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WACS > Anatomy of Pelvic Floor and Prolapse > Flashcards

Anatomy of Pelvic Floor and Prolapse Flashcards

1
Q

Passive support of the pelvic floor

A

Fascia and ligaments

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2
Q

Active support of the pelvic support

A

Muscles of the pelvic floor (levator ani)

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3
Q

3 layers of the pelvic floor from superior to inferior

A

The pelvic fascia
The pelvic diaphragm
The urogenital diaphragm

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4
Q

Muscles of the anal sphincter complex

A

Internal anal sphincter
Conjoined longitudinal muscle
External anal sphincter

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5
Q

T/F: Internal anal sphincter is extension of the circular muscle layer of the rectum

A

T

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6
Q

T/F: Internal anal sphincter is under constant maximal contraction

A

T

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7
Q

% of resting anal tone provided by the internal anal sphincter

A

50 - 85%

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8
Q

Autonomic innervation of the internal anal sphincter

A

Parasympathetic…..S2-4
Sympathetic……..thoracolumbar ganglia (L5)

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9
Q

T/F: Suggested that both parasympathetic and sympathetic innervation cause inhibition of contraction

A

T

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10
Q

Formation of the conjoined longitudinal muscle

A

Extension of the longitudinal muscle layer of the rectum, along with levator ani muscle fibers

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11
Q

Structural support, anchoring the anorectum to the pelvis

A

Conjoined longitudinal muscle

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12
Q

T/F: External anal sphincter comprises a single layer of striated muscles

A

F. Multiple layers of striated muscle

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13
Q

% of resting anal tone provided by the external anal sphincter

A

25 - 30%

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14
Q

Somatic innervation of the external anal sphincter

A

Somatic innervation from the inferior rectal branch of the pudendal nerve (S2-3) and the perineal branch of S4

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15
Q

Levator ani muscles

A

Ischiococcygeus

Iliococcygeus

Pubococcygeus
Puborectalis Lig
Pubovaginalis Lig
Pubovesical Lig.

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16
Q

Origin and insertion of ischiococcygeus

A

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

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17
Q

What forms the arcus tendineus

A

Arcus tendinous is a fibrous band formed by the fascia of the obturator internus

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18
Q

The iliococcygeus originates from what part of the arcus tendineus

A

posterior half of the arcus tendinous

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19
Q

The 2 insertion points of the iliococcygeus

A

Inserted into the side of the coccyx and ano-coccygeal raphe

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20
Q

The muscle arising from the anterior half of the arcus tendineus

A

Pubococcygeus

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21
Q

3 origins of the pubococcygeus

A

Arises from the anterior half of arcus tendineus, side and posterior surface of the pubis

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22
Q

2 insertion points of the pubococcygeus

A

Inserts into the tip of the coccyx and ano-coccygeal raphe

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23
Q

The 3 groups formed by the anterior fibres of the pubococcygeus

A

Puborectalis
Pubovaginalis
Pubo-vesical ligament

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24
Q

The anorectal angle is formed by which muscle

A

Puborectalis

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25
Q

The U-shaped and medial most part of the levator ani

A

Puborectalis

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26
Q

Origin and insertion of puborectalis

A

From the back of pubic bone & inserted into the ano-rectal junction

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27
Q

Origin and insertion of the pubovaginalis

A

Arises from the back of the pubis and inserted into the vagina and the perineal body

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28
Q

T/F: Tearing of the pubovaginalis results in 3rd degree perineal tear

A

T

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29
Q

The most anterior group of the pubococcygeus

A

Pubovesical ligament

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30
Q

Origin and insertion of the pubovesical ligament

A

It arises from the back of the pubic bone

Inserts into the junction between the
bladder and the urethra

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31
Q

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

A

Pubococcygeus

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32
Q

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

A

Pubococcygeus

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33
Q

The muscle that during sexual relationship helps to tighten the phallus to contribute to orgasm in the female

A

Pubococcygeus

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34
Q

The muscle that allows for gross fecal continence

A

Puborectalis and the anorectal angle

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35
Q

The muscle that relieves pressure from the sphincter process

A

Puborectalis and the anorectal angle

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36
Q

What is responsible for gas and liquid continence

A

The sphinter complex

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37
Q

Defecation occurs with the relaxation of the – and contraction of the other levator muscles

A

Puborectalis

38
Q

The most common pelvic organ prolapse

A

Cystocele

39
Q

The 2 anterior compartment prolapse

A
  1. Bladder prolapse called cystocele (most common pelvic organ prolapse)
  2. Urethral prolapse called urethrocele
40
Q

The 2 middle compartment prolapse

A

Uterine prolapse
Vaginal vault prolapse

41
Q

The 2 posterior compartment prolapse

A
  1. Small bowel prolapse called enterocele.
  2. Rectal prolapse called rectocele
42
Q

T/F: With normal tone of the levator ani the anorectal angle is acute and the levator plate is horizontal

A

T

43
Q

Loss of tone in the levator ani results in –, – and –

A
  1. Change in the vaginal axis
  2. Sagging of the levator plate
  3. Enlargement of the urogenital
    hiatus
44
Q

