmed Mostafa Fouad MD,MRCOG Ass. Prof. Obst &Gyn Alexandria university Obturator externus muscle Puborectalis Iliococcygeus muscle muscle Pubococcygeus muscle Sacrotuberous ligament Sacrospinous ligament Sacrospinous ligament Iliococcygeus muscle Sacrotuberous ligament Gluteus maximus muscle Sacrum Coccyx Ischial spine Sacrospinous ligament Ischial tuberosity Sacrotuberous ligament Sacrospinous ligament fixation Sacrospinous Fixation / Richter Alcock’s (Pudendal) canal Pudendal nerve Internal pudendal vessels & pudendal nerve Pelvic Floor Ligaments The Sacrospinous Ligaments Vaginal Apical Repair Sacrospinous Ligament Suspension Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle The two main muscles: The levator ani muscle group: Pubococcygeus, puborectalis, and iliococcygeus. They muscles extend from the lateral pelvic walls downward and medially to fuse with each other posteriorly. The levator hiatus lies anteriorly and accommodates the urethra, vagina, and anus. The coccygeus muscles A triangular muscle arises from the ischial spine and inserts onto the sacrum and coccyx Obturator internus muscle Levator ani muscles This is a dorsal lithotomy view of the pelvic floor muscles. Anatomy and Physiology Pelvic floor: .A Pelvic floor is a muscular diaphragm that separates the pelvic cavity above from the perineal space below. It is formed by the levator ani and coccygeus muscles, and is covered by parietal fascia. The levator ani muscles on either side arise from posterior surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine. Anterior compartment defect Cystocele Pubocervical fascia Review Type by Type The Cystocele It is an herniation of the bladder compressing the vagina There are 2 types: Bladd Midline Cystocele (Central • Defect) er Paravaginal Cystocele (Lateral • Defect) Vagina Review Type by Type The Midline / Central cystocele is due to a damaged PCF. Its aspect is a bulge with a smooth surface Review Type by Type The Paravaginal/Lateral cystocele is due to a damaged PCF at the level of the ATFP. Its aspect is a bulge with a surface with folds Anterior compartment defect Cystocele Anterior compartment defect Cystocele Rectovaginal fascia Posterior compartment defect Rectocele Anatomy and Physiology Pelvic floor: .A Pelvic floor is a muscular diaphragm that separates the pelvic cavity above from the perineal space below. It is formed by the levator ani and coccygeus muscles, and is covered by parietal fascia. The levator ani muscles on either side arise from posterior surface of pubic symphysis, the white line over fascia covering obturator internus and ischial spine. DeLancey model De Lancey JO. Am J Obstet Gynecol. 1992. A) DeLancey model: Cardinal ligament Uterosacral ligament De Lancey JO. Am J Obstet Gynecol. 1992. Vesicouterine space Cardinal ligament Uterosacral ligament Rectouterine space What will you do? What will you do? Main cause of POP are: Acquired Congenital Levator muscle weakness Inborn weakness of Ligaments injury support system. Nerve injury (Pudendal nerve) Endopelvic fascial weakness Perineal body weakness ACOG 2007 Risk factors Genetic predisp. ↑ IA pressure Vaginal birth Obesity Parity Chronic constipation Menopause ↑ Straining Advancing age Prior pelvic surgery Connective tissue dis. ACOG 2007 Diagnostic staging for pelvic organ prolapse WHP conference 2018 WHP conference 2018 Prevent ive MANAG EMENT Conser Surgical vative Smoking Independent risk factor for incontinence May be associated with prolapse Obesity Independent risk factor for incontinence. Fecal incontinence. Association with prolapse Menopause Vagina and urethra have similar lining. Pelvis and urethra have ER- alfa and beta. Vaginal atrophy after menopause is associated with uro-genital atrophy and incontinence and repeated UTI which can improved by vaginal estrogen application. How to manage uterine prolapse? WHP conference 2018 WHP conference 2018 Currently there is no rigorous evidence from randomized controlled trials regarding the use of conservative interventions in the management of pelvic organ prolapse. (Adams 2004) WHP conference 2018 Pessaries WHP conference 2018 Currently there is no evidence from randomised controlled trials upon which to base treatment of women with pelvic organ prolapse through the use of mechanical devices/pessaries. There is no consensus on the use of different types of device, the indications, nor the pattern of replacement and follow-up care. (Hagen 2004) WHP conference 2018 Surgical management WHP conference 2018 The ideal procedure should be Safe. Effective. long lasting. free of any morbidity. cost-effective . and provide normalization of function with patient satisfaction . National Institute for Health and Clinical Excellence. June 2008 WHP conference 2018 Routes of surgery and procedures for uterine prolapse Route of surgery Uterine sparing Uterine non sparing Abdominal Sacrohysteropexy/sacrocervicopexy Abdominal hysterectomy Pectineal ligament suspension + sacrocolpopexy /+ Modified McCall culdoplasty Vaginal Manchester procedure Vaginal hysterectomy Uterosacral suspension/placation + culdoplasty Sacrospinous fixation /+ sacrospinous fixation Le Forte and other colpocleisis Joint Retropubic suspension vaginal / abdominal Laparoscopic Ventrosuspension Laparoscopic hysterectomy with Uterosacral ligament plication sacrocolpopexy Hysteropexy with culdoplasty Amid classified synthetic meshes according to their pore size and fiber type WHP conference 2018 Amid PK. Hernia 1997 Complications of Mesh WHP conference 2018 Jacquetin B. Int Urogynecol J (2009) A) DeLancey model: Cardinal ligament Uterosacral ligament De Lancey JO. Am J Obstet Gynecol. 1992. WHP conference 2018 High uterosacral ligament suspension with fascial reconstruction: WHP conference 2018 Richardson AL. J Pelvic Surg. 1995 Abdominal sacraohysteropexy WHP conference 2018 Abdominal sacral colpopexy was associated with a lower rate of recurrent vault prolapse and less dyspareunia than the vaginal sacrospinous colpopexy. The abdominal colpopexy had a longer operating time, longer recovery and higher cost than the vaginal surgery. Maher et al. Cochrane Database Syst Rev. 2009 WHP conference 2018 The abdominal colpopexy had a longer operating time, longer recovery and higher cost than the vaginal surgery. Maher et al. Cochrane Database Syst Rev. 2009 WHP conference 2018 Sacrospinous ligament fixation Sacrum Coccyx Ischial spine Sacrospinous ligament Ischial tuberosity Sacrotuberous ligament WHP conference 2018 Sacrospinous Fixation / Richter ARC 20/4/2107 57 Sacrotuberous ligament Sacrospinous ligament WHP conference 2018 Vaginal Apical Repair Sacrospinous Ligament Suspension Sacrospinous ligament fixation entails attachment of the vaginal apex to the sacrospinous ligament, the tendinous component of the coccygeus muscle WHP conference 2018 Thank You ARC 20/4/2107 60.
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