Anatomy of urinary incontinence and prolapse Flashcards
What does the pelvic floor separate?
Pelvic cavity from perineum
Important role in support to pelvic organs
What makes up the pelvic floor?
Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane
What are the main functions of the pelvic floor?
Maintenance of urinary and faecal continence
Support of pelvic organs
What 2 muscle groups form the pelvic diaphragm?
Levator ani
Coccygeus
What passes through the anterior gap between the medial borders of the pelvic diaphragm?
Urogenital hiatus containing urethra and vagina (in females)
What are the 3 parts to the levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
Where does the levator attach to?
Pubic bones, ischial spines, tendinous arch of levator ani
Perineal body, coccyx and walls of organs in midline
Is the levator ani tonically contracted?
Yes; most of time
Will relax to allow for urination and defecation
What innervates the levator ani?
Pudendal nerve
Nerve to levator ani
Describe the puborectalis?
Attaches form pubic bone to form a sling around rectum = FAECAL continence
Describe the pubococcygeus
Attaches from posterior aspect of pubic bone to insert onto the midline coccyx
Inserts onto the vagina and prostate
Describe the iliococcygeus?
Attaches from ileum/ ischial spine
Most lateral
What are the pelvic ligaments which provide support to pelvic organs?
Endopelvic fascia Uterosacral Transverse cervical (cardinal) Lateral ligament of bladder Lateral rectal ligaments
What makes up the endopelvic fascia?
Connective tissue “packing”
Loose areolar tissue
Fibrous; collagen and elastic fibres
Where does the deep perineal pouch lie?
Below the fascia covering the inferior aspect of the pelvic diaphragm
Above perineal membrane
What is contained within the deep perineal pouch?
Urethra Vagina (in females) Bulbourethral gland (male) Neurovascular bundle for penis/ clitoris Extensions of ischioanal fat pads Deep transverse perineal muscle Compressor urethrae External urethral sphincter
What muscles are contained within the deep perineal pouch?
Deep transverse perineal muscle
Compressor urethrae
External urethral sphincter
Where can the perineal membrane be found?
Superficial to deep perineal pouch
Where will the perineal membrane attach?
Laterally to sides of pubic arch, closing the urogenital triangle
Are there openings in the perineal membrane?
Yes; for urethra and vagina
Where does the superficial perineal pouch lie?
Below perineal membrane
In the male, what does the superficial perineal pouch contain?
Root of penis: bulb (spongiosum), crura (cavernosum), bulbospongiosus and ischiocavernosus
Proximal spongy urethra
Superficial transverse perineal muscle
Branches of internal pudendal and pudendal nerve
Do the muscles in the superficial perineal pouch contribute to the perineal body?
No
In the female, what does the superficial perineal pouch contain?
Female erectile tissue and assoc muscles:
Clitoris and crura (cavernosum)
Bulb of vestibule; bartholin’s glands
Bulbospongiosus and ischiocavernosus muscle
Superficial transverse perineal muscle
Branches of internal pudendal vessels and pudendal nerve
Describe the difference in location of bulbourethral gland in males and females?
Male; deep perineal pouch
Female; superficial perineal pouch
What is one of the most important structures in support of pelvic floor?
Perineal body in superficial perineal pouch
Describe the layers of the pelvic floor as you move from internal to superficial?
Pelvic diaphragm Deep perineal pouch Perineal membrane Erectile tissue Superficial perineal pouch
Which muscles maintain urinary continence?
External urethral sphincter
Compressor urethrae
Levator ani
Which muscle maintains faecal continence?
Puborectalis bends the anorectum anteriorly maintaining continence after rectal filling
What can cause injury to the pelvic floor?
Pregnancy Childbirth Chronic constipation Obesity Heavy lifting Chronic cough or sneeze Previous injury to pelvis/ pelvic floor Menopause
What will urinary continence depend on?
Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall
What will a prolapse commonly involve?
Uterus
Vagina
Bladder
Rectum
What is a prolapse due to?
Failure of support of pelvic organs
What is a vaginal prolapse?
Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
Presents as a lump in vaginal wall
What are the different names given to prolapses?
Bladder; cystocele
Small bowel; enterocele
Rectum; rectocele
Urethra; urethrocele
What will patients decribe when they have a uterine prolapse?
Dragging sensation
Feeling of a lump
Urinary incontinence
What are the different types of uterine prolapse?
1st degree; cervix drops into superior vaginna
2nd degree; cervix drops further by still above opening of vagina
3rd degree; cervix drops below opening of vagina
4th degree; cervix and uterus below opening of vagina
What are the 2 methods to treat vagina and uterine prolapse?
Sacrospinous fixation
Mesh
Describe sacrospinous fixation
Sutures placed in sacrospinous ligament just medical to ischial spine to repair cervical/ vault descent
Performed vaginally
What risks are assoc with a sacrospinous fixation?
Injury to pudendal NVB and sciatic nerve
Describe “incontinence” surgery?
Trans-obturator support
Mesh through obturator canal to create a sling around the urethra
Incisions through vagina and groin
