ANATOMY OF URINARY INCONTINENCE & PROLAPSE Flashcards
What makes up the pelvic floor?
3 layers:
- Pelvic diaphragm (top)
- Muscles of perineal pushes (middle)
- Perineal membrane (bottom)
What does the pelvic floor do?
Separates the pelvic cavity above from the perineum below and plays an important role in providing support to pelvic organs and maintaining continence (urinary & faecal)
What makes up the pelvic diaphragm?
Pelvic diaphragm is the deepest layer and has the appearance of a sling. Consists of 2 muscle groups:
- Levator ani (anterior & medial)
- Coccygeus (posterior & lateral )
What is the urogenital hiatus?
Anteriorly a gap between the medial borders of the pelvic diaphragm. The passage for the urethra (M+F) and vagina (F)
Where does the levator ani attach?
The 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 the levator ani?
Puborectalis - most medially
Pubococcygeus
Iliococcygeus
What innervates the levator ani?
Pudendal nerve and nerve to levator ani
The levator ani is ______ contracted most of the time - it must ______ to allow urination & defaecation
Tonically
Relax
Where is the deep perineal pouch?
Lies below the fascia covering the inferior aspect of the pelvic diaphragm and lies above the perineal membrane. A shallow compartment containing a number of structures
What structures does the deep perineal such contain?
Part of the urethra (and vagina in females)
Bulbourethral glands in male (Cowper’s glands)
Neurovascular bundle for penis/clitoris
Extensions of the sischioanal fat pads and muscles
What muscles are contained within the deep perineal pouch?
M+F both have an external urethral sphincter
Both also have a compressor urethrae
Males have a deep transverse perineal muscle - skeletal muscle
Females have a band of smooth muscle
What is the perineal membrane?
Used to be referred to as the urogenital diaphragm - superficial to the deep perineal pouch
A thin sheet of tough, deep fascia
Opening for urethra (and vagina in females)
Where does the perineal membrane attach?
Attached laterally to the sides of the pubic arch, closing the urogenital triangle
What is contained in the superficial perineal pouch in females?
Female erectile tissue and associated muscle:
- Clitoris and crura (crura is formed from tissue called corpus cavernous)
- Bulbs of vestibule - paired
- Associated muscles - lie on top of the spongy/cavernous tissue - bulbospongiousus and ischiocavernosus
- Bartholin’s glands, transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
What is contained in the superficial pouch in males?
Contains root of penis:
- Bulb - corpus spongiosum; crura - corpus cavernous
- Associated muscle - bulbospongiosus and ischiocavernosus
- Proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
What role does the perineal body play?
Links all the layers of the pelvic floor. A ball of tissue that contains fibrous tissue (collagen, elastic) and both skeletal and smooth muscle. Is where a number of the muscle converge and interweave
What functions does the pelvic floor have?
Provides support to the pelvic organs - is usually tonically contracted
Will actively contract during things like sneezing, coughing, vomiting to maintain continence
How can the pelvic floor be injured?
Pregnancy - pressure & stress Childbirth - stretching or tearing pelvic floor muscles themselves OR pudendal nerve damage which supplies the muscles Chronic constipation Obesity Heavy lifting Chronic cough or sneeze Previous injury to pelvis/pelvic floor Menopause
What is urinary incontinence?
The involuntary loss of urine
What does continence depend on?
Urinary bladder neck support - some from the external urethral sphincter & smooth muscle in the urethral walls
External urethral sphincter
Smooth muscle in urethral wall
In general, what is a prolapse?
Can involve the uterus, vagina or both (and can even involve the bladder and rectum). Essentially is a failure of support for the pelvic organs
What is a vaginal prolapse?
Herniation of urethra, bladder, rectum or rectouterine such through supporting fascia Presents as a lump in vaginal wall Urethra = urethrocele Bladder = cystocele Rectum = rectocele Rectouterine pouch = entre ocele
What is uterine prolapse?
Descent of the cervix/uterus into the vagina
What is a 1st degree uterine prolapse?
When just the cervix is dropping into the vagina
What is a 2nd degree uterine prolapse?
The cervix is dropping to a level just inside the opening of the vagina
What is a 3rd degree uterine prolapse?
The cervix is outside the vagina
What is a 4th degree uterine prolapse?
The entire uterus is outside the vagina
How does a uterine prolapse often present?
As a dragging sensation or feeling a lump and urinary incontinence
What are the treatment options for a prolapse?
Supraspinous fixation
- sutures are placed in the sacrospinous ligament just medial to the ischial spine to repair cervical/vault descent
- Performed vaginally
- risk of injury to pudendal NVB and sciatic nerve
- used for prolapse rather than incontinence
Incontinence surgery
- Trans-obturator approach
- Mesh is fed through the obturator foramen to create a sling posterior to the urethra and back out the other side. It is then stitched in place
- The foramen is sued for the NVB
- Incisions are made in the groin at each side and the vagina
- The sling effectively support s the urethra
