3. The Pelvic Floor

Question 1

What is the function of the pelvic floor?

Answer 1

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

Question 2

By what 3 mechanisms does the pelvic floor offer support?

Answer 2

Suspension
Attachment
Fusion

Question 3

What do the cardinal ligaments do?

Answer 3

Hold cervix and upper vagina in place

Question 4

What do the utersacral ligaments do?

Answer 4

Holding back of the cervix and upper vagina laterally

Question 5

What are the attachments provided by?

Answer 5

Arcus tendinosus fascia pelvis (white line)

Endopelvic fascia - stretches from white line laterally, to vaginal wall medially

Question 6

What does fusion involve?

Answer 6

Urogenital diaphragm and perineal body

Question 7

What is the lower half of the vagina supported by?

Answer 7

Fusion of vaginal endopelvic fascia to the perineal body posteriorly, the levator ani laterally and the urethra anteriorly

Question 8

What are the components of the pelvic floor?

Answer 8

Predominantly levator ani muscles
Urogenital diaphragm/perineal membrane
Perineal body
Perineal muscles
Posterior compartment

Question 9

Describe the levator ani muscles

Answer 9

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

Question 10

What are the perineal muscles?

Answer 10

Transverse perineal muscles - superficial and deep

Bulbospongiosus

Question 11

Describe the urogenital diaphragm

Answer 11

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

Question 12

Describe the perineal body

Answer 12

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

Question 13

What is the blood supply of the pelvic floor?

Answer 13

Internal and external pudendal arteries and drains through corresponding veins

Question 14

What is the lymphatic drainage of the pelvic floor?

Answer 14

Inguinal lymph nodes

Question 15

What is the nerve supply of the pelvic floor?

Answer 15

Branches of the pudendal nerve

Question 16

What is a pelvic organ prolapse?

Answer 16

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

Question 17

What is prolapse in anterior compartment called?

Answer 17

Cystocoele
Urethrocoele
Cystourethrocoele

Question 18

What is a prolapse in the middle compartment?

Answer 18

Uterus may prolapse - uterine prolapse
Entire uterus - procidentia
Post-hysterectomy vault prolapse

Question 19

What is a prolapse in the posterior compartment?

Answer 19

Rectum may prolapse into posterior part of vagina - rectocele
Loops of bowel may prolapse into rectovaginal space - enterocele

Question 20

What are the risk factors for prolapse?

Answer 20

Age
Parity
Vaginal delivery
Obesity and causes of chronic raised intra-abdominal pressure

Question 21

What factors need to be considered in prolapse management?

Answer 21

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

Question 22

What are the non-surgical options of prolapse?

Answer 22

Pessaries - ring, shelf, gelhorn

Question 23

Which incontinence is due to pelvic floor?

Answer 23

Stress incontinence

Question 24

What is vestibulodynia?

Answer 24

Painful vulva

Question 25

What is vaginisimus?

Answer 25

Pain on vaginal penetration due to involuntary muscle spasm

Question 26

What are the consequences and complications of FGM?

Answer 26

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

Question 27

What does posterior compartment pelvic floor dysfunction present as?

Answer 27

Vaginal or rectal bulge/lump
Constipation
Incomplete evacuation
Dyssynergic defection
Anal incontinence

Question 28

What are the causes of posterior compartment pelvic floor dysfunction?

Answer 28

Structural
Drugs
Dehydration
Immobility
Pregnancy
Postoperative pain