224. Pelvic Floor Disorders

Question 1

What are the levels of pelvic organ support and how do they shape female anatomy?

Answer 1

I: uterosacral and cardinal ligaments: apical support of vagina (circular shape of cervix)
II: Arcus tendineous fascia pelvis: lateral/longitudinal support (square shape of vagina)
III: perineal muscles: distal support (round shape of introitus)

Question 2

Differentiate between endopelvic fascia, parietal fascia, visceral fascia

Answer 2

Endopelvic Fascia: loose c.t. containing collagen, elastin, smooth muscle, anchored to parietal fascia of muscles

Parietal Fascia: Dense c.t. limited vascular supply, covers pelvic muscles, provides attachment to bony pelvis

Visceral Fascia: suspends viscera over pelvic floor, conduit for nerves vessels lymph system

Question 3

Prevalence of Pelvic Floor Disorders

RFs for pelvic floor disorders

Answer 3

Prevalence: 1/3 women!! Urinary incontinence is MOST COMMON problem

RF: Aging, obesity, CHILDBIRTH (most consistent RF), constipation, smoking

Question 4

Pelvic Organ Prolapse (POP)

• what is it
• how to spot diff types of protrusion
• RFs
• Sx
• Tx
• what happens in a sarcocolpopexy, USLS, SSLS, Colpocleisis

Answer 4

Loss of uterine support = protrusion of viscera and wall eversion
Bladder protrusion: ant vaginal wall
Rectum protrusion: Post vaginal wall
Apical Compartment: entire vagina everted

RF: genetic, aging tissue, pelvic floor injury (childbirth, lifestyle)

Sx: BULGE, urinary incontinence, bowel problems (straining, stool trapping, fecal incontinence), sexual discomfort

Tx:
Mechanical Pessary: insert to hold organs up above pelvic floor
Surgical: Reconstructive (native tissue or nonnative mesh to allow intercourse, normal appearance) vs. Obliterative (close vaginal canal and genital hiatus)

Sarcocolpopexy: mesh suspension of vagina to sacrum (anterior long ligament)
Uterosacral Ligament Suspension (USLS): Use native USL to suspend vagina to ALL of sacrum
Sacrospinous Ligament Suspension (SSLS): suture vagina to one side SSL - deviates vagina to one side
Colpocleisis

Question 5

Urinary Incontinence

• differences between stress UI and urgency UI
• tx (4 for SUI, 3 for UUI)

Answer 5

SUI: neuromuscular injury to pudendal N. = ext urethral sphincter cannot fx to hold urine

UUI: loss of CNS control of mAChRs on bladder (problem in bladder wall) = urinary urgency, frequency, nocturia, leakage (bladder contracts spontaneously)

Tx:
SUI: Burch colposuspension: suture urethra to ileopectineal ligament
Autologous Fascia Sling: loop fascia from abd wall around urethra like sling
Minimally Invasive Midurethral Sling: safer without abd approach
Pessary: non-surgical removable insert with knob compressing urethral outlet (requires cleaning)

UUI
Tier 1: conservative: bladder retraining (timed voids), fluid mgmt
Tier 2: meds (antimuscarinics to stop contraction, b3 agonists to increase symps)
Tier 3: sacral neuromodulation to stim nerve root, botox injection to detrusor m.

Question 6

Fecal Incontinence

• describe the rectoanal inhibitory reflex
• pathophys: functional vs structural abnormality
• tx

Answer 6

Rectoanal Inhibitory Reflex: internal anal sphincter relaxes and samples contents (gas liquid solid)

• if defection: relax puborectalis, sling, ext anal sphincter, pass stool
• if no want defecation: ext anal sphincter contracts, doubling anal canal pressure, puborectalis contracts, stool in rectum

Functional Abnormality

• constipation/fecal impaction causes loose stool float around it
• loose stool due to physical immobility, drugs, cognitive impairment

Structural Abnormality
- anal sphincter m injury, rectal abnormalities, pudendal n. injury, CNS/SC injury

Tx:
Functional: alter stool consistency: psyllium husk (bulking agent), low dose loperamide (slows stool transit and more reabs and more int anal sphinter tone), tx underlying constipation, bathroom cues for cog impairment, physical assistance, ENEMA to empty rectum before planned activity
Structural: Pelvic Floor PT (increase anal sphincter tone), vaginal bowel control device, anal bulking, sacral neuromodulation, sphincteroplasty (repair anal sphincter m. only for young women who RECENTLY injured it in childbirth)