3. The Pelvic Floor Flashcards
What is the function of the pelvic floor?
Support the pelvic organs (vagina, uterus, ovaries, bladder and rectum)
Maintain intra-abdominal pressure during coughing, vomiting, sneezing, laughing
Facilitate defaecation and micturition
Maintain continence
Facilitate childbirth
By what 3 mechanisms does the pelvic floor offer support?
Suspension
Attachment
Fusion
What do the cardinal ligaments do?
Hold cervix and upper vagina in place
What do the utersacral ligaments do?
Holding back of the cervix and upper vagina laterally
What are the attachments provided by?
Arcus tendinosus fascia pelvis (white line)
Endopelvic fascia - stretches from white line laterally, to vaginal wall medially
What does fusion involve?
Urogenital diaphragm and perineal body
What is the lower half of the vagina supported by?
Fusion of vaginal endopelvic fascia to the perineal body posteriorly, the levator ani laterally and the urethra anteriorly
What are the components of the pelvic floor?
Predominantly levator ani muscles Urogenital diaphragm/perineal membrane Perineal body Perineal muscles Posterior compartment
Describe the levator ani muscles
Form a U-shaped sheet
Stretches backwards and inwards from either side of the pelvis to meet in the middle line
Encircles the urethra, vagina and the rectum and reaching the coccyx
What are the perineal muscles?
Transverse perineal muscles - superficial and deep
Bulbospongiosus
Describe the urogenital diaphragm
Triangular sheet of dense fibrous tissue
Spans the anterior half of the pelvic outlet
Arises from the inferior ischiopubic ramus
Attaches medially to the urethra, vagina and perineal body
Describe the perineal body
Occupies a central position on the pelvic floor, between the vagina and rectum
Point of insertion of the levator ani muscles
Attached posterior to the external anal sphincter and the coccyx
What is the blood supply of the pelvic floor?
Internal and external pudendal arteries and drains through corresponding veins
What is the lymphatic drainage of the pelvic floor?
Inguinal lymph nodes
What is the nerve supply of the pelvic floor?
Branches of the pudendal nerve
What is a pelvic organ prolapse?
Refers to loss of support for the uterus, bladder, colon or rectum, leading to prolapse of one or more of these organs into the vagina
What is prolapse in anterior compartment called?
Cystocoele
Urethrocoele
Cystourethrocoele
What is a prolapse in the middle compartment?
Uterus may prolapse - uterine prolapse
Entire uterus - procidentia
Post-hysterectomy vault prolapse
What is a prolapse in the posterior compartment?
Rectum may prolapse into posterior part of vagina - rectocele
Loops of bowel may prolapse into rectovaginal space - enterocele
What are the risk factors for prolapse?
Age
Parity
Vaginal delivery
Obesity and causes of chronic raised intra-abdominal pressure
What factors need to be considered in prolapse management?
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
What are the non-surgical options of prolapse?
Pessaries - ring, shelf, gelhorn
Which incontinence is due to pelvic floor?
Stress incontinence
What is vestibulodynia?
Painful vulva
What is vaginisimus?
Pain on vaginal penetration due to involuntary muscle spasm
What are the consequences and complications of FGM?
Acute - haemorrhage, infection, sepsis, death
Late - sexual difficulties, fertility issues, pain, urine outflow obstruction
Obstetric - fear of childbirth, postpartum haemorrhage
Psychological - flashbacks, PTSD, self-esteem issues
What does posterior compartment pelvic floor dysfunction present as?
Vaginal or rectal bulge/lump Constipation Incomplete evacuation Dyssynergic defection Anal incontinence
What are the causes of posterior compartment pelvic floor dysfunction?
Structural Drugs Dehydration Immobility Pregnancy Postoperative pain
