4 - Pelvic Floor Flashcards
What are the ligaments supporting the uterus?
- Pubocervical
- Transverse/Cardinal (inferior broad ligament)
- Uterosacral
Arise from the sides of the cervix and lateral fornix of vagina
What is the clinical importance of the cardinal ligaments?
Commonly removed in a hysterectomy as a reservoir for cancerous cells sometimes
Label the following superficial structures of the female pelvic floor.
Label the deep muscles of the female pelvic floor
What are the functions of the pelvic floor?
- Support the pelvic organs like vagina, uterus, ovaries, bladder, rectum
- Maintain intra-abdominal pressure during sneezing and laughing
- Facilitate childbirth
- Continence
What are the 3 levels of support that the pelvic floor provides?
1. Suspension: by cardinal and uterosacral ligaments. round ligament holds in anteversion
2. Attachment: attachment to other pelvic organs e.g vagina to endopelvic fascia, levator ani and perineal body
3. Fusion: fusion of tissues, e.g urogenital diaphragm and perineal body
What is the lower half of the vagina supported by?
Anterior: urethra
Laterally: levator ani
Posterior: perineal body
How does the urethra maintain continence?
Lies anteriorly and above the fascia so in increased intra-abdominal pressure it gets compressed against the fascia closing it
What ar the main components of the pelvic floor?
- Urogenital diaphragm/Perineal membrane
- Perineal body
- Perineal muscles
What are the deep muscles of the pelvic floor?
- Coccygeus
- Levator ani: pubococcygeus, puborectalis, iliococcygeus
Midpoint is the perineal body. Fibres insert on lower part of coccyx and anococcygeal raphe
What are the superficial muscles of the pelvic floor?
- Transverse hold vagina laterally
- Bulbospongiosus can be torn by stretching
What might you do if a mother is having an issue with delivery as the baby is too large? What are the risks and benefits of this procedure?
- Medio-lateral episiotomy
- May cause issues with infection, haemorraghe, external anal sphincter and dyspareunia
- Done to avoid damage to perineal body as this is central to support
- Also done to prevent perineal damage like 2nd/3rd degree tears
What is the perineal body and the urogenital diaphragm?
- Perineal body: Central point between vagina and rectum. Site of attachment for pelvic floor muscles and structure
- Urogenital Diaphragm: Sheet of dense fibrous tissue across anterior half of pelvic floor, attached to vagina, urethra and perinally body. Support
What is the blood supply and innervation to the pelvic floor?
Blood: external and internal pudendal arteries
Lymphatics: inguinal
Nerve: pudendal nerves S2,S3,S4, so damage to this nerve issue with pelvic floor support
Label this diagram of the pelvic floor
What are some conditions caused by pelvic floor dysfunction?
- Pelvic organ prolapse
- Urinary incontinence
- Posterior compartment pelvic floor dysfunction
How can we classify pelvic organ prolapses?
- Loss of support for the uterus, bladder, colon or rectum so there is a prolapse into the vagina
- Some can be symptomatic, e.g dragging, pain on sex, constipation and some asymptomatic
What are some causes and risk factors of pelvic organ prolapse?
- Age
- Parity (how many kids)
- Vaginal delivery
- Obesity
- Chronic raised intra-abdominal presire
- Postmenopausal oestrogen deficiency
- CT and Neurological disorders, e.g DMD, Marfan’s
How would you assess a present pelvic organ prolapse?
- History: patient may find a lump down below or something coming down
- Symptoms like constipation or dragging
- Examine and use the POP-Q system
How would you manage a pelvic organ prolapse?
Need to consider severity, how much QoL lost, fitness for surgery, plans for children, nature of work, sexual activity
- Non surgical: Use of pessaries
- Surgical: hysterectomy, mesh in a vault prolapse (risk of reoccurence)
How do you prevent an obstetric anal sphincter injury?
- High morbidity rate if 3rd/4th degree tears
- Episiotomy
- Encourgae mother not to push when head is crowning
What is stress incontinence, what are the risk factors and how is it managed?
- Dysfunction of pelvic floor so when raised intra-abdominal pressure there is inadequate support to urethral sphincter so leakage of urine
- Same risk factors as POP, oestrogen deficiency and age especially
- 1st line is pelvic floor exercises. Can also surgically create slings to support urethral sphincter
What are some vulval problems that the pelvic floor can cause?
- Vestibulodynia: painful vulva due to tension in the levator ani muscles
- Vaginismus: pain on vaginal penetration due to involuntary muscle spasm
What is the definition and different types of female genital mutilation?
Procedures involving parital or total removal of the external female genitalia or other injury to female genital organs.
What are the complications with FGM?
What should you do if you discover someone is a victim of FGM?
- Illegal for UK nationals to do this here or abroad
- Also illegal to close back after episiotomy even if lady requests it
- Needs to be reported to police and put as safeguarding if female is under 18
What is posterior compartment pelvic floor dysfunction?
- Range of conditions affecting posterior pelvic floor, e.g constipation and incomplete evacuation, anal incontinence
- In women usually due to OASIS
What is the point of insertion of the levator ani muscles?
Perineal body
According to the WHO classification, which part of the female external genitalia is predominantly affected in type 3 FGM?
Labia majora
How does the perineal body function to maintain pelvic organ support
Acts as point of attachment for perineal muscles
What are some risk factors for pelvic organ prolapse?
- Menopause
- Heavy lifting
- CT disorder
- Vaginal delivery: stretch of ligaments, damage to muscle, stretching of pudendal nerve
Distinguish between spermatogenesis and spermiogenesis. Where does each occur?
Give 2 risk factors for developing CIN.
What is the lymphatic drainage of the cervix?
When do syncytiotrophoblasts start to produce hCG in significant levels?
2 weeks after conception
Why may the mother develop anaemia during the second trimester of pregnancy
Increase in plasma volume greater than increase in red cell mass. Dilutional anaemia