Strongest support of the uterus

A

Transverse cervical/Mc Kenrodt Ligament

45
Q

Runs from the pubis to the fundus of the cervix

A

Pubocervical ligament

46
Q

Arises from the back of the uterus and attaches to the sacrum on either side

A

Uterosacral ligament

47
Q

5 causes of prolapse

A
  1. Injury sustained during child birth:
    C. During instrumental vaginal delivery especially with forceps and there is exertion of traction on the support.
  2. Respiratory problems e.g in bronchitis
  3. Post-hysterectomy
  4. Congenital weakness
  5. Aging (menopause) due hypoeostrogen state
48
Q

9 precipitating factors for prolapse

A

Chronic constipation
Chronic cough
Lifting of heavy objects
Manual work
Straining for long period
Large intra-abdominal tumour
Ascites
Pregnancy
obesity

49
Q

4 determinants of incidence of prolapse

A

Level of obstetric care

Parity of the patient

Pelvic anatomy

Cultural factors e.g farming

50
Q

6 clinical features of prolapse

A

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

51
Q

How many degrees of uterovaginal prolapse

A

4 degrees

52
Q

1st degree UV prolapse:

A

Descent of the cervix to below the level of the Ischial spine but does not protuse through the introitus

53
Q

2nd degree UV prolapse:

A

Descent of the cervix to the introitus.

54
Q

The clinically commonest degree of UV prolapse

A

2nd degree

55
Q

3rd degree UV prolapse:

A

The entire uterus comes out of the introitus

56
Q

4th degree UV prolapse

A

The entire length of vaginal wall comes out along with the uterus
(procidentia):

57
Q

7 differential diagnoses of prolapse

A

Vulva tumour

Polypoid tumour

Cervical polyp

Hypertrophied or elongated cervix

Vaginal cyst

Peri-urethral cyst

Diverticulum of the urethra

58
Q

3 complications of UV prolapse

A

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

59
Q

4 ways of preventing prolapse

A

Well supervised labour

Postnatal exercises

Good surgical technique at hysterectomy

Small family size

60
Q

2 modes of treatment of prolapse

A

Non-surgical and surgical

61
Q

8 determinants of surgical treatment of prolapse

A

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

62
Q

6 non-surgical treatment of prolapse

A

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

63
Q

2 antiseptics for vaginal packing

A

acriflavine or hibitane

64
Q

3 materials for making pessaries

A

Plastic, rubber and silicone

65
Q

5 indications for pessary use

A

Pregnancy

Puerperium

Patients who desire to get pregnant soon after consultation

Surgery contra-indicated

To allow healing of decubitus ulcers

66
Q

Follow-up protocol after pessary insertion:

A

Give antibiotics
See every 3-6 months
Change every 6 months

67
Q

How often should pessaries be changed

A

Every 6 months

68
Q

How often should the patient be seen following pessary insertion

A

3 - 6 months

69
Q

3 examples of pessaries

A

Inflatable
Doughnut
Gellhorn

70
Q

11 preoperative investigations/measures

A

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

71
Q

6 surgical procedures for prolapse

A
  1. Colporrhaphy
  2. Vaginal hysterectomy and
    colporrhaphy
  3. Manchester (Forthergil)
    operation
  4. Partial (Defort’s) colpoclesis
  5. Complete colpoclesis
  6. Vaginal wall suspension
72
Q

Repair of the vaginal wall

A

Colporrhaphy

73
Q

2 types of colporrhaphy

A

anterior as for cystourethrocoele
posterior as for rectocoele

74
Q

Muscles tightened in colporrhaphy

A

It involves opening the vaginal wall and tightening the appropriate muscles:
Pubovesical in Cystourethrocoele
puborectalis in Rectocoele

75
Q

2 indications for vaginal hysterectomy and colporrhaphy

A

In uterovaginal prolapse
In women who have no wish to bear children

76
Q

Manchester or — operation

A

Fothergil

77
Q

Manchester (Forthergil) operation is useful in which degree of prolapse

A

2nd degree prolapse

78
Q

T/F: Manchester (Forthergil) operation is for patients who still want to get pregnant

A

T

79
Q

4 components of Manchester (Forthergil) operation

A

Anterior colporrhaphy to remove the cystourethrocoele

Shortening of the cervix

Shortening of the transverse cervical ligament

Posterior colpoperineorrhaphy (optional)

80
Q

The optional component of the Manchester (Forthergil) operation

A

Posterior colpoperineorrhaphy

81
Q

Partial colpocleisis is also known as

A

Defort’s colpocleisis

82
Q

Type of colpocleisis for women still menstruating

A

Partial (Defort’s)

83
Q

Occlusion of the vagina with spaces at the sides

A

Partial (Defort’s) colpocleisis

84
Q

Type of colpocleisis indicated in old women and women that are not sexually active

A

Complete colpocleisis

85
Q

2 types of colpocleisis

A

Partial (Defort’s)
Complete

86
Q

Done for post hysterectomy prolapse

A

Vaginal wall suspension

87
Q

Attaching the vaginal vault to the sacrum

A

Vaginal wall suspension

88
Q

T/F: vaginal wall suspension is done through the abdominal approach

A

T

89
Q

3 post operative care following prolapse surgery

A

Urethral catheterisation to prevent urinary retention and to rest the bladder

Vaginal packing to reduce bleeding

Antibiotics as necessary

90
Q

11 complications of surgery for prolapse

A

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

91
Q

Which surgery for prolapse can be complicated with cervical incompetence

A

Manchester operation

WACS (19 decks)

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