Bladder or urethra prolapses - cystocoele - bladder - uretherocele - urethra - cystourethrocoele - both

Lecture 4 - Pelvic floor Flashcards by Anmol Landa

Functions of the pelvic floor

Support pelvic organs - vagina, uterus, bladder, ovaries and rectum
Maintain intra-abdominal pressure during coughing, vomiting, sneezing and laughing
Facilitate defaecation and micturition
Maintain fecael and urinary continence
Facilitate childbirth
Keeps uterus anteverted and antiflexed

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How do pelvic floor muscles offer support?

Suspension
Fusion
Attachment

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Suspension

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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Attachment

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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Fusion

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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Endopelvic fascia and the urethra

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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Components of the pelvic floor

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

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Levator ani muscles

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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Pelvic diaphragm

Coccygeus

Levator ani muscles

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Perineal body

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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Urogenital diaphragm

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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Perineal muscles

Bulbospongiosus
Ischiocavernosus
Superficial transverse perineus
Deep transverse perineus

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Iatrogenic damage of perineal muscles

Iatrogenic damage during a mediolateral episiotomy in childbirth.

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Medio-lateral episiotomy

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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Blood supply

Internal and external pudendal arteries

Internal and external pudendal vein

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Lymph drainage

Inguinal lymph nodes

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Nerve supply

Pudendal nerve (S2, S3, S4)

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Pelvic organ prolapse (POP)

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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Anterior POP

Bladder or urethra prolapses

cystocoele - bladder
uretherocele - urethra
cystourethrocoele - both

Middle POP

Uterus prolapses

Posterior POP

Rectum or bowel prolapses

rectocoele
enterocoele - bowel enters pouch of Douglas

Vault prolapse

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

Risk factors for POP

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

Parity

No. of pregnancies that reach viable gestational age

History and examination of POP

Lump down below Dragging sensation POP-Q system Constipation

Treatment and management of POP

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

Procidentia

Whole uterus prolapses into the vagina

Ehlers Danlos

Collagen fibre abnormality of the dermis and tendons | Frequent joint dislocations and stretchy skin

Marfan's

Mutation in the fibrillin 1 gene | Abnormal elastin - long bones, lax joints and fragile vascular walls so increased risk of aneurysm

Obstetric anal sphincter injuries (OASIs)

Perineal tear involving the anal sphincter complex - 3rd and 4th degree tears - Can result in significant morbidity

Prevention of OASIs

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

Urinary continence

Increased abdominal pressure causes leakage of urine | Inadequate support of the external urethral sphincter

Risk factors for urinary incontinence

``` Oestrogen deficiency - post menopausal Age - old Obesity - increases intra-abdominal pressure Parity Vaginal delivery ```

History urinary incontinence

Passing urine when: coughing, sneezing and laughing (raised intra abdominal pressure) Can do urodynamic studies

Management of urinary incontinence

Pelvic floor muscle training | Surgery (if symptoms persist) - creates sling to support the urethral sphincter

Vestibulodynia

Painful vulva

Vaginismus

Pain on vaginal penetration due to involuntary muscle spasms

Why can vaginal problems occur

Due to taut levator ani muscles and tight vaginal opening

Consequences of female genital mutilation

``` Sepsis Haemorrhage Infection Severe pain and chronic pain Sexual dysfunction Menstrual disorder Psychological effects Difficulty conceiving ```

Type 1 FGM

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

Type 2 FGM

Partial or total removal of the clitoris and the labia minora

Type 3 FGM

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

Type 4 FGM

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

Posterior compartment pelvic floor dysfunction presentation

``` Vaginal or rectal bulge Constipation Incomplete evacuation anal incontinence Dyssynergic defecation - dysregulated nerve control ```

Causes of posterior compartment pelvic floor dysfunction

``` Rectocoele/ rectal prolapse and other structural abnormalities Dehydration Immobility Pregnancy Postoperative pain ```

Anal/faecal incontinence

Involuntary loss of flatus, liquid or solid stool

Commonest cause of anal/faecal incontinence

Obstetric anal sphincter injury