Prolapse and Disorders of the Pelvic Floor

Prolapse and Disorders of the pelvic floor



1. Pelvic support

Bony pelvis: ̴ ⸦ ȣϴ ϸ ü support ʴ´. Pelvic organs ַ pelvic floor muscle activity ligamentous attachment ̿ ش.

Levator ani muscle : ̴ pelvic floor κ ϰ ̸, diaphragmatic portion(iliococcygeus) ׺ ߿ pubovisceral porion ̷.

() Iliococcygeus portion pelvic side ġ arcus tendinous ischial spine Ͽ rectumڿ ġϴ midline raphe .

() Pubovisceral portion

l U-shape β ̷µ pubic bone Ͽ ٴ´. ̵ Ǹ pubic bone µ ̷ muscular band puborectalis or pubococcygeus muscle̶ θ. Ȯ pubovisceral muscle̴.

l Pubovisceral muscle ν , , 䵵 pubic bone Ǹ ̷ lumen Ų. ̷ urinary and fecal continence ſ ߿ϸ genital organ(vagina, cervix, uterus) ߿ϴ.

l Pubovisceral muscle κ(puborectalis) 䵵 ΰ ִ endopelvic fascia ٰ Ǹ κ type 1muscle fiberμ ׻ Ͽ 䵵 ϸ, ÿ type 2 muscle fiber ް ȭ(coughing, sneezing) Ͽ urethral closure ν DZ ´.

l External anal sphinter levator ani muscle Ͽ 빰 ϸ ܺο ް ȭ Ͽ pelvic floor closure Ѵ.

Pelvic ligaments

() ŷκ pelvic ligaments pelvic supprot ߿ϸ Դ. ̵ muscle activity ޾ ⸦ ڸ ġϵ ϴ ̸, ü weight-bearing structure ƴϴ. urogenital hiatus þ о pelvic organ prolapse ȴ.

() Round, infundibulopelvic, cardinal ligaments ַ areolar tissue, blood vessels, muscle fibers ̷ supportive strength , ڱð ڸ ְϴ ٰ һ̴. ̷ ligaments endopelvic fascia ڱ pelvic side wall attachŴν, ̷ Ⱑ pelvic floor ִ ְ ش.

Connective tissue

() ü ϸ ַ elatin collagen ̷. ̷connective tissue Ӽ ϴ capsules ϱ⵵ϰ, δ븦 ѷδ fascia Ѵ. ̷ connective tissue ǽ .

() Connective tissue stress Ͽ turnover and remodeling ġ dynamic tissue.

l ȣ ȭ collagen ߿ ġ Ǿ ӽ, parturition, agingȿ ̷ ȭ ϴ.

l  proline hydroxylase activity Ŵνcollagen turnover Ų.

l Nutrition connective tissue integrity ߿ ´.

l Vitamine C deficiency collagen synethesis ָ ʷѴ.

() ϸ connective tissue abnormalities prolapse and related condition ſ ߿ Ҷ Ѵ. pelvic support defects پ ο ϸ, ӻ̳ ġ ȯڸ ٷ ִ.



2. Definition and Classification of Prolapse

definition : pelvic organ downward or forward displacement

grade : genital prolapse vagina Ǵµ ,0-3(Ȥ 0-4)grading scale Ǿ ִ. 0 no prolapse 3(Ȥ 4) total prolapse(procidentia) ǹѴ.

Terms :  Ǿ , ַ prolapse ⿡ ߰ , prolapse ߱ϴ specific defects ؼ Ǹ ʰ ִٴ ִ.

() Cystocele : bladder downward displacement

() Cystourethrocele : urethra prolapse ϴ cystocele

() Uterine prolapse : uterus cervix introtus descent

() Rectocele : rectum posterior vaginal lumen protrusion

() Enterocele : small bowel vaginal lumen herniation

Pelvis support Ư Կ ϴ ߿ϴ. anterior vaginal support, lateral vaginal support, posterior vaginal support, support of the vaginal apex, total vaginal length ϴ .

ϸ prolapse ҽô غ ( hymen, ischial spine) ؼ ϴ . uterine prolapse strainingÿ cervix hymen 2cmؿ Ǿ١ 簡, cystoceleÿ ant! erior vaginal wall hymen ͼ hymen ring 5cm distendϿ Ѵ.



3. prolapse

pelvic prolapse ġᰡ ʿġ ȯڿ pelvic support ҽǵǴ ̸ ġᰡ ʿ Ų.

feeling of pressure ΰ Ѵٴ ̴. ̷ ¿ , ħ Ȯġ ð 鼭 Ȯ.

Ư prolapse Ư õȴ.

() Loss of anterior vaginal support : urethral hypermobility ʷϿ stress urinary incontinence ߱ ִ.

