clinical anatomy of urinary incontinence and prolapse Flashcards
what are the 3 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 is pelvic diaphragm made up of?
- levator ani and coccygeus
> has appearance of a sling
what is the urogenital hiatus?
- anterior gap between medial borders for passage of the urethra in both sexes and vagina in female
what muscle forms most of the pelvic diaphragm?
- levator ani
where does levator ani attach?
- pubic bones, ischial spines and tendinous arch of levator ani
- perineal body, coccyx and walls of organs in midline
what are 3 parts of levator ani?
- iliococcygeus
- pubococcygeus
- puborectalis
> tonically contracted most of the time
lifts anus
what innervates levator ani?
- dual nerve supply
> pudendal nerve (S2, S3, S4)
> S4 and sometimes S5
what provides additional support to pelvis?
- endo-pelvic fascia
- pelvic ligaments (utero-sacral ligament, transverse cervical ligament, lateral rectal, lateral ligament of bladder)
what lies deep to fascia covering the inferior aspect of pelvic diaphgram?
- deep perineal pouch
> lies above perineal membrane
what is in the deep perineal pouch?
- contains part of urthera (and vagina in females), bulbourethral glands in male, neurovascular bundle for penis/clitoris, extensions of ischioanal fat pads and muscles
what are 3 important muscles of female perineal pouch?
- external urethral sphincter
- compressor urethrae
- deep transverse perineal muscle
what lies superficial to deep perineal pouch?
- perineal membrane - thin sheet of though, deep fascia
where does perineal membrane attach to?
- ataches laterally to sides of pubic arch, closing urogenital triangle
- together w perineal body it is last passive support of pelvic organs
where does superficial perineal pouch lie in female
- lie below perineal membrane
what is contained within superficial perineal pouch?
- clitoris and crura - corpus cavernosum
- bulbs of vestibule - paired
- assoc muscles - bulbospongiosis and ischiocavernous (constrict to keep engorgement of blood vessels)
what do greater vestibular glands (bartholins glands)?
- secrete mucus to lubricate vagina and vulva
what is contained within superficial perineal p-uch of the male
- contains root of penis - bulb and assoc muscles (bulbospongiosus and ischicavernous)
- also contains proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve)
functions of pelvic floor?
- provide support to pelvic organs: normally tonically contracted, actively contracts in response to coughing, sneezing or vomiting
- also helps maintain continence
what helps maintain continence in urinary system?
- external urethral sphincter, compressor urethrae, levator ani
what helps maintain faecal continence in pelvic floor?
- tonic contraction of puborectalis bends the anorectum anteriorly
- active contraction maintains continence after rectal filling
injury to pelvic floor?
- pregnancy
- childbirth - stretching or tearing pudendal nerve damage
- chronic constipation
- obesity
- heavy lifting
- chronic cough or sneeze
- previous injury to pelvis/pelvic floor
- menopause - as oestrogen levels decline tissues of vagina, vulva and urethra become thinner and break down
urinary incontinence depends on?
- urinary bladder neck support
- external urethral sphincter
- SM in urethral wall
- stress intontinence
prolapse can involve what?
- uterus, vagina or both
what is a vaginal prolapse?
- herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
- presents as a lump in vaginal wall
what is a uterine prolapse?
- descent of uterus
- dragging sensation
- feeling of ‘lump’
- urinary incontinence
what is treatment and repair for prolapse?
- sacrospinous fixation
sutures placed in sacrospinous ligament
just medial to ischial spine
to repair cervical/vault descent
performed vaginally
what structures are at risk of injury in sacrospinous fixation
- pudendal NVB and sciatic nerve as these structures lie just posterior to sacrospinous ligament
what is the trans-obturator approach
- mesh through obturator canal - making a space in obturator foramen for passage of obturator NVB
- creating a sling around urethra
- incisions through vagina and groin
