Anatomy of Urinary Incontinence and Prolapse Flashcards
What is the pelvic floor responsible for?
- important to support pelvic organs
- important to maintain urinary and FECAL continence
- resistance to increase in intra-abdominal pressure and intra-pelvic pr.
What is the pelvic floor?
separates the pelvic cavity from the perineum
What is it made of?
3 layers
- pelvic diaphragm
- muscles of the perineal pouches
- perineal membrane
What is the pelvic diaphagrm and what muscles does it consist of?
- the DEEPEST layer of the pelvic floor
- 2 muscle groups: Levator ani + Coccygeus
Refer to slide 3 on the anatomy lecture. What are the first 2 hiatus found in the anterior gap, btw the medial borders of thepelvic diaphragm in a female…
How is it diff. in men?
- first small= Urethra
- second large opening (no distinct form)= Vagina
- men have no vagina; therefore only ONE opening (urethra) found in the anterior gap
- —-both sexes have a centrally positioned hiatus = Rectum
What does the pelvic diaphragm appear as?
- a sling
Like how there is 3 parts to the pelvic floor. There is also 3 parts to the levator ani muscle- a constituent of the pelvic diaphgram….Name these 3 muscles.
- Puborectalis
- Pubococcygeus
- Iliococcygeus
Describe the shape of the pelvic floor.
- Funnel Shaped; attached to the walls of the lesser pelvis
What is the shape of the puborectalis m.?
-is a U-shaped muscle ext. from the bodies of the PUBIC bones, past the urogenital hiatus and AROUND the anal canal
What is the importance of the puborectalis muscle?
- to maintain FECAL continence
- its TONIC contraction bends the canal ANTERIORLY= Anorectal angle (90*) at the anorectal jxn —-keeping shit in
Where does the pubococcygeus muscle extend to?
- from the PUBIC bone and anterior aspect of the tendinous arch
-around the urogenital hiatus
> runs posteromedially> attaches at coccyx and anococcygeal ligament
The extent of the iliococcygeus muscle?
start anteriorly at the ischial spines and posterior aspect of the tendinous arch.
- attaches posteriorly to the coccyx and the anococcygeal ligament.
Which of the 3 muscles of the levator ani; is considered to be the LEVATOR of the pelvic floor?
the iliococcygeus muscle
- elevates the pelvic floor and the anorectal canal
The levator ani muscle is _______ most of the time…must be ______ to allow urination and defecation to occur.
TONICALLY CONTRACTED
RELAXED
What is the nerve supply of the levator ani muscle?
- pudendal nerve (S2, S3, S4)
- nerve to levator ani
(anterior ramus of S4)
Name 2 additional supports for the pelvic organs.
- Endo-pelvic fascia
- pelvic ligaments
What is the endo-pelvic fascia?
-consists of some loose areolar tissue, -some fibrous tissue (collagen and elastic fibres)
Name some pelvic ligaments.
- –uterosacral lig.
- –transverse cervical
- lateral ligament of bladder
- lateral rectal ligaments
Where is the deep perineal pouch located?
- below the fascia covering the INFERIOR aspect fo the PELVIC diaphragm
- above the perineal membrane
What does the DEEP Perineal pouch consist of?
- part of the urethra
- vagina
- bulbourethral glands in MALES
- neurovascular bundle of penis/clitoris
- extensions of ischioanal fat pads
- muscles
Where is the perineal membrane located? What is it?
- superficial to the deep perineal pouch —-attaches laterally to the sides of the pubic arch (closing the UROGENITAL triangle)
- THIN sheet of TOUGH, DEEP fascia
Does the perineal membrane have any openings?
- yes
- for urethra and vagina
What is the last passive support of the pelvic organs?
- Perineal membrane along with the perineal body
What are the boundaries of the anal triangle?
bounded by the coccyx, sacrotuberous ligaments, and a theoretical line between the ischial tuberosities.
Where is the superficial perineal pouch located?
- BELOW the perineal membrane
What does the superf. perineal pouch contain?
- root of penis
(bulb- corpus spongiosum, crura, corpus cavernosum)
(associated muscles- bulbospongiosum and ischiocavernosus) - also contains proximal spongy (penile) urethra, superficial transverse perineal muscle
and branches of internal pudendal vessels and pudendal nerve
If the bulbar urethra is to rupture, where might the urine be extravasated?
- accumulates in the superficial perineal pouch (around the scrotum, penis and lower abdomen)
Below the perineal membrane = superficial perineal pouch. What is located in the female’s perineal pouch?
Erectile tissue and associated m.
- clitoris and crura (corpus carvernosum)
- bulbs of vestibule
- associated muscles (bulbospongiosus and ischiocavernosus)
Name the non-erectile structures in the superficial perineal pouch.
- also has : greater vestibular glands, superficial transverse perineal muscle and
branches of internal pudendal vessels and pudendal nerve
What parts of the pelvic floor provides support for urinary continence?
- external urethral sphincter
- levator ani
- compressor urethrae
How may the pelvic floor get injured?
- pregnancy (childbirth- stretching and tearing of pudendal nerve)
- chronic constipation
- obesity
- heavy lifting
- chronic cough and sneeze
- previous injury to pelvis/floor
- menopause
Urinary continence depends on?
- urinary bladder NECK support
- external urethral sphincter
- smooth muscle in urethral WALL
What is prolapse?
- gynae problem; COMMON!
- d.t FAILURE of support for pelvic organs; pelvic organs may herniate (could involve uterus, vagina or both); bladder and rectum too
What herniates in a vaginal prolapse?
- herniation of urethra, bladder, rectum or rectouterine pouch through the supporting fascia
- presents as a lump through the vaginal WALL
Name the diff. types of prolapse in the pelvis?
- urethrocele, cystocele, rectocele, enterocele
How does a uterine prolapse feel?
- dragging sensation
- feels like a lump
- urinary incontinence
What are the diff. types of uterine prolapse?
1st Degree: cervix drops in to vagina
2nd : cervix comes down to the OPENING of the vagina
3rd: cervix s OUTSIDE the vagina
Can a uterine prolapse be treated? How?
Yes
- —sacrospinous fixation (suture placed in the sacrospinous ligament)
- medial to ISCHIAL spine
- repairs the cervical descent
- performed vaginally
What is the risk of repairing a uterine prolapse?
risk of damaging the pudendal nerve and the sciatic nerve
Can urinary incontinence be treated?
- yes
- —trans-obturator approach
- mesh through the obturator canal (NVB space)
- create a sling around the urethra
- incisions through the vagina and groin
