3 Flashcards
What are the functions of the pelvic floor?
- support the pelvic organs (mainly vagina, uterus, ovaries, bladder and rectum)
- maintain intra-abdominal pressure during coughing, vomiting, sneezing and laughing
- facilitate defecation and micturition
- maintain urinary and faecal continence
- facilitate childbirth
- breathing
- sexual function
What are the three mechanisms that help the pelvic floor to support? Define them
- Suspension: maintains an “anti-gravity” position by providing strong vertical support, mainly from the cardinal ligaments and Uterosacral ligaments
- Attachment: structures piercing the pelvic floor muscles are attached to it, for example the vagina is supported by its attachment to endopelvic fascia, levator ani muscle and the perineal body
- Fusion: support that arises from fusion of different tissues, for example the urogenital diaphragm and the perineal body, implies link, connection, inseparable
- Ex: lower half of vagina is supported by fusion of vaginal endopelvic fascia to the perineal body posteriorly, levator ani laterally and urethra anteriorly
Describe the cardinal ligament
- holds the cervix and upper vagina in place
- a transverse ligament that works against gravity
Describe the Uterosacral ligaments
-holding the back of the cervix and upper vagina laterally
Describe the round ligament
- maintains the antiverted position of the uterus
- more of a position support
Describe the two fascia that help with attachment
- Argus tendinitis fascia pelvis (AFTP): aka the “white line”
- Endopelvic fascia: stretches like a hammock from the white line laterally, to the vaginal wall medially
- urethra lies anterior and above it and, thus, gets compressed against it during increased intra-abd pressure
- IMPORTANT IN MAINTAING URINARY CONTINENCE (forces urethra to close)
What are the layers of the pelvic floor, from top to bottom?
- Levator ani muscles
- urogenital diaphragm/perineal membrane
- perineal body (fusion of all the muscles)
- perineal muscles
- posterior compartment
Describe the deep muscles of the pelvic floor
-U-shaped set of muscles that act like a sling to encircle the urethra, vagina and rectum, and provide support for these organs
-stretches backwards and inwards from either side of the pelvis to meet in the middle line
-originates from back of the pubic bone, the white line over obturator internus, and medial aspect of ischial spine
-some of the fibres are inserted as they encircle the urethra, some are inserted as they encircle the vagina, where they take part in forming the perineal body
-some fibres are inserted as they encircle the rectum and rest are inserted in the lower part of the coccyx and anococcygeal raphe
THREE MUSCLES: puborectalis (around rectum), pubococcygeus, iliococcygeus
What are the 3 superficial muscles and what is their purpose?
- most commonly involved in perineal trauma-accident, sexual, obstetric
- Bulbospongiosus, ischiocavernosus, superficial transverse perineal
Describe a medio-lateral episiotomy
- done to avoid damage to the perineal body, b/c of its integral role in providing pelvic floor support as a site of attachment
- can be done if baby is large or difficult deliver
- can cause complications such as infection, haemorrhage, dyspareunia and damage to anal sphincter
- done to prevent perineal damage
- bulbospongiosus and transverse perineal muscles undergo iatrogenic damage
Describe the perineal body
- central point between the vagina and the rectum
- main function is to act as a site of attachment for pelvic floor muscles and other structures that provide support for the pelvic floor
- attached posteriorly to external anal sphincter and the coccyx
- support of the perineal structures rely on it
Describe the urogenital diaphragm
- Triangular sheet of dense fibrous tissue that spans the anterior half of the pelvic floor
- also attaches to the urethra, vagina and perineal body
- arises from the inferior ischiopubic Ramus
- supports the pelvic floor
What is the blood supply, innervation, venous and lymphatic drainage of the pelvic floor?
- blood supply: internal and external pudendal artery and drains through CORRESPONDING veins
- lymphatic drainage: inguinal lymph nodes
- nerve supply: branches of the pudendal nerve which derives its fibres from the ventral branches of the second, third and fourth sacral nerve
Describe pelvic floor dysfunction
-wide range of symptoms and conditions that can arise as a result of problems to do with pelvic floor Different types: -Pelvic organ prolapse -Incontinence: urinary (stress) -Posterior compartment pelvic floor dysfunction -Obstetric trauma including episiotomy -FGM -Vaginismus -Vulval pain syndromes
What is pelvic organ prolapse?
- loss of support for the uterus, bladder or colon which results of a prolapse of any of these organs into the vagina
- not life-threatening but has a significant impact on quality of life, perception of body image and can cause depressive symptoms
- associated with significant function disturbances including: anorectal, urinary, and sexual
What are the POPs in the anterior compartment?
- usually relates to bladder and/or urethra
- cystoceole: bladder
- urethrocoele: urethra
- cystourethrocoele: both
What POP can occur in the middle compartment?
- uterine prolapse
- procidentia: when ENTIRE uterus prolapses
- after a hysterectomy: apex may still prolapse which is called POST_HYSTERECTOMY VAULT PROLAPSE
What POP can occur in the posterior compartment?
- rectum may prolapse into the posterior part of the vagina-rectocele
- loops of bowel may prolapse into the rectovaginal space (pouch of Douglas): enterocele
What are the causes and risk factors of POP?
- age
- parity
- mode of delivery (i.e. vaginal delivery)
- oestrogen deficiency
- chromic increased abd pressure, obesity
- connective tissue or neurological disorders (ex. Muscular dystrophy, Marfans)
What type of history and examination would you take for pt’s with POP?
- pt. Will feel a lump down below, or something “coming down”, dragging
- may also experience constipation if rectal prolapse
How would you manage a pt with POP?
Need to consider these factors:
-nature of symptoms and degree of bother
-nature and extent of prolapse
-completion of family and future pregnancy plans
-sexual activity
-fitness for surgery and anaesthesia
-woman’s goals
-work, physical activity and domestic circumstances
Non surgical option: pessaries (holds the pelvis and its organs up between the two bones) including ring, shelf, and gel horn pessaries
Surgical option:
-more definitive treatment
-risk of recurrence and potential complications
-can be performed vaginally, abdominal, laparoscopically
-included anterior/posterior repair, vaginal hysterectomy etc.
