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Repro > Lecture 4 - Pelvic floor > Flashcards

Lecture 4 - Pelvic floor Flashcards

1
Q

Functions of the pelvic floor

A
  1. Support pelvic organs - vagina, uterus, bladder, ovaries and rectum
  2. Maintain intra-abdominal pressure during coughing, vomiting, sneezing and laughing
  3. Facilitate defaecation and micturition
  4. Maintain fecael and urinary continence
  5. Facilitate childbirth
  6. Keeps uterus anteverted and antiflexed
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2
Q

How do pelvic floor muscles offer support?

A

Suspension
Fusion
Attachment

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3
Q

Suspension

A

Cardinal ligaments - holds cervix and upper vagina in place

Uterosacral ligaments - holds back of cervix and upper vagina laterally

Round ligament - maintains anteverted position of the uterus

  • offer vertical support against gravity
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4
Q

Attachment

A

Provided by the - arcus tendinosus fascia pelvis (ATFP) [white line]
Endopelvic fascia - stretches from white line laterally to vaginal wall medially

To pelvic organs such as the vagina, rectum and ureters e.g. vagina is attached to:

  • levator ani muscles
  • endopelvic fascia
  • perineal body
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5
Q

Fusion

A

To urogenital diaphragm and perineal body

The vaginal endopelvic fascia is fused to the perineal body posteriorly, levator ani laterally and urethra anterior

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6
Q

Endopelvic fascia and the urethra

A

Urethra lies anterior and superior to the endopelvic fascia therefore can get compressed against it during increased intra-abdominal pressure which maintains urinary continence

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7
Q

Components of the pelvic floor

A 
Levator ani muscles
Urogenital diaphragm
Perineal body 
Perineal muscles
Deep posterior compartment of the buttocks
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8
Q

Levator ani muscles

A

Puborectalis
Iliococcygeus
Pubococcygeus

Origin: pubic bone, white line over the obturator internus muscle and ischial spines

Insertion: Inserted when they encircle the urethra, vagina (contribute to perineal body) and rectum. Also inserts onto coccyx and anococcygeal raphe

  • encircle the rectum, vagina and urethra
  • innervated by the pudendal nerve (S2, S3, S4)
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9
Q

Pelvic diaphragm

A

Coccygeus

Levator ani muscles

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10
Q

Perineal body

A

Central point of pelvic floor between the vagina and rectum

Site of insertion for levator ani muscles

Attached posteriorly to the external anal sphincter and the coccyx

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11
Q

Urogenital diaphragm

A

Triangular sheet of dense fibrous tissue that spans the anterior half of the pelvic floor

Arises from the ischiopubic ramus

Attaches to the urethra, vagina and perineal body

Supports pelvic floor

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12
Q

Perineal muscles

A

Bulbospongiosus
Ischiocavernosus
Superficial transverse perineus
Deep transverse perineus

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13
Q

Iatrogenic damage of perineal muscles

A

Iatrogenic damage during a mediolateral episiotomy in childbirth.

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14
Q

Medio-lateral episiotomy

A

Surgical procedure done when the baby is too big, difficult delivery or when using instruments

Medio-lateral to avoid damage to the perineal body

Can cause:

  • infection
  • haemorrhage
  • dyspareunia
  • damage to the anal sphincter
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15
Q

Blood supply

A

Internal and external pudendal arteries

Internal and external pudendal vein

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16
Q

Lymph drainage

A

Inguinal lymph nodes

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17
Q

Nerve supply

A

Pudendal nerve (S2, S3, S4)

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18
Q

Pelvic organ prolapse (POP)

A

Loss of support for the uterus, baldder and colon causes them to prolapse into the vagina

Effects:

  • Anorectal disturbance
  • Urinary function disturbance
  • Sexual disturbance
  • pain
  • infection
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19
Q

Anterior POP

A

Bladder or urethra prolapses

  • cystocoele - bladder
  • uretherocele - urethra
  • cystourethrocoele - both
20
Q

