Anatomy 9 - Anatomy of urinary incontinence and prolapse Flashcards
What is the purpose of the pelvic floor? (3)
Separates the pelvic cavity from the perineum
Plays important role in providing support to pelvic organs
Plays an important role in maintaining continence (urinary and faecal)
3 layers of the pelvic floor?
Pelvic diaphragm
Muscles of the perineal pouches
Perineal membrane
Which is the deepest layer of the pelvic floor?
Pelvic dipahragm
What 2 muscles make up the pelvic diaphragm?
Levator ani
Coccygeus
What shape is the pelvic diaphragm?
Sling-shaped
What is the name for the anterior gap between the medial borders of the pelvic diaphragm muscles?
Urogenital hiatus
Purpose of the urogenital hiatus?
Passageway for urethra (males and females) and vagina
Is levator ani or coccygeus more posterior?
Coccygeus
What ligament does coccygeus lie on?
Sacrospinous ligament
Attachments of levator ani?
Pubic bone, ischial spines and tendinous arch of levator ani
Perineal body, coccyx and walls of organs in midline
3 parts of levator ani? (from medial to lateral)
Puborectalis
Pubococcygeus
Iliococcygeus
What happens to the levator ani when you urinate/ defecate?
It must relax
Nerve supply to levator ani?
Pudendal nerve
Nerve to levator ani
Apart from the pelvic floor, what are 2 other groups of supportive tissues for the pelvic organs?
Endo-pelvic fascia
Pelvic ligaments
What is endo-pelvic fascia?
Connective tissue “packing” -> what the bladder and rectum expand into
What is the endo-pelvic fascia made of?
Loose areolar tissue (loose connective tissue) Fibrous tissue (collagen and elastic fibres)
Name 5 supporting pelvic ligaments?
Utero-sacral ligamnet Transverse cervical ligament (cardinal ligament) Tendinous arch of pelvic fascia Tendinous arch of levator ani Lateral ligament of bladder
Where does the deep perineal pouch lie?
Below the fascia covering the inferior aspect of the pelvic diaphragm
Above the perineal membrane
What does the deep perineal pouch contain? (6)
Part of the urethra Part of the vagina in females Bulbourethral glands in male Neurovascular bundle of penis/ clitoris Extensions of the ischioanal fat pads Muscles
Deep perineal pouch muscles in males and females?(3)
External urethral sphincter
Compressor urethrae
Deep transverse perineal muscles
Is the deep transverse perineal muscle voluntary or involuntary in males?
Skeletal = voluntary
Is the deep transverse perineal muscle voluntary or involuntary in females?
Smooth (involuntary)
What does the perineal membrane separate?
Superficial and deep perineal pouch
What is the perineal membrane?
Thin sheet of tough, deep fascia
What does the perineal membrane attach to laterally?
Pubic arch
What does the perineal membrane close?
Urogenital traingle
Are there any holes in the perineal membrane?
Yes, for the urethra and the vagina in geamles
Where does the superficial perineal pouch lie?
Below the perineal membrane
What does the root of the penis consist of?
Bulb
Crura
Associated muscles (bulbospongiosus and ischiocarvernosus)
What does the superficial perineal pouch consist of in the male? (4)
Root of the penis
Proximal spongy urethra
Superficial transverse perineal muscle
Branches of internal pudendal vessels and pudendal nerve
Is the superficial perineal pouch part of the pelvic floor?
No
What does the female superficial perineal pouch contain?
Female erectile tissue
Greater vestibular glands
Superficial transverse perineal muscle
Branches of internal pudendal vessels and nerve
Name the erectile tissue in females? (3)
Crura and clitorris
Bulbs of vestibule (paired)
Associated muscles - bulbospongiosus and ischiocavernosus
What is located at the bottom of the bulbs of vestibule in females?
Greater vestibular glands (bartholin’s glands)
What structure between the vagina and anus is important for pelvic floor support?
Perineal body
How does the pelvic floor provide support to pelvic organs?
Normally tonically contracted and actively contracts during coughing, sneezing and vomiting
What parts of the pelvic floor help maintain urinary continence? (3)
External urethral sphincter
Compressor urethrae
Levator ani
How does the pelvic floor help to maintain faecal continence?
Tonic contraction of puborectalis bends the anorectum anteriorly
Active contraction maintains continence after rectal filling
How can childbirth lead to pelvic floor injury?
Stretching or tearing
Pudendal nerve damage
Is the external urethral sphincter voluntary or involuntary in females?
Voluntary (same as in males)
What does urinary continence depend on? (3)
Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall
What structures can prolapse? (6)
Uterus Vagina Bladder Urethra Rectum Intestine
Name for part of prolapsed bladder?
Cystocele
Name for part of prolapsed intestine?
Enterocele
Name for part of prolapsed rectum?
Rectocele
Name for part of prolapsed urethra?
Urethrocele
What is the name for the herniation of urethra, bladder, rectum or rectouterine pouch through the supporting fascia of the vagina?
Vaginal prolapse
How does a vaginal prolapse present?
Lump in vaginal wall
1st degree uterine prolapsed?
Slippage of the cervix slightly further down
2nd degree uterine prolapsed?
Both the cervix and uterus sliding down
3rd degree uterine prolapsed?
Whole uterus slides down, passing out of the body
Treatment of a uterine prolapsed?
Sacrospinous fixation - sutures placed in sacrospinous ligament to repair cervical descent
Describe incontinence surgery?
Mesh put through obturator canal to create a sling around the urethra
(incisions made through vagina and groin)
What can be injured during prolapse repair? (2)
Sciatic nerve
Pudendal NVB
