Anatomy of Urinary Incontinence & Prolapse Flashcards
What are the 3 layers of the pelvic floor from INTERNAL to EXTERNAL?
- pelvic diaphragm
- muscles of perineal pouches
- perineal membrane
Describe the components of the pelvis diaphragm and how they are arranged?
- levator ani (group) + coccygeus
- appearance of a sling
- Anterior gap = urogenital hiatus
Where do the levator ani muscles attach to?
Pubic bones ischial spines Perineal body coccyx walls of organs in midline (vagina in females and prostate in males
What are the 3 parts that make up the levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
What nerves innervate levator ani?
- pudendal nerve
- nerve to levator ani
Levator ani muscle is tonically contracted all of the time. What is the reason for this?
To maintain continence
Must relax to allow urination and defecation
What additional support structures (aside from pelvic floor muscles) are found in the pelvis?
endo-pelvic fascia
=> connective tissue ‘packing’ (some loose and some fibrous)
Pelvic ligaments uterosacral transverse cervical (cardinal) lateral ligament of bladder lateral rectal ligaments
What structures are found in the deep perineal pouch?
- part of the urethra (and vagina in females)
- bulbourethral (Cowper’s) glands in male
OR Bartholin’s glands in female - neurovascular bundle for penis/clitoris
- extensions of the ischioanal fat pads and muscles:
What muscles found in the deep perineal pouch help to maintain urinary continence?
External urethral sphincter
Compressor urethrae
What name is given to the Deep transverse perineal muscle in females?
Not a named muscle as thought to be smooth rather than skeletal
What is the perineal membrane?
- Thin sheet of tough, deep fascia
- Attaches laterally to the sides of the pubic arch, closing the urogenital triangle
(Openings for the urethra (and vagina in females)) - passive support of pelvic organs
What structures are found in the superficial perineal pouch of the male?
Contains root of penis:
=> Bulb – corpus spongiosum
=> crura – corpus cavernosum
Associated muscles
bulbospongiosus (over bulb)
ischiocavernosus (over crura)
What structures are found in the superficial perineal pouch of the female?
Clitoris and crura – corpus cavernosum
Bulbs of vestibule (x2 on either side rather than one in male)
Associated muscles
bulbospongiosus (over 2 bulbs)
ischiocavernosus (over clitoris and crura)
When does the pelvic floor actively contract?
Actively contracts when increased abdominal pressure
=> Coughing, sneezing, vomiting
How does puborectalis help to maintain fecal continence
Tonic contraction bends the anorectum anteriorly into right angle
Active contraction maintains continence after rectal filling as it basically closes off angle even further
How can the pelvic floor be injured?
Pregnancy Childbirth stretching or tearing (Pudendal nerve damage) Chronic constipation Obesity Heavy lifting Chronic cough or sneeze Previous injury to pelvis/pelvic floor Menopause
What 3 factors does urinary continence depend on?
- urinary bladder neck support
- external urethral sphincter
- smooth muscle in urethral wall
What is meant by vaginal prolapse?
- herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
- presents as a lump in vaginal wall
(urethrocele, cystocele, rectocele, enterocele)
HOw may patients present and describe the feeling of uterine prolapse?
dragging sensation
feeling of ‘lump’
may also present with urinary incontinence
HOw can prolapse be treated/repaired surgically?
Fix vaginal wall to underlying strong sacrospinous ligament via sutures
- usually done on RHS as easiest to mmove rectum out of way to complete procedure, but can be done on LHS, or both
What risk is involved with sacrospinous suturing to treat prolapse?
Risk of injury to pudendal NVB and sciatic nerve
What surgery can be used to treat incontinence?
Trans-obturator approach
Mesh inserted through obturator canal
Creates another sling around the urethra to maintain continence
