Clinical Anatomy of Urinary Incontinence & Prolapse Flashcards
What is the pelvic floor?
Separates pelvic cavity from perineum
What are the roles of the pelvic floor?
Provide support to pelvic organs
Plays a role in maintaining continence
What are the three layers of pelvic floor (debated)?
Pelvic diaphragm
Muscles of perineal pouches
Perineal membrane
What is the pelvic diaphragm and what does it consist of?
Deepest layer of pelvic floor (most internal layer)
Consists of two muscle groups:
- Levator ani + coccygeus
What exists between the medial borders of the pelvic diaphragm?
An anterior gap between medial borders
- Urogenital hiatus
- Passage for urethra and vagina
What does the pelvic diaphragm look like?
Appearance of a sling
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What does the levator ani attach?
Pubic bones, ischial spines and tendinous arch of levator ani
Perineal body, coccyx and walls of organs in midline
Describe tonic contraction of levator ani
Tonically contracted most of time
What are the 3 muscles of the levator ani?
Puborectalis
Pubococcygeus
Iliococcygeus
What innervates the levator ani?
Pudendal nerve and nerve to levator ani
The levator ani forms most of what?
Pelvic diaphragm
What does the endo-pelvic fascia consist of?
Some loose areolar tissue
Some fibrous (collagen and elastic fibres)
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Describe the pelvic ligaments
Fibrous endo-pelvic fascia
Uterosacral
Transverse cervical (cardinal)
Lateral ligament of bladder
Lateral rectal ligaments
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Where does the deep perineal pouch lie?
Below the fascia covering the inferior aspect of pelvic diaphragm
Above perineal membrane
What does the deep perineal pouch contain?
Part of urethra (and vagina in females), bulbourethral glands in male, neuromuscular bundle for penis / clitoris, extensions of sischioanal fat pads and muscles
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Label this diagram
Where does the perineal membrane lie?
Superficial to deep perineal pouch
What is the perineal membrane?
Thin sheet of tough, deep fascia
Attaches laterally to the sides of pubic arch, closing the urogenital triangle
What does the perineal membrane have openings for?
Urethra and (vagina in females)
Together with the perineal body, what is the last passive support of the pelvic organs?
Perineal membrane
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Label this diagram
Where does the superficial perineal pouch lie in females?
Lies below perineal membrane
What does the superficial perineal pouch contains in females?
Contains female erectile tissue and associated muscle:
- Clitoris and crura - corpus cavernosum
- Bulbs of vestibule - paired
- Associated muscles - bulbospongiosus and ischiocavernosus
Also contains greater vestibular glands, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
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Describe where the superficial perineal pouch in males lie
Below perineal membrane
Is the superficial perineal pouch part of pelvic floor?
Technically no, but needs to be covered for completion
What does the superficial perineal pouch in males contain?
Contains root of penis
- Bulb: corpus spongiosum, crura - corpus cavernosum
- Associated muscles - bulbospongiosus and ischiocavernosus
Also contains proximal spongy (penile) urethra, superficial transverse perineal muscle and branches of internal pudendal vessels and pudendal nerve
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What is another name for greater vestibular glands?
Bartholin’s glands
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What is the perineal body important for?
Support of pelvic floor
Going from top to bottom in this image, what is deep and what is superficial?
Top 3 pelvic floor
Bottom 2 superficial perineal pouch
What are functions of pelvic floor?
Provides support to pelvic organs
Helps maintain continence
How does pelvic floor provide support to pelvic organs?
Normally tonically contracted
Actively contracts - coughing, sneezing, vomiting
How does the pelvic floor maintain continence?
Urinary - external urethral sphincter, compressor urethrae, levator ani
Faecal - tonic contraction of puborectalis bends the anorectic anteriorly; active contraction maintains continence after rectal filling (anorectal angle decreases if contraction of muscle and this maintains faecal continence)
When can injury to pelvic floor occur?
MAJOR/COMMON
Pregnancy
Childbirth - stretching or tearing; pudendal nerve damage
Minor / less common
Chronic constipation
Obesity
Heavy lifting
Chronic cough or sneeze
Previous injury to pelvis / pelvic floor
Menopause
What is urinary incontinence?
Involuntary loss of urine
What does urinary continence depend on?
Urinary bladder neck support
External urethral sphincter
Smooth muscle in urethral wall
What organs can be involved in prolapse?
Can involve uterus, vagina or both (also bladder and rectum)
What is prolapse?
Common gynaecological disorder
Failure of support for pelvic organs
What is vaginal prolapse and how does it present?
Herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia
Presents as lump in vaginal wall
Urethrocele, cystocele, rectocele, enterocoele
Label this diagram
Describe uterine prolapse and degrees of uterine prolapse
Descent of uterus
1st, 2nd or 3rd degree
Dragging sensation
Feeling of lump
Urinary incontinence
What prolapse can be treated?
Both uterine and vaginal prolapse
What is sacrospinous fixation?
Sutures placed in sacrospinous ligament just medial to ischial spine
To repair cervical / vault descent
Performed vaginally
In sacrospinous fixation, there is risk of injury to?
Pudendal neurovascular bundle and sciatic nerve
Describe incontinence surgery
Trans-obturator approach
Mesh through obturator canal (space in obturator foramen for passage of obturator neurovascular bundle)
Create a sling around urethra
Incisions through vagina and groin
