Pelvic Floor Dysfunction
OB & GYN Hospital, Fudan University
Lei Yuan , MD
ylronda@163.com
Questions
What does pelvic floor consist
of?
Where are they?
(Location, Function)
Pelvis
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Anatomy of Pelvic floor
anal triangle
urogenital triangle
skin
subcutaneous tissue
superficial perineal fascia
ischiorectal fossa
bulbospongiosus m./ ischiocavernosus m./
superfical transverse perineal m.
Inferior fasica of UG diaphragm
deep transverse perineal m.
Superior fasica of UG diaphragm
Inferior fasica of Pelvic diaphragm
levator ani m., coccygeus m.
superior fasica of Pelvic diaphragm
Pelvic diaphragm
坐骨尾骨肌
髂尾肌
(Iliococcygeus)
耻尾肌 (Pubococcygeus)
耻骨直肠肌 (Puborectalis)
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Arcus tendineus（white line）
盆筋膜腱弓(白线)
(Arcus tendineus fasciae pelvis)
肛提肌腱弓
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Fascia and ligaments
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Anatomy of Pelvic floor
anal triangle
urogenital triangle
skin
subcutaneous tissue
superficial perineal fascia
ischiorectal fossa
bulbospongiosus m./ ischiocavernosus m./
superfical transverse perineal m.
Inferior fasica of UG diaphragm
deep transverse perineal m.
Superior fasica of UG diaphragm
Inferior fasica of Pelvic diaphragm
levator ani m., coccygeus m.
superior fasica of Pelvic diaphragm
Longitudinal view
Function of pelvic diaphragm
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Function of pelvic floor
 Supportive structure Pelvic organ prolapse
 Orchestrate a series of physiological
function
 Parturition
 Micturition
 Defecation
Lower urinary tract disorder (SUI)
Anorectal Disorder
( fecal incontinence)
Integral Theory (Petros）
Anatomic anomaly functional
abnormalities
Site specific defects
 LEVEL 1 ligaments(cardinal lig. Uterosacral lig.)
 LEVEL 2 pelvic diaphragm, muscle( levator ani.)
 LEVEL 3 perineum & soft tissue
Integral Theory (Petros）
RFRF
Restoration of form(structure) leads
to Restoration of function
Principles of surgery
 Retain;
 Reconstruction;
 Replacement(mesh)
3 levels of support
Delancey, 1994
Three zones
(compartments )of pelvis
Anterior zone
Middle zone
Posterior zone
Case discussion
Chief complain：feeling a ball in the
vagina for 4 years and progressively
worsen for the last 6 months
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www.china-obgyn.net
Question
What else would you like to know
about the patient’s history?
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Risk factors for PFD
Pregnancy
Vaginal childbirth
Menopause
Aging
Hypoestrogenism
Chronically increased intra-abdominal pressure
Chronic obstructive pulmonary disease (COPD)
Constipation
Obesity
Pelvic floor trauma
Genetic factors
Race
Connective tissue disorders
Hysterectomy
Spina bifida
 Age?
 The causes of uterine prolapse?
chronic coughing? Chronic diarrhea or constipation? Cachexia?
 Clinical symptoms
bulge symptom; urinary and bowel symptoms; sexual
symptom; pain
 Accessory examination and history acquiring
History of pregnancy and parturition
History of DM、TB, etc
Accessory examination to exclude malignant disease and other
nervous system disease
 Previous treatment
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The complete case
 Chief complain:
feeling a ball in the vagina for 4 years and progressively
worsen for the last 6 months
 History:
Previous menstruation: regular, 7/27-32，moderate volume;
dysmenorrhea(-). Natural menopause for 30 yrs and never
receive HRT after menopause. No abnormal vaginal bleeding
and vaginal discharge.
Sensation of a vaginal protrusion 4 yrs ago and the size was
the same like a bean, the symptom was deteriorated when
standing or pelvic pressure increased while alleviated after
lying down. Pessary use was recommended 1 yr ago, however,
the patient didn’t use it because of the difficulty of removing
the pessary.
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The symptom was deteriorated in the last 6 months with the
egg-like ball bulged totally from the vagina when walking and
only part of it can be returned to the vagina after lying down.
