Anatomy of Pelvic Floor and Prolapse Flashcards
Passive support of the pelvic floor
Fascia and ligaments
Active support of the pelvic support
Muscles of the pelvic floor (levator ani)
3 layers of the pelvic floor from superior to inferior
The pelvic fascia
The pelvic diaphragm
The urogenital diaphragm
Muscles of the anal sphincter complex
Internal anal sphincter
Conjoined longitudinal muscle
External anal sphincter
T/F: Internal anal sphincter is extension of the circular muscle layer of the rectum
T
T/F: Internal anal sphincter is under constant maximal contraction
T
% of resting anal tone provided by the internal anal sphincter
50 - 85%
Autonomic innervation of the internal anal sphincter
Parasympathetic…..S2-4
Sympathetic……..thoracolumbar ganglia (L5)
T/F: Suggested that both parasympathetic and sympathetic innervation cause inhibition of contraction
T
Formation of the conjoined longitudinal muscle
Extension of the longitudinal muscle layer of the rectum, along with levator ani muscle fibers
Structural support, anchoring the anorectum to the pelvis
Conjoined longitudinal muscle
T/F: External anal sphincter comprises a single layer of striated muscles
F. Multiple layers of striated muscle
% of resting anal tone provided by the external anal sphincter
25 - 30%
Somatic innervation of the external anal sphincter
Somatic innervation from the inferior rectal branch of the pudendal nerve (S2-3) and the perineal branch of S4
Levator ani muscles
Ischiococcygeus
Iliococcygeus
Pubococcygeus
Puborectalis Lig
Pubovaginalis Lig
Pubovesical Lig.
Origin and insertion of ischiococcygeus
Arises from the tip of the iscial spine close to the origin of obturator internus
Inserted into the coccyx and lower part of the sacrum
What forms the arcus tendineus
Arcus tendinous is a fibrous band formed by the fascia of the obturator internus
The iliococcygeus originates from what part of the arcus tendineus
posterior half of the arcus tendinous
The 2 insertion points of the iliococcygeus
Inserted into the side of the coccyx and ano-coccygeal raphe
The muscle arising from the anterior half of the arcus tendineus
Pubococcygeus
3 origins of the pubococcygeus
Arises from the anterior half of arcus tendineus, side and posterior surface of the pubis
2 insertion points of the pubococcygeus
Inserts into the tip of the coccyx and ano-coccygeal raphe
The 3 groups formed by the anterior fibres of the pubococcygeus
Puborectalis
Pubovaginalis
Pubo-vesical ligament
The anorectal angle is formed by which muscle
Puborectalis
The U-shaped and medial most part of the levator ani
Puborectalis
Origin and insertion of puborectalis
From the back of pubic bone & inserted into the ano-rectal junction
Origin and insertion of the pubovaginalis
Arises from the back of the pubis and inserted into the vagina and the perineal body
T/F: Tearing of the pubovaginalis results in 3rd degree perineal tear
T
The most anterior group of the pubococcygeus
Pubovesical ligament
Origin and insertion of the pubovesical ligament
It arises from the back of the pubic bone
Inserts into the junction between the
bladder and the urethra
The muscle that helps in raising pelvic diaphragm when it is necessary to raise intra-abdominal pressure:
During defaecation
During micturition
During coughing
During sneezing
During vomiting and forced expiration
Pubococcygeus
The muscle that during parturition
helps to support the head of the baby, guide the head towards the vaginal canal and helps in the expulsion of the fetus
Pubococcygeus
The muscle that during sexual relationship helps to tighten the phallus to contribute to orgasm in the female
Pubococcygeus
The muscle that allows for gross fecal continence
Puborectalis and the anorectal angle
The muscle that relieves pressure from the sphincter process
Puborectalis and the anorectal angle
What is responsible for gas and liquid continence
The sphinter complex
Defecation occurs with the relaxation of the – and contraction of the other levator muscles
Puborectalis
The most common pelvic organ prolapse
Cystocele
The 2 anterior compartment prolapse
- Bladder prolapse called cystocele (most common pelvic organ prolapse)
- Urethral prolapse called urethrocele
The 2 middle compartment prolapse
Uterine prolapse
Vaginal vault prolapse
The 2 posterior compartment prolapse
- Small bowel prolapse called enterocele.
- Rectal prolapse called rectocele
T/F: With normal tone of the levator ani the anorectal angle is acute and the levator plate is horizontal
T
Loss of tone in the levator ani results in –, – and –
- Change in the vaginal axis
- Sagging of the levator plate
- Enlargement of the urogenital
hiatus
Strongest support of the uterus
Transverse cervical/Mc Kenrodt Ligament
Runs from the pubis to the fundus of the cervix
Pubocervical ligament
Arises from the back of the uterus and attaches to the sacrum on either side
Uterosacral ligament
5 causes of prolapse
- Injury sustained during child birth:
C. During instrumental vaginal delivery especially with forceps and there is exertion of traction on the support. - Respiratory problems e.g in bronchitis
- Post-hysterectomy
- Congenital weakness
- Aging (menopause) due hypoeostrogen state
9 precipitating factors for prolapse
Chronic constipation
Chronic cough
Lifting of heavy objects
Manual work
Straining for long period
Large intra-abdominal tumour
Ascites
Pregnancy
obesity
4 determinants of incidence of prolapse
Level of obstetric care
Parity of the patient
Pelvic anatomy
Cultural factors e.g farming
6 clinical features of prolapse
History of something coming out of the vaginal Reducible or not
More prominent on standing or reduces on lying down down
Dragging sensation or pelvic discomfort
Backache
Abnormal vaginal discharge or bleeding due to ulceration of the prolapsed area
Urinary symptoms- urinary retention or urgency
Difficulty indefaecation
How many degrees of uterovaginal prolapse
4 degrees
1st degree UV prolapse:
Descent of the cervix to below the level of the Ischial spine but does not protuse through the introitus
2nd degree UV prolapse:
Descent of the cervix to the introitus.