Middle POP

A

Uterus prolapses

21
Q

Posterior POP

A

Rectum or bowel prolapses

  • rectocoele
  • enterocoele - bowel enters pouch of Douglas
22
Q

Vault prolapse

A

Post hysterectomy
Supportive ligaments are cut to remove the uterus
Apex of the vagina prolapses

23
Q

Risk factors for POP

A

Connective tissue - Ehlers Danlos syndrome and Marfan’s
Neurological disorders - muscular dystrophy
Obesity - chronic increases in intra- abdominal pressure
Age - older (main)
Parity
Vaginal mode of delivery
Oestrogen deficiencies - post menopause

24
Q

Parity

A

No. of pregnancies that reach viable gestational age

25
Q

History and examination of POP

A

Lump down below
Dragging sensation
POP-Q system
Constipation

26
Q

Treatment and management of POP

A

Education - prolapse can reoccur
Surgery: mesh support (high complications) in vault prolapse or hysterectomy
Pessaries

27
Q

Procidentia

A

Whole uterus prolapses into the vagina

28
Q

Ehlers Danlos

A

Collagen fibre abnormality of the dermis and tendons

Frequent joint dislocations and stretchy skin

29
Q

Marfan’s

A

Mutation in the fibrillin 1 gene

Abnormal elastin - long bones, lax joints and fragile vascular walls so increased risk of aneurysm

30
Q

Obstetric anal sphincter injuries (OASIs)

A

Perineal tear involving the anal sphincter complex

  • 3rd and 4th degree tears
  • Can result in significant morbidity
31
Q

Prevention of OASIs

A

Restricted use of episiotomy
Mediolateral episiotomy
Perineal protection at crowning
Encourage mother not to push when the head is crowning

32
Q

Urinary continence

A

Increased abdominal pressure causes leakage of urine

Inadequate support of the external urethral sphincter

33
Q

Risk factors for urinary incontinence

A 
Oestrogen deficiency - post menopausal 
Age - old
Obesity - increases intra-abdominal pressure
Parity
Vaginal delivery
34
Q

History urinary incontinence

A

Passing urine when: coughing, sneezing and laughing (raised intra abdominal pressure)

Can do urodynamic studies

35
Q

Management of urinary incontinence

A

Pelvic floor muscle training

Surgery (if symptoms persist) - creates sling to support the urethral sphincter

36
Q

Vestibulodynia

A

Painful vulva

37
Q

Vaginismus

A

Pain on vaginal penetration due to involuntary muscle spasms

38
Q

Why can vaginal problems occur

A

Due to taut levator ani muscles and tight vaginal opening

39
Q

Consequences of female genital mutilation

A 
Sepsis
Haemorrhage
Infection
Severe pain and chronic pain 
Sexual dysfunction 
Menstrual disorder 
Psychological effects 
Difficulty conceiving
40
Q

Type 1 FGM

A

Partial or total removal of the clitoris and/or the prepuce

41
Q

Type 2 FGM

A

Partial or total removal of the clitoris and the labia minora

42
Q

Type 3 FGM

A

Narrowing of the vaginal orifice with creation of covering seal by cutting and appositioning the labia minor or majora

43
Q

Type 4 FGM

A

All other harmful procedures to the female genitalia for non-medical purposes - pricking, piercing, incising, scraping or cauterising

44
Q

Posterior compartment pelvic floor dysfunction presentation

A 
Vaginal or rectal bulge
Constipation 
Incomplete evacuation 
anal incontinence 
Dyssynergic defecation - dysregulated nerve control
45
Q

Causes of posterior compartment pelvic floor dysfunction

A 
Rectocoele/ rectal prolapse and other structural abnormalities
Dehydration
Immobility 
Pregnancy 
Postoperative pain
46
Q

Anal/faecal incontinence

A

Involuntary loss of flatus, liquid or solid stool

47
Q

Commonest cause of anal/faecal incontinence

A

Obstetric anal sphincter injury

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