Female Pelvic Floor Disorders

Question 1

What are the major muscles of the female pelvis and what do they do?

Answer 1

• Levator Ani Muscles: Primary support to the pelvic viscera. These are paired muscles that contain both Type I and Type II muscle fibers and sling around the rectum, vagina, and urethra.
  
  • Puborectalis
  • Pubococcygeus
  • Iliococcygeus
• Coccygeus: Reinforces the levator ani muscles posteriorly. Arise from the ischial spine and inserts on the lower aspect of the sacrum/upper aspect of the coccyx.
• Genital Hiatus: Intentional orifice in the pelvic diaphragm to allow egress of urethra/vagina/rectum from the pelvis. Diameter of the hiatus will change during passage of urine/stool, intercourse, parturition.

Question 2

What are the DeLancey levels of support?

Answer 2

• There are three levels of support with muscular, ligamentous, and connective tissue components providing bilateral and symmetric support to the pelvic viscera:
  
  • DeLancey Level I. Upper or apical support
    
    • cardinal-uterosacral ligament
    • defects lead to uterine prolapse and vaginal vault prolase (if had prior hysterectomy)
  • DeLancey Level II. Mid-level and lateral vaginal support
    
    • pubocervical fascia
    • defects lead to anterior and posterior wall prolapse
  • DeLancey Level III. Distal, urethral, perineal support
    
    • defects lead to urethral hypermobility
    • perineal deficiency

Question 3

List the three major catagories of pelvic floor disorders?

Answer 3

• Pelvic organ prolapse - vaginal hernia of one of the pelvic organs
• Urinary control problems
• Bowel control problems

Question 4

What are the subdivisions or pelvic organ prolapse?

Answer 4

• Anterior Compartment: Cystocele
• Apical Compartment: Uterine Prolapse
• Posterior Compartment: Rectocele

Question 5

What are the major divisions of urinary control problems?

Answer 5

• Urinary Incontinence: The involuntary loss of urine
• Stress Urinary Incontinence: The involuntary loss of urine on effort or physical exertion or on sneezing or coughing.
• Urgency Incontinence: The involuntary loss of urine associated with urgency

Question 6

What are the subdivisions of bowel control problems?

Answer 6

• ** Fecal Incontinence**: A lack of control over defecation, leading to involuntary loss of bowel contents- including flatus, liquid stool elements and mucus, or solid feces.
• Rectal Prolapse: Rectum wall prolapse down from the normal anatomic position with associated pelvic floor dysfunction. This may occur while straining to defecate or during rest.

Question 7

What are the risk factors, common symptoms, and etiology of pelvic organ prolapse?

Answer 7

• Risk Factors:
  
  • childbirth
  • operative delivery
  • aging tissue
  • connective tissue disorders
  • estrogen deficiency
  • smoking status
  • chronic lung disease
  • chronic increased intra-abdominal pressure:
    
    • obesity
    • constipation
    • cough
• Common Symptoms:
  
  • vaginal bulge
  • pressure
  • protrusion
  • urinary problems
  • bowel problems
  • sexual dyscomfort
• Etiology dependant on clinical findings, level of support defect. Usually due to a weakness, laxity, tear in ligament/connective tissue support in combination with weakness of pelvic floor muscles

Question 8

What is the management of pelvic prolapse?

Answer 8

• Sacrocolpopexy
  
  • take anterior longitudinal ligament
  • abdominal surgery, now laproscopically
  • attaching vagina to anterior longitudinal ligament
  • use a mesh graft to do that
    
    • applying mesh to anterior wall

Question 9

What are the risk factors, common symptoms, and etiology of urinary incontinence?

Answer 9

• Risk Factors:
  
  • female
  • age
  • childbirth
  • previous pelvic surgery
  • increased body weight
  • chronic cough/smoking
  • neurologic disorders
• Common Symptoms:
  
  • Stress Incontinence:
    
    • sudden spurt of urine with increases in abdominal pressure such as cough, sneeze, exercise
  • Urge Incontinence:
    
    • leakage or urine with onset of urge
    • can’t make it to the bathroom in time, key-in-door trigger
    • hearing/feeling water trigger
• Etiology:
  
  • ​Stress Incontinence: weakened support of bladder neck/urethra, weak urethral sphincter
  • Urge Incontinence: uninhibited detrusor contractions/bladder overactivity, neurologic diseases (spinal cord disorder injury, CNS disorders- hydrocephalis, dementia).

Question 10

What are the risk factors, common symptoms, and etiology of fecal incontinence?

Answer 10

• Risk Factors:
  
  • female
  • childbirth
  • age>65
  • poor overall health
  • prior anorectal/pelvic surgery (hemorrhoids, anal fissurotomy)
• Common Symptoms: Unintentional loss of gas, mucous, liquid/soft/solid stool
• Etiology:
  
  • Anal continence is influenced by a variety of factors including rectal compliance, stool consistence, neurologic function, and an intact anal sphincter complex mechanism
  • As such, anal incontinence can be related to motility disorders, inflammatory conditions of the rectum, anal sphincter injury or dysfunction, pelvic floor dysfunction, vaginal or rectal prolapse, fecal impaction, cognitive impairment, and neurologic disorders

Question 11

What is the rectoanal inhibitory reflex?

Answer 11

• Integration of neuronal information and muscle function
• Stool in the rectum – rectal distension – transient decrease in IAS tone and increase in EAS tone
• “sampling” of contents in upper anal canal to ascertain whether solid, liquid or gas
• Voluntary contraction of EAS and PR, decreased anorectal angle, increased anal canal pressure, IAS regains resting tone, stool moves to upper/mid rectum