Anatomy of Urinary Incontinence and Prolapse Flashcards
What does ghe pelvic floor separate?
separates pelvic cavity from perineum
What is the role of the pelvic floor?
- provides support to organs
- maintains continence
- urinary
- faecal
What are the three layers of the pelvic floor?
Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane
What is the deepest layer of the pelvic floor?
Pelvic diaphragm
What are the two muscle groups of the pelvic diaphragm?
Levator Ani
Coccygeus
What is contained between medial borders in the anterior gap in the pelvic floor ?
Urogenital hiatus
Passage for urethra and vagina
What forms most of the pelvic diaphragm?
Levator ani
What does the levator ani attach to?
- pubic bones, ischial spines and tendinous arch of levator ani
- perineal body, coccyx and walls of organs in midline
What are the three parts of the levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
What is the innervation of the levator ani?
- Pudendal nerve
- Nerve to levator ani
When must the levator ani relax?
To allow urination and defecation
What additional support is provided (other than pelvic floor) to the organs of the pelvis?
Endo-pelvic fascia
Pelvic ligaments
What is the endo-pelvic fascia?
Connective tissue ‘packing’
Some loose areolar tissue
Some fibrous; collagen and elastic fibres
Name the pelvic ligaments?
- uterosacral
- transverse cervical (cardinal)
- lateral ligament of bladder
- lateral rectal ligaments
Where is the deep perineal pouch?
Lies below the fascia covering the inferior aspect of the pelvic diaphragm and above the perineal membrane
What is contained in the deep perineal pouch?
- Part of the urethra (and vagina in females)
- bulbourethral gland in males
- neurovascular bundle for penis/clitoris
- extensions of ischianal fat pads and muscles
Where is the perineal membrane?
Superficial to deep perineal pouch
What is the perineal membrane?
Thin sheet of tough, deep fascia
Together with perineal body it is the last passive support of the pelvic organs
Where does the perineal membrane attach?
Laterally to the sides of the pubic arch, closing the urogenital triangle
What is contained in the superficial perineal pouch (males)
- root of penis
- bulb- corpus spongiosum, crura- corpus cavernosa
- associated muscles- bulbospongiosus and ischiocavernosis
- proximal spongy (penile) urethra
- superficial transverse perineal muscle
- branches of internal pudendal vessels and pudendal nerve
Where is the superficial perineal pouch?
Below the perineal membrane
What is contained in the superficial perineal pouch in women?
- Clitoris and crura- corpus cavernosa
- Bulbs of vestibule - paired
- Associated muscles -bulbospongiosus and ischiocavernosus
- greater vestibular glands
- superficial transverse perineal muscle
- Branches of internal pudendal vessels and pudendal nerve
When does the pelvic floor actively contract?
Coughing, sneezing, vomiting
What helps maintain urinary continence?
External urethral sphincter
Compressor urethrae
Levator ani
What helps maintain faecal continence?
Tonic contraction of puborectalis bends the anorectum anteriorly
Active contraction maintains continence after rectal filling
What causes injury to the pelvic floor?
- pregnancy
- childbirth
- stretching or tearing
- pudendal nerve damage
- chronic constipatio
- 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 spincter
Smooth muscle in urethral wall
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 types of prolapse?
Urethrocele
Cystocele
Rectocele
Enterocele
What are the degrees of uterine prolapse
1st, 2nd and 3rd
How may uterine prolapse present?
Dragging sensation
Feeling of a lump
Urinary incontinence
How can a uterine prolapse be repaired?
Sacrospinous fixation
Sutures placed in sacrospinous ligament- just medial to ischial spine, to repair cervical/vault descent. Performed vaginally. Risk of injury to pudendal NVB and sciatic nerve.
Incontinence surgery
Trans-obturator approach. Place mesh through obturator canal, create a sling around the urethra. Incisions through vagina and groin.
