Anatomy of Urinary Incontinence and Prolapse Flashcards
what is the pelvic floor
layer separating the pelvic cavity from the perineum
role of the pelvic floor
provides support to pelvic organs
maintained urinary and faecal continence
what are the three areas of the pelvic floor
Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane
what is the pelvic diaphragm
deepest layer of the pelvic floor
two muscles groups:
elevator ani
+
coccygeus
what is the urogenital hiatus
anterior gap between medial borders of the pelvic diaphragm
passage for urethra and vagina
which muscle forms most of the pelvic diaphragm
elevator ani
what are the 3 parts of the elevator ani
Puborectalis (from the pubic bone, comes down and forms a sling around the rectum)
Pubococcygeus (middle one, from the pubic bone and inserts in the midline of the coccyx and organs on the midline eg, vagina or prostate)
Iliococcygeus (comes from ilium to the coccyx)
where is the perineal body
fibromuscular skeleton of the pelvic floor
located between urogenital hiatus and anus
all pelvic floor muscles attach
what is the innervation of the elevator ani
pudenal nerve to levator ani
how does the elevator ani prevent incontinenece
its usually tonically contracted
it relaxed to allow urination and deification
what additional support is found in the pelvis
endo-pelvic fascia
pelvic ligaments
what is the endo-pelvic fascia
connective tissue ‘packing’
some fibrous tissue
some loose areolar tissue
what are the pelvic ligaments
transverse cervical ligament utero-sacral ligament transverse cervical lateral ligament of the bladder lateral rectal ligaments
what is the tendinous arch of the levator ani
fascia lying above the obturator interns muscle where the levator ani attaches
what is the deep perineal pouch
lies below the pelvic diaphragm
lies above the perineal membrane
contains part of the urethra, vagina, bulbourethral glands in male, neuromuscular bundle for penis/clitoris, extensions of sischioanal fat pad muscles
what muscles are in the deep perineal pouch
external urethral spinchter
compressor urethrae
deep transverse perineal muscle
difference between the deep transverse perineal muscle in males and females
in females its usually just unnamed smooth muscle
in males its skeletal muscle
what is the perineal membrane
thin sheet of tough membrane below the deep perineal pouch
attaches laterally to the sides of the pubic arch closing the urogenital triangle
the last passive support og the pelvic organs
what is the superficial perineal pouch
layer below the perineal membrane
what does the superficial perineal membrane contain in males
root of penis
bulb-corpus spongiosum, Crura- corpus cavernous
associated muscles - bulbospongiosus and ischiocavernosus
superficial transverse perineal muscle
where does 90% of the blood go through during an erection and why
90% goes through the corpus cavernous
this is so that the urethra is not compressed in the corpus spongiosum and sperm can get out
where does the ischicavernosus lie
over the corpus cavernous
where does bulbospongiosus lie
over the corpus spongiosum
what is in the superficial perineal pouch in females
cliterus and crura (made from corpus cavernous)
Bulbs of vestibule (corpus spongiosum, split into two on females)
greater vestibular glands (bartholins glands)
muscles:
- bulbospongiosus
- ischiocavernosis
when does the pelvic floor actively contract
coughing, sneezing, vomiting
to maintain continence
how does the pelvic floor maintain urinary continence
external urethral spinchter
compressor urethrae
elevator ani
how does the pelvic floor maintain faecal continence
tonic contraction of puborectalis (bends anorectic anteriorly so faeces doesn’t just come out)
active contraction maintains continence after rectal filling
what causes injury to the pelvic floor
Pregnancy
Childbirth (stretching or tearing of muscle, damage to the pudenal nerve)
Chronic constipation obesity heavy lifting chronic cough or sneeze previous injury to pelvic/pelvic floor menopause
what is prolapse
failure of pelvic organ support
can be uterus, vagina or both
also bladder or rectum
what is vaginal prolapse
pelvic organs protrude into the vagina
cystocele - bladder protruding into wall of vagina
enerocyele - bowel in pouch of Douglas protruding into wall of vagina
rectocele- rectum protruding into the vagina
presents as lump in vaginal wall
what is uterine prolapse (and degrees)
when uterus moves down and potentially out of the vagina
1st - cervix drops into upper vagina
2nd - cervix has descended into the vagina but above the opening
3rd -cervix completely exits the vagina
4th- cervix and uterus outside of the vagina
presentation of uterine prolapse
feeling of ‘lump’
dragging sensation
urinary incontinence
Surgical treatment for uterine prolapse
sacrospinous fixation
- sutures placed in sacrospinous ligament to attach it to vagina
- this holds the vagina and the cervix up
performed vaginally
risk to prudential nerve bundle - try to place suture medially to the pudenal nerve
treatment of incontinence
Trans-obturator approach
mesh put through the obturator canal to put a slin around the urethra
