November 2002 · Vol. 14, No. 11Pelvic-support defects: a guide to anatomy and physiology
Due to high postoperative failure rates, the traditional treatment for pelvic-organ prolapse—hysterectomy with anterior and posterior colporrhaphy—is being replaced by procedures that target specific pelvic defects. Thus, a familiarity with pelvic-support mechanisms is crucial to determining corrective measures.
THOMAS
JULIAN,
MDDr. Julian is professor and director, division of gynecology, department of OBG, at the University of Wisconsin Hospital and Clinics in Madison, Wis.
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KEY POINTS
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The levator complex of muscles and the surrounding connective tissue, vessels, and nerves are often referred to as the pelvic floor.
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Studies have shown damage to muscle bundles of the levator and nerves of the pelvic floor after childbirth, including atrophic and degenerative muscle changes and slow nerveconduction velocities.
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To maintain urinary continence, there must either be an intrinsic urethral pressure greater than the pressure in the bladder or occlusion of the urethra when intra-abdominal pressure increases.
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Childbirth, chronic coughing, heavy lifting, or just inherent connective-tissue weakness and aging—each of these can cause pathophysiologic changes in the muscular and fascial structures of the pelvic floor, possibly leading to pelvic-support defects and, over time, pelvic-floor dysfunction. Patients with this condition may experience discomfort, urinary or fecal incontinence, or organ prolapse.
Traditionally, hysterectomy with anterior and posterior colporrhaphy has been the standard treatment for pelvic-organ prolapse. But due to this procedure’s high postoperative failure rate,1-3 a new approach is beginning to emerge. Lately, clinicians in the field of pelvicfloor dysfunction have begun advocating specialized evaluation techniques—among them, site-specific physical examinations, urodynamic testing, anal manometry, and anal sphincter ultrasound—to identify and measure anatomic and physiologic pelvic-support defects. Once the physician has determined the specific cause of the patient’s dysfunction, he or she can then direct treatment toward that defect.4 Therefore, when site-specific examination uncovers a paravaginal defect, for example, or ultrasound demonstrates anal sphincter disruption, a repair can be planned that will include correcting those problems.
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