Anatomy of Urinary Incontinence and Prolapse Flashcards
functions of the pelvic floor
separates pelvic cavity from perineum
important role in supporting pelvic organs
important role in urinary and faecal continence
what are the 3 layers of the pelvic floor?
pelvic diaphragm
muscles of perineal pouches
perineal membrane
which is the deepest layer of the pelvic floor and what is it made of?
pelvic diaphragm
2 main muscle groups
- levator ani
- occygeus
describe the pelvic diaphragm
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
which layer forms most of the pelvic diaphragm?
levator ani
where does the levator ani attach?
pubic bones, ischial spines and tendinous arch of levator ani
- perineal body, coccyx and walls of organs in midline
what are the 3 parts of levator ani?
puborectalis
pubococcygeus
iliococcygeus
what is the perineal body?
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
describe action of levator ani?
tonically contracted most of the time
must relax to allow urination and defecation
innervation of levator ani?
pudental nerve
nerve to levator ani
what gives additional support to the pelvic floor?
endo-pelvic fascia - connective tissue "packing" - some loose areolar tissue - some fibrous tissue (collagen and elastic fibres) pelvic ligaments
which pelvic ligaments give additional support to pelvic floor?
uterosacral transverse cervical (cardinal) lateral ligament of bladder lateral rectal ligaments (also fibrous endo-pelvic fascia)
what is tendinous arch of levator ani?
thickened area of the fascia which covers obturator internus
where is the deep perineal pouch found?
below the fascia covering the inferior aspect of the pelvic diaphragm
above the perineal membrane
what is found within the deep perineal pouch?
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
what deep perineal muscles are found in the deep perineal pouch?
external urethral sphincter
compressor urethrae
deep transverse perineal muscle (smooth muscle in females)
what is the perineal membrane?
thin sheet of tough deep fascia found superficial to deep perineal pouch
functions of the perineal membrane?
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
where is the superficial perineal pouch?
below perineal membrane
what is found in the male superficial perineal pouch?
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
what is found within the superficial perineal pouch in females?
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
functions of the pelvic floor?
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)
what can cause injury to pelvic floor?
pregnancy and childbirth chronic constipation obesity heavy lifting chronic cough or sneeze previous injury to pelvis/pelvic floor menopause
what does urinary continence depend on?
urinary bladder neck support
external urethral sphincter
smooth muscle in urethral wall
what is prolapse and what structures are involved?
failure of support for pelvic organs
can involve uterus, vagina (or both), bladder and rectum
types of vaginal prolapse?
urethrocele (urethra) cystocele (bladder) rectocele (rectum) enterocele (small bowel) all can herniate through supporting fascia
how does a vaginal prolapse present?
lump in vaginal wall
what are the 3 (or 4) degrees of uterine prolapse
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
features of uterine prolapse?
dragging sensation
feeling of a lump
urinary incontinence
how can a prolapse be repaired surgically?
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
surgical management for incontinence?
incontinence surgery
- trans-obturator approach
- mesh put trough obturator canal to create a sling around te urethra
