Pelvic Relaxation、 Uterus prolapse  子宮下垂  

　

　

Pelvic relaxation is the loss of the stuctures that support the contents of the female pelvis. The result is a group of clinical symptoms ,manifested by complaints of pelvic heaviness , discomfort and genital protrusion.

 Supportive anatomic structures:

a. bony pelvis.

b. pelvic diaphragm (levator ani muscle complex and its superior and  inferior fascia ).

c. urogenital diaphragm.

d. cardinal and uterosacral ligments.

e. bulbocavernous muscle and external sphincter ani muscle.

f. perineal body.

 Pelvic organs involved in pelvic relaxation and associated clinical manifestations

a. bladder: cyctocele, pelvic pressure, genital protrusion

b. urethra: urethrocele (urethral detachment), stress urinary incontinence.

c. rectum: rectocele, defecatory dysfunction, genital protrusion.

d. uterus and cervix : uterine descensus (uterovaginal prolapse ), pelvvc pressure, genital protrusion.

e. vagina: anterior wall prolapse (cyctocele, urethrocele, cystourethrocele); posterior wall prolapse (rectocele, enterocele); vault prolapse.

f. omentum and bowel : enterocele, vault prolapse.

 Etilogy of plvic support disorders:

1. congenital weakness of tissues

2. aging. collagen is lost from the connective tissues of postmenopausal women ,causing loss of strength

3. vagal delivery . passage of an infant through the birth canal stretches and weaken the levators and connective tissues of the pelvis

4. exercise .  frequent strenuous exercise

 diagnosis

symptoms

A. prolapse: uterus prolapse completely prolapse beyond the introitus termed "procedentia"

Grading：生殖泌尿器官脫垂程度的分級(grading)，一直不是很清楚且沒有特定標準。因為這種分級方式(比如只分minimal、moderate、severe)對於器官脫垂原因的探討與治療效果的評估會造成不確實的後果。

I. Vaginal profile：這是由Baden與Walker在1972年首先提出，後來又經Shull作了修正。他們以hymen與陰道的中點來做分級的標的(land mark)。以子宮頸尿道或膀胱而言，讓病人的腹部充分用力的情況下，子宮頸(portio)在陰道中點以上，即未超過中點時為zero degree，當portio cervix超過中點時，為first degree，而portio cervix到達hymen的level為second degree，當portio cervix超過hymen為third degree，假如整個子宮倒翻出來，則為fourth degree。但是，enterocele的分級則另有一套；以陰道由culdesac到hymen的長度來分。當culdesac達1/4 to hymen為first degree，達1/2 to hymen為second degree，達3/4 to hymen為third degree，culdesac掉到hymen level則為fouth degree。

II. ICS(International Continence Society)System：這是ICS在1994年所提出一種新的分級法(如圖)。

Point Aa的定義是在前陰道壁的中間線，離尿道口3公分處。因此假如沒有脫垂的話，Aa與hymen的關係為-3cm，假如complete vault eversion則為+3cm。這個分級系統較為專業且複雜，又經統計分析證實，上述兩個分級系統各有其存在的必要性且具相關正確性。對一般臨床醫師而言，vaginal profile足矣！

以上兩個系統的檢查法如下：病人先將膀胱排空，以supine position受檢。檢查者先觀其external genitalia與introitus。再用Sims speculum放入陰道審視有否urethrocele、cystocele、utero-vaginal prolapse、enterocele或rectocele，然後讓病人腹部用力至上述器官掉到最低點為止。

 B. pelvic discomfort: dull lower back or pelvic pain, introital irritation, dyspareunia

C. urinary symptoms:

a. stress urinary incontinence

b. recurrent urinary infection

c. urinary obstruction

D. rectal symptoms:

a. difficult defecation

b. incontinence 

Treatment of pelvic support disorders 

Choice of Treatment

Expectent management:

No symptoms or relatively mild, patient should be taught the technique of perineal muscle exercise and encouraged to do them. 

Estrogen replacement , Kegel's exercise

 Pessaries: too ill to undergo operation or p't refuses operation 

Surgical management indication:

Sugery should be undertaken only in the patient who is either still symptomatic after nonsurgical approaches have been attempted or desires  sugical intervention in lieu of nonsurgical therapy. 

1. Surgery for uterine prolapse

vaginal hysterectomy with colporrhaphy , McCall Culdoplasty and to reattaching the endopelvic fascia and the uterosacral ligment to vaginal cuff to provide additional support or sacrospinous ligment fixaton or abdominal approach retroperitonel uterosacropexy 

2. Surgery for cystocele: Corrected by anterior colporrhaphy

 3. Surgery for rectocele: Correctd by posterior colporrhphy  

4. Uteropexy: abdominal uterine suspension eg. Gilliam suspension ,and colporrhaphy without hysterectomy with prolapse who desire future fertility .

Operation for Complete eversion of the vagina:

1. Colpectomy and colpocleisis eldly women,not sexally active can be managed by surgically removing the vagina and closing the space

2. Colpopexy younger women retain sexal function

a. transvaginal sacrospious colpopexy

b. transabdominal sacral colpopexy Both opertions are highly successful in resuspending the vaginal apex.