However, the protrusion can be totally returned to the vagina
by hand. No concurrent urinary frequency, urinary urgency,
seldom complain of voiding dysfunction but didn’t receive any
treatment. Good control of urination and never had involuntary
leakage of urine with coughing.
No abdominal pain or low back pain, no abnormal vaginal
discharge. No change in appetite or sleep pattern, no cachexia,
complain of constipation in recent months.
 Previous history:
Hypertension for 1 yr, BP：130-140/50-60mmHg,maxium:
180/80mmHg. Current treatment: Levamlodipine Beslate p.o
DM for 6-7yrs， Current treatment: Insulin 14u(am),
0u(noon), 5u(pm), s.c; Acarbose: 1# tid, p.o
No previous surgery
 Marital and Fertile History:
G2P2，1963，1966 vaginal delivery，fetal birth weight :3kg
No dystocia history
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Pelvic examination Valsalva maneuver
– Vagina: no congestion
– Cervix: atrophy, decent totally beyond the hymen
– Uterus: decent totally beyond the hymen, atrophy,
unfixed, no tenderness
– Adnexal: normal
– Vagino-recto-abdominal examination: normal
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POP-Q
+3
+5
+5
4
2
7
+3
+5
+6
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Question
Initial diagnosis?
1. Pelvic floor dysfunction: Anterior III,
Middle IV, Posterior III
2. II-DM
3. Chronic hypertension
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Question
 Next step? (Accessory examination)
Urodynamics
Detect blood glucose(BG), BP
ECG+Holter
Pulmonary function (>70ys)
Echocardiography(>70ys)
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Question
Treatment( Principle? Option?)




Pessary
Laprotomy
Laproscopy
Vaginal surgery
 Transvaginal hysterectomy +Pelvic floor reconstruction(Total
prolift)
 Transvaginal hysterectomy + anterior and posterior vaginal
wall repair
 Transvaginal hysterectomy + Sacrospinous Ligament Fixation
 + Midurethral Slings (tension free vaginal tape , TVT)
 Transvaginal hysterectomy +Lefort surgery
 Lefort surgery
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Treatment principles（1）
Treatment choice depends on the type
and severity of symptoms, age and
medical co-morbidities, desire for
future sexual function and/or fertility,
and risk factors for recurrence
Treatment principles(2)
Conservative treatment
 Indication: mild-moderate prolapse
 Procedures: Pessary
Pelvic floor muscle exercise
(Kegel exercises, biofeedback therapy)
Treatment principles(3)
Surgical treatment
 Indication: severe prolapse(>III),
fail of conservative treatment
 Procedures: Obliterative procedures (Lefort
colpocleisis; complete colpocleisis)
Reconstructive procedures (depend on
different compartments)
• If with concurrent SUI, midurethral sling is
recommended
术式
 Anterior compartment
 anterior colporrhaphy（repair）
 If with moderate or severe SUI： TVT （Tension-Free Vaginal
Tape）
TVT-O
 Middle compartment （uterine prolapse, vaginal
vault prolapse, enterocele, Douglas hernia）
 Tradition：vaginal hysterectomy、Manchester surgery、
colpocleisis
 Now：Pubovaginal Sling（PIVS）、Sacrospinous Ligament
Fixation （SSLF)
 Posterior compartment
 posterior colporrhaphy（repair）
 Mesh
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POP-Quantification
STAGE 3
STAGE 2
STAGE 4
Quiz: POP-Q application
1. POP-Q score？
Anterior：III°(Ba+6)
Posterior：I°(Bp-2)
Middle(vaginal vault)：I°（C-2）
2.Management
阴道前壁修补术
经阴道阴道旁修补术
TVT-O
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Quiz: POP-Q application
1. POP-Q score？
Posterior：III °(Bp+5)
Middle(vaginal vault)：I°（C-6）
2.Management
经阴道后路悬吊带术（p-IVS）
骶棘韧带固定术（SSLF）
Posterior colporrhaphy
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Treatment
人类站起来了，
器官却掉下去了
When human being stand up,
Their organs decent…
Take home message
Understand the anatomy of pelvic floor and
etiology of pelvic floor dysfunction.
Understand definition and types of pelvic organ
prolapse and principle of treatment.
Understand definition and types of lower urinary
tract disorders and principle of treatment.