The clinically commonest degree of UV prolapse
2nd degree
3rd degree UV prolapse:
The entire uterus comes out of the introitus
4th degree UV prolapse
The entire length of vaginal wall comes out along with the uterus
(procidentia):
7 differential diagnoses of prolapse
Vulva tumour
Polypoid tumour
Cervical polyp
Hypertrophied or elongated cervix
Vaginal cyst
Peri-urethral cyst
Diverticulum of the urethra
3 complications of UV prolapse
Keratinization due to exposure and repeated abrassion and thickening
Decubitus ulcers on the cervix due to kinking of the blood vessels with relative ischaemia leading to oedematous cervix, abrassions
Obstructive lesions of the urinary tract
4 ways of preventing prolapse
Well supervised labour
Postnatal exercises
Good surgical technique at hysterectomy
Small family size
2 modes of treatment of prolapse
Non-surgical and surgical
8 determinants of surgical treatment of prolapse
Age of patient
Marital status
Reproductive career
Plan about future sexual relationship
Degree of prolapse including symptoms
Other associated problems
Patient’s clinical condition
Patient’s desire
6 non-surgical treatment of prolapse
Physiotherapy especially in post natal period and in minor degree prolapse
Lifestyle changes, such as avoiding certain activities.
Faradism: application of heat to the muscles to ake them contract
Hormone replacement therapy in minor degree prolapse especially in old and post-menopausal patients
Treatment of decubitus ulcers involves packing the vaginal with antiseptic-containing gauze ( moistined with acriflavine or hibitane)
Use of pessaries
2 antiseptics for vaginal packing
acriflavine or hibitane
3 materials for making pessaries
Plastic, rubber and silicone
5 indications for pessary use
Pregnancy
Puerperium
Patients who desire to get pregnant soon after consultation
Surgery contra-indicated
To allow healing of decubitus ulcers
Follow-up protocol after pessary insertion:
Give antibiotics
See every 3-6 months
Change every 6 months
How often should pessaries be changed
Every 6 months
How often should the patient be seen following pessary insertion
3 - 6 months
3 examples of pessaries
Inflatable
Doughnut
Gellhorn
11 preoperative investigations/measures
Pap smear
Biopsy of decubitus ulcer
Urine for m/c/s
Renal function test especially when there is repeated infections
Chest x-ray especially in history of cough
Cystoscopy to look at the interior lining of the bladder and the urethra.
Intravenous pyelogram (IVP) to show the size, shape, and position of the kidneys, bladder, ureters, and urethra.
Computed tomography scan (CT scan) to produce detailed pictures of structures inside the pelvic area.
Urodynamic studies to see how your body stores and releases urine.
Weight reduction in obese patient
Treatment of chest infections and other other medical conditions if present
6 surgical procedures for prolapse
- Colporrhaphy
- Vaginal hysterectomy and
colporrhaphy - Manchester (Forthergil)
operation - Partial (Defort’s) colpoclesis
- Complete colpoclesis
- Vaginal wall suspension
Repair of the vaginal wall
Colporrhaphy
2 types of colporrhaphy
anterior as for cystourethrocoele
posterior as for rectocoele
Muscles tightened in colporrhaphy
It involves opening the vaginal wall and tightening the appropriate muscles:
Pubovesical in Cystourethrocoele
puborectalis in Rectocoele
2 indications for vaginal hysterectomy and colporrhaphy
In uterovaginal prolapse
In women who have no wish to bear children
Manchester or — operation
Fothergil
Manchester (Forthergil) operation is useful in which degree of prolapse
2nd degree prolapse
T/F: Manchester (Forthergil) operation is for patients who still want to get pregnant
T
4 components of Manchester (Forthergil) operation
Anterior colporrhaphy to remove the cystourethrocoele
Shortening of the cervix
Shortening of the transverse cervical ligament
Posterior colpoperineorrhaphy (optional)
The optional component of the Manchester (Forthergil) operation
Posterior colpoperineorrhaphy
Partial colpocleisis is also known as
Defort’s colpocleisis
Type of colpocleisis for women still menstruating
Partial (Defort’s)
Occlusion of the vagina with spaces at the sides
Partial (Defort’s) colpocleisis
Type of colpocleisis indicated in old women and women that are not sexually active
Complete colpocleisis
2 types of colpocleisis
Partial (Defort’s)
Complete
Done for post hysterectomy prolapse
Vaginal wall suspension
Attaching the vaginal vault to the sacrum
Vaginal wall suspension
T/F: vaginal wall suspension is done through the abdominal approach
T
3 post operative care following prolapse surgery
Urethral catheterisation to prevent urinary retention and to rest the bladder
Vaginal packing to reduce bleeding
Antibiotics as necessary
11 complications of surgery for prolapse
Urinary retention
Haemorrhage
Thromboembolic disease
Infection
Stress incontinence
Dyspareunia
Apareunia
Recurrence of prolapse
Cervical incompetence in Manchester operation
Gynaetresia
Cervical cancer in neglected decubitus ulcer
Which surgery for prolapse can be complicated with cervical incompetence
Manchester operation
