Anatomy of Urinary Incontinence and Prolapse

Question 1

functions of the pelvic floor

Answer 1

separates pelvic cavity from perineum
important role in supporting pelvic organs
important role in urinary and faecal continence

Question 2

what are the 3 layers of the pelvic floor?

Answer 2

pelvic diaphragm
muscles of perineal pouches
perineal membrane

Question 3

which is the deepest layer of the pelvic floor and what is it made of?

Answer 3

pelvic diaphragm
2 main muscle groups
- levator ani
- occygeus

Question 4

describe the pelvic diaphragm

Answer 4

looks like a sling
anterior gap between medial borders
- urogenital hiatus (allows for passage of urethra and vagina)
theres technically another sort of gap between medial borders for passage of rectum but muscles clamp closed so not really a gap

Question 5

which layer forms most of the pelvic diaphragm?

Answer 5

levator ani

Question 6

where does the levator ani attach?

Answer 6

pubic bones, ischial spines and tendinous arch of levator ani
- perineal body, coccyx and walls of organs in midline

Question 7

what are the 3 parts of levator ani?

Answer 7

puborectalis
pubococcygeus
iliococcygeus

Question 8

what is the perineal body?

Answer 8

fibromuscular skeleton of muscular pelvic floor
where basically all of the muscles of pelvic floor insert
between urogenital hiatus and rectum
damage has huge impact on continence

Question 9

describe action of levator ani?

Answer 9

tonically contracted most of the time

must relax to allow urination and defecation

Question 10

innervation of levator ani?

Answer 10

pudental nerve

nerve to levator ani

Question 11

what gives additional support to the pelvic floor?

Answer 11

endo-pelvic fascia
- connective tissue "packing"
- some loose areolar tissue
- some fibrous tissue (collagen and elastic fibres)
pelvic ligaments

Question 12

which pelvic ligaments give additional support to pelvic floor?

Answer 12

uterosacral
transverse cervical (cardinal)
lateral ligament of bladder
lateral rectal ligaments 
(also fibrous endo-pelvic fascia)

Question 13

what is tendinous arch of levator ani?

Answer 13

thickened area of the fascia which covers obturator internus

Question 14

where is the deep perineal pouch found?

Answer 14

below the fascia covering the inferior aspect of the pelvic diaphragm
above the perineal membrane

Question 15

what is found within the deep perineal pouch?

Answer 15

contains part of the urethra (and vagina in females)
bulbourethral glands in male
neurovascular bundle for penis/clitoris
extensions of the ischioanal fat pads and muscles

Question 16

what deep perineal muscles are found in the deep perineal pouch?

Answer 16

external urethral sphincter
compressor urethrae
deep transverse perineal muscle (smooth muscle in females)

Question 17

what is the perineal membrane?

Answer 17

thin sheet of tough deep fascia found superficial to deep perineal pouch

Question 18

functions of the perineal membrane?

Answer 18

attaches laterally to sides of the pubic arch, closing the urogeital triangle
openings for the urethra (and vagina in females)
together with the perineal body, it is the last passive support of the pelvic organs

Question 19

where is the superficial perineal pouch?

Answer 19

below perineal membrane

Question 20

what is found in the male superficial perineal pouch?

Answer 20

root of penis

• bulb (corpus spongiosum) and crura (corpus cavernosum)
• associated muscles (bulbospongiosus and ischiocavernosus)

also contains proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve

Question 21

what is found within the superficial perineal pouch in females?

Answer 21

female erectile tissue and associated muscle

• clitoris and crura (corpus cavernosum)
• bulbs of vestibule (paired)
• associated muscles (bulbospongiosus and ischiocavernosus)

also contains greater vestibular glands (AKA bartholins glands), superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve

Question 22

functions of the pelvic floor?

Answer 22

supports pelvic organs
- normally tonically contracted
- actively contrats during sneezing, vomiting etc
maintains continence
- urinary (external urethral sphincter, compressor urethrae, levator ani)
- faecal (tonic contraction of puborectalis bends anorectum anteriorly, active contraction maintains continence after rectal filling)

Question 23

what can cause injury to pelvic floor?

Answer 23

pregnancy and childbirth
chronic constipation
obesity
heavy lifting
chronic cough or sneeze
previous injury to pelvis/pelvic floor
menopause

Question 24

what does urinary continence depend on?

Answer 24

urinary bladder neck support
external urethral sphincter
smooth muscle in urethral wall

Question 25

what is prolapse and what structures are involved?

Answer 25

failure of support for pelvic organs

can involve uterus, vagina (or both), bladder and rectum

Question 26

types of vaginal prolapse?

Answer 26

urethrocele (urethra)
cystocele (bladder)
rectocele (rectum)
enterocele (small bowel)
all can herniate through supporting fascia

Question 27

how does a vaginal prolapse present?

Answer 27

lump in vaginal wall

Question 28

what are the 3 (or 4) degrees of uterine prolapse

Answer 28

1st = cervix drops down into upper vagina
2nd = cervix descends more into vagina but still above opening of vagina
3rd = cervix completely exits the vagina, can be felt outside
4th (sometimes described) = uterus outside of vagina

Question 29

features of uterine prolapse?

Answer 29

dragging sensation
feeling of a lump
urinary incontinence

Question 30

how can a prolapse be repaired surgically?

Answer 30

sacrospinous fixation

• sutures placed in sacrospinous ligament, just medial to the ischial spine to repair cervical/vault descent
• performed vaginally and can damage pudendal NVB and sciatic nerve

Question 31

surgical management for incontinence?

Answer 31

incontinence surgery

• trans-obturator approach
• mesh put trough obturator canal to create a sling around te urethra