clinical anatomy of urinary incontinence and prolapse

Question 1

what are the 3 layers of the pelvic floor?

Answer 1

• pelvic diaphragm
• muscles of perineal pouches
• perineal membrane

Question 2

what is the deepest layer of the pelvic floor?

Answer 2

• pelvic diaphragm

Question 3

what is pelvic diaphragm made up of?

Answer 3

• levator ani and coccygeus
  > has appearance of a sling

Question 4

what is the urogenital hiatus?

Answer 4

• anterior gap between medial borders for passage of the urethra in both sexes and vagina in female

Question 5

what muscle forms most of the pelvic diaphragm?

Answer 5

• levator ani

Question 6

where does levator ani attach?

Answer 6

• pubic bones, ischial spines and tendinous arch of levator ani
• perineal body, coccyx and walls of organs in midline

Question 7

what are 3 parts of levator ani?

Answer 7

• iliococcygeus
• pubococcygeus
• puborectalis

> tonically contracted most of the time
lifts anus

Question 8

what innervates levator ani?

Answer 8

• dual nerve supply
  > pudendal nerve (S2, S3, S4)
  > S4 and sometimes S5

Question 9

what provides additional support to pelvis?

Answer 9

• endo-pelvic fascia
• pelvic ligaments (utero-sacral ligament, transverse cervical ligament, lateral rectal, lateral ligament of bladder)

Question 10

what lies deep to fascia covering the inferior aspect of pelvic diaphgram?

Answer 10

• deep perineal pouch
  > lies above perineal membrane

Question 11

what is in the deep perineal pouch?

Answer 11

• contains part of urthera (and vagina in females), bulbourethral glands in male, neurovascular bundle for penis/clitoris, extensions of ischioanal fat pads and muscles

Question 12

what are 3 important muscles of female perineal pouch?

Answer 12

• external urethral sphincter
• compressor urethrae
• deep transverse perineal muscle

Question 13

what lies superficial to deep perineal pouch?

Answer 13

• perineal membrane - thin sheet of though, deep fascia

Question 14

where does perineal membrane attach to?

Answer 14

• ataches laterally to sides of pubic arch, closing urogenital triangle
• together w perineal body it is last passive support of pelvic organs

Question 15

where does superficial perineal pouch lie in female

Answer 15

• lie below perineal membrane

Question 16

what is contained within superficial perineal pouch?

Answer 16

• clitoris and crura - corpus cavernosum
• bulbs of vestibule - paired
• assoc muscles - bulbospongiosis and ischiocavernous (constrict to keep engorgement of blood vessels)

Question 17

what do greater vestibular glands (bartholins glands)?

Answer 17

• secrete mucus to lubricate vagina and vulva

Question 18

what is contained within superficial perineal p-uch of the male

Answer 18

• 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)

Question 19

functions of pelvic floor?

Answer 19

• provide support to pelvic organs: normally tonically contracted, actively contracts in response to coughing, sneezing or vomiting
• also helps maintain continence

Question 20

what helps maintain continence in urinary system?

Answer 20

• external urethral sphincter, compressor urethrae, levator ani

Question 21

what helps maintain faecal continence in pelvic floor?

Answer 21

• tonic contraction of puborectalis bends the anorectum anteriorly
• active contraction maintains continence after rectal filling

Question 22

injury to pelvic floor?

Answer 22

• 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

Question 23

urinary incontinence depends on?

Answer 23

• urinary bladder neck support
• external urethral sphincter
• SM in urethral wall
• stress intontinence

Question 24

prolapse can involve what?

Answer 24

• uterus, vagina or both

Question 25

what is a vaginal prolapse?

Answer 25

• herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
• presents as a lump in vaginal wall

Question 26

what is a uterine prolapse?

Answer 26

• descent of uterus
• dragging sensation
• feeling of ‘lump’
• urinary incontinence

Question 27

what is treatment and repair for prolapse?

Answer 27

• sacrospinous fixation

sutures placed in sacrospinous ligament
just medial to ischial spine
to repair cervical/vault descent
performed vaginally

Question 28

what structures are at risk of injury in sacrospinous fixation

Answer 28

• pudendal NVB and sciatic nerve as these structures lie just posterior to sacrospinous ligament

Question 29

what is the trans-obturator approach

Answer 29

• 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