() Large anterior vaginal prolapse(or vaginal vault eversion): voiding difficulty ߱ ִ. ̰ urethra ͼ urethra compressingϰų kinking ߱ؼ bladder emptying ҿϰ Ѵ.

() Rectocele inefficient rectal emptying ߱ , constipation ȴ.



4. Examination of the patient with Prolapse

Vagina DZ ϸ dorsal lithotomy postionӸ ƴ϶ standing position ǾѴ. ȯڷ Ͽ ġ ħ ÷ Ͽ prolapase Ǵ ȮѴ. ڼ rectovaginal examination ǽϿ occult enterocele cul-de-sac ִ ȮѴ.

Prolapse ִ Ȯ vaginal support anterior , posterior, lateral wall Ȯν prolapse ġ , ٸ ݵ prolapse ִ ȮѴ.

Ϲ hymen ȿ ѵ prolapse ߿伺 , Ư ̾ ô ׷.



5. Treatment of Pelvic Organ Prolapse

ô ġᰡ ʿġ , stress incontinence surgical bladder neck suspension ҷ ܴ. ̷ anterior vagina øν posterior vagina forward ȴ. posterior cul-de-sac levator plateκ Ǿ enterocele, uterine prolapse, vaginal vault eversion , rectocele ȭ ֱ ̿ ߰Ͽ culdoplasty, rectocele or enterocele repair, hysterectomy 䱸Ǿ.

Pelvic muscle exercise : stress incontinence ִ urethral support ȭŴν significant prolapse ִ ش.

Pelvic organ support ߿ pelvic muscleε , ̷ pelvic support ⿩ϴ connective tissue stress Ǿ ȴ. fascial attachments ıǰ ӻ ǹִ prolapse ȴ. ̷ 쿡 tone Ŵν õ ȿ ϴ.

Pessary : Ӹ diaphragm ϵ ο ˸ ũ pessary Ѵ. ̷ pessary ϴ 쿡 ݵ well-estronized vagina̾ϸ, post menopause pessary 4-6ֵ intravaginal estrogen cream ϴ ȣȴ.

Surgery : ǥ abnormal pelvic support ν ȯ ȭϴ ̴. 밳 ȯڴ ϳ̻ ϴ ߿ϴ.

() Vaginal hysterectomy : uterine prolapse Ǹ, ٸ ļ(anterior and posterior colporrhaphy or enterocele repair) ÿ డϴٴ ̴. ÿ ؾ cul-de-sac closingŰ ؾѴٴ Ͱ endopelvic fascia uterosacral ligament vaginal cuff reattachingŴν support ؾѴٴ ̴.

() Manchester/Fothergill Operation : ̴ 밳 anterior-posterior colporrhapy ȴ.켱 bladder cervixκ ڸѴ cervix amputationŰ, cardinal ligament anterior cervical stump ٿְ posterior vagina opening ݾִ ̴.

() Uteropexy : ӽ ϴ nulliparous uterine prolapse 쿡 켱 perssary ϰ dz, ̹ sacrospinous ligament fixation Ȥ retroperitoneal andominal uterosacropexy ϰ ȴ. ü mesh or fascia uterosacral ligament sutureش ٽ anterior longitudinal ligament of the sacrum suturingִ ̴.

() Paravaginal defect repair operation : anterior vaginal prolapse bladder neckƷ endopelvic fascia plicationŰ anterior colporrhaphyϿ ġ ִ. ̷ anterior vaginal prolapse endopelvic fascia lateral detachment lateral repair . ü endopelvic fascia arcus tendinous fasciae pelvis reattachedȴ.

() Posterior colporrhaphy

l rectocele repair posterior vagina  rectum pararectal fasciaκ ڸѴ levator animuscle rectum plicationְ vaginal epithelium closingش.

l Enterocele rectum peritoneal herniaμ ˻ÿ ο δ.peritoneal sac Ȯϰ excisionϰ permanent material ̿Ͽ purse-string suture ְ ȴ. ׷ vaginal closureش.

() Operations for complete eversion of the vagina : ſ ̹ ڱ ȯڿ vagina eversion κ 쿡 ʿϴ. ̴ prolapse ũⰡ ũ, ð , 幰 vaginal evisceration ߻ ֱ ̴.

l Colpectomy and Colpocleisis : sexually active ƴѰ쿡 vagina ϰ(colpectomy) closingϴ(colpocleisis) ִ.

l Transvaginal Sacrospinous Colpopexy : sexual function ϱ⸦ ϴ ϸ, vaginal apex (ַ ) sacrospinous ligament one or two sutures ִ ̴. ſ ̳ ϸ ַ anterior prolapse ϴ.

l Transabdominal sacral colpopexy : graft of fascia artificial mesh vagina suture sacrum ٽ sutureν anterior longitudinal ligament suspensionȴ. ſ ̳ ϸ posterior prolapse ϴ.