Lecture 4: Pelvic floor Flashcards
What are the functions of the pelvic floor?
- Support of the pelvic organs (vagina, uterus, ovaries, bladder, rectum)
- facilitate micturition (urination) and defecation and maintain urinary/faecal continence
- maintains a high intra-abdominal pressure during sneezing, laughing, coughing
- contributes to the birth canal and facilitates childbirth
What are the three levels of support in the pelvic floor?
- suspension
- attachment
- fusion
How does suspension support the pelvic organs?
Maintains an ‘anti-gravity’ position by providing a strong verticle support, from the cardinal ligaments and uterosacral ligaments
How does attachment support the pelvic organs?
Comes from attachments on the pelvic organs
e.g. vagina is supported by its attachment to endopelvic fascia, levator ani muscles, and the perineal body
How does fusion support the pelvic organs?
Arises from fusion of different tissues
e.g. urogenital diaphragm abd perineal body
What is the composition of the pelvic floor?
Deep muscles: Levator ani muscles make up majority of pelvic floor: set of U-shaped muscles acting like a sling, thereare three muscles -pubococcygeus -puborectalis -iliococcygeus
Superficial muscles:
- bulbospongiosus
- ischiocavernosus
- superficial transverse perineal
What structures do the levator ani muscles encircle?
-urethra
-vagina
-rectum
It provides support for these organs
What is the midpoint of the attachments for the levator ani muscles?
Perineal body
What superficial muscles can undergo iatrogenic damage during childbirth?
Bulbospongiosus and the transverse perineal muscles undergo iatrogenic damage in a medio-lateral episiotomy in childbirth (cutting vagina)
-this is to avoid damage to the perineal body as it is an integral role in pelvic floor support as site of attachment
Why is an episiotomy done?
If the baby is large/ there is a difficult delivery/ use of forceps in delivery. It is done to prevent further perineal damage
What complications can an episiotomy cause?
- infection
- haemorrhage
- damage to anal sphincter
- dyspareunia (pain during sex)
What is the perineal body?
Central point between the vagina and the rectum. Its main function is to act as a site of attachment for pelvic floor muscles and other structures providing support
What is the urogenital diaphragm?
Sheet of dense fibrous tissue that spans the anterior half of the pelvic floor
What is the innervation of the pelvic floor?
Pudendal nerve
What is pelvic organ prolapse?
Loss of support for the uterus/bladder/colon can result in a prolapse of any of these organs into the vagina
- implications on quality of life due to its disturbance to anorectal, urinary and sexual function
- can also cause altered sense of body image, leading to depressive symptoms
- source of pain and infection
How can pelvic organ prolapse be classified?
By the compartment the prolapse has occured in, and the organ that has prolapsed
Anterior compartment (bladder/urethra)
- cystoceole (bladder)
- urethrocoele (urethra)
- cystourethrocoele (both)
Middle compartment
-uterus prolapses into the vagina, various degrees depending on how far the prolapse was
Posterior compartment (bowel/surrounding structures)
- rectocoele (rectum)
- enterocoele (loops of bowel entering rectouterine pouch)
What is a vault prolapse?
Apex of the vagina (vault) can prolapse
Can occur after a hysterectomy as the supportive ligaments have been cut when removing the uterus
What are the risk factors for pelvic organ prolapse?
- age
- parity (no. of times a woman has given birth)
- mode of delivery (particularly vaginal delivery)
- oestrogen deficiency (post/peri-menopausal)
- chronic increased abdominal pressure
- connective tissue/neurological disorders
What symptoms does a patient present with in pelvic organ prolapse?
- feeling a lump down below
- something ‘coming down’
- symptoms relating to where the prolapse is occuring e.g. constipation
How do you manage a pelvic floor prolapse?
Centered on how much the prolapse is interfering with the patients quality of life, the severity of the prolapse, and how fit they are for surgical procedure Non-surgical: -use of pessaries (ring pessaries) Surgical: depends of prolapse type -removal of uterus (hysterectomy) -mesh support for a vault prolapse
Educate patients that prolapses can reoccur
What does dysfunction of the pelvic floor usually result in?
Stress incontinence
-increased abdominal pressure causes ‘leaks’ of urine, as the support to the urethral sphincter via the pelvic floor is inadequate
What are the risk factors for developing stress incontinence?
Same as those for pelvic floor prolapse, especially: age and oestrogen deficiency
What are the symptoms of stress incontinence?
- passing urine on laughing/coughing/activities increasing intraabdominal pressure
- may not be much to see on examination other than an obvious injury to the pelvic floor
- urodynamic studies can be used to investigate further
How do you manage urinary incontinence?
- pelvic floor muscle training
- surgical intervention can be used to create ‘slings’ to support the urethral sphincter
What are some vulval problems?
Patients experience pain with no finding on examination
-related to tension of the levator ani muscles
What is FGM?
Female genital mutilation (illegal in UK, reported and safeguarding if <18yo)
- damaging female external genitalia
- significant consequences such as severe pain, sepsis, haemorrhage
- long term complications include psychological effects, sexual dysfunction, difficulty conceiving, chronic pain, menstrual disorders
What is posterior compartment pelvic floor dysfunction?
Range of conditions affecting the posterior part of the pelvic floor.
The anal sphincter is attached to levator ani muscles, so any damage can lead to loss of voluntary control of defecation
-can get constipation/incomplete evacuation/anal incontinence
