Anatomy of Urinary Incontinence and Prolapse

Question 1

What separates the pelvic cavity from the perineum?

Answer 1

The pelvic floor

Question 2

What does the pelvic floor play an important role in?

Answer 2

Providing support to pelvic organs and maintaining continence

Question 3

What are the three layers of the pelvic floor?

Answer 3

Pelvic diaphragm, muscles of perineal pouches, perineal membranes

Question 4

What is the deepest layer of the pelvic floor?

Answer 4

Pelvic diaphragm = has appearance of sling

Question 5

What two muscle groups make up the pelvic diaphragm?

Answer 5

Levator ani and coccygeus

Question 6

What is the urogenital hiatus?

Answer 6

Anterior gap in the pelvic diaphragm between the medial borders = allows passage of urethra and vagina

Question 7

What forms most of the pelvic diaphragm?

Answer 7

Levator ani

Question 8

What are the attachments of the pelvic diaphragm?

Answer 8

Pubic bones, ischial spines, tendinous arch of levator ani, perineal body, coccyx, walls of midline organs

Question 9

What are the three parts of levator ani?

Answer 9

From midline out = puborectalis, pubococcygeus, iliococcygeus

Question 10

Why must levator ani relax to allow urination and defaecation?

Answer 10

It is tonically contracted most of the time

Question 11

What is the innervation of levator ani?

Answer 11

Pudendal nerve and nerve to levator ani

Question 12

What structures offer extra support to the pelvic floor?

Answer 12

Endopelvic fascia and pelvic ligaments

Question 13

What are some features of the endopelvic fascia?

Answer 13

Connective tissue packing = some loos areolar tissue, some collagen and elastic fibres

Question 14

What are the pelvic ligaments?

Answer 14

Uterosacral ligament, transverse sacral ligament, lateral ligament of the bladder, lateral rectal ligaments

Question 15

What are some features of the pelvic ligaments?

Answer 15

Fibrous endopelvic fascia

Provide support to pelvic organs

Question 16

Where is the deep perineal pouch located?

Answer 16

Lies above the perineal membrane

Lies below the fascia covering inferior aspect of pelvic diaphragm

Question 17

What are the contents of the deep perineal pouch?

Answer 17

Parts of urethra (and vagina), bulbourethral glands in males, neurovascular bindle for penis/clitoris, extensions of ischioanal fat pads and muscles

Question 18

Where is the perineal membrane located?

Answer 18

Superficial to the deep perineal pouch = thin sheet of tough deep fascia

Question 19

Where does the perineal membrane attach?

Answer 19

Laterally to the sides of the pubic arch = closes urogenital triangle, has openings for urethra and vagina

Question 20

What are the last passive supports of the pelvic organs?

Answer 20

Perineal body and perineal membrane

Question 21

Where is the superficial perineal pouch located?

Answer 21

Below the perineal membrane

Question 22

What does the superficial perineal pouch contain in males?

Answer 22

Root of penis = bulb (corpus spongiosum and crura of corpus cavernosum), bulbospongiosus and ischiocavernosus muscles
Proximal spongy urethra, superficial transverse perineal muscle, branches of internal pudendal vessels and pudendal nerve

Question 23

What does the superficial perineal pouch contain in females?

Answer 23

Clitoris and crura of corpus cavernosum, bulbospongiosus and ischiocavernosus muscles, paired bulbs of vestibule, greater vestibular glands, superficial transverse perineal muscle, branches of internal pudendal vessels and pudendal nerve

Question 24

What is the normal state of the pelvic floor?

Answer 24

Normally tonically contracted = actively contracts when coughing, sneezing or vomiting

Question 25

How does the pelvic floor help maintain urinary continence?

Answer 25

External urethral sphincter, compressor urethrae and levator ani all contribute

Question 26

How does the pelvic floor help maintain faecal continence?

Answer 26

Tonic contraction of puborectalis bends the anorectum anteriorly
Active contraction maintains continence after rectal filling

Question 27

What are some causes of injury to the pelvic floor?

Answer 27

Pregnancy and childbirth, chronic constipation, obesity, heavy lifting, chronic cough, previous injury, menopause

Question 28

What is urinary incontinence?

Answer 28

Involuntary loss of urine

Question 29

What does urinary continence depend on?

Answer 29

Urinary bladder neck support, external urethral sphincter and smooth muscle in urethral wall

Question 30

What structures can prolapse involve?

Answer 30

Uterus, vagina or both = also bladder and rectum

Question 31

What causes prolapse?

Answer 31

Failure of support for pelvic organs

Question 32

What is vaginal prolapse?

Answer 32

Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia

Question 33

How does vaginal prolapse present?

Answer 33

Lump in vaginal wall

Question 34

What are the different types of vaginal prolapse?

Answer 34

Urethrocele = urethral prolapse
Cystocele = prolapse of bladder
Rectocele = rectal prolapse 
Enterocele = prolapse of small bowel

Question 35

What is uterine prolapse?

Answer 35

Descent of uterus = graded from 1st-3rd degree

Question 36

What are some symptoms of uterine prolapse?

Answer 36

Dragging sensation
Feeling of lump
Urinary incontinence

Question 37

What are the treatment options for prolapse?

Answer 37

Sacrospinous fixation and incontinence surgery

Question 38

What occurs in sacrospinous fixation?

Answer 38

Sutures placed in sacrospinous ligament just medial to ischial spine = performed vaginally, repairs cervical/vault descent

Question 39

What structures are at risk of injury during sacrospinous fixation?

Answer 39

Pudendal neurovascular bundle and the sciatic nerve

Question 40

What are the features of incontinence surgery?

Answer 40

Trans-obturator approach = mesh through obturator canal to create sling around urethra, incisions through vagina and groin