Pelvic floor

Question 1

What are teh fucntions of the pelvic floor muscles

Answer 1

 support the pelvic organs – namely the vagina, uterus,
ovaries, bladder and rectum
 maintain intra-abdominal pressure during coughing, vomiting, sneezing and laughing
 facilitate defaecation and micturition
 maintain urinary and faecal continence
 facilitate childbirth.

Question 2

Wat are the 3 mechanisms in which the pelvic floor muscles provide support

Answer 2

Via are 3 mechanisms: 1. Suspension 2. Attachment 3. Fusion

Question 3

What is suspension

Answer 3

 Essentially, vertical support
 Working against gravity  Strength is required
 The cardinal ligaments- holding the cervix and upper vagina in place
 The uterosacral ligaments – holding the back of the cervix and upper vagina laterally
 The round ligament- maintain the anteverted position
of the uterus

Question 4

Describe attachment

Answer 4

Provided by the
 Arcus tendinosus fascia pelvis (ATFP)- also known as the “white line”
 Endopelvic fascia- stretches like a hammock from the white line laterally, to the vaginal wall medially
 Urethra lies anterior and above it and, thus, gets compressed against it during increased intra-abdominal pressure. Important in maintaining urinary continence

Question 5

What Is fusion

Answer 5

 Implies link, connection, inseparable  Involves the urogenital diaphragm and the perineal
body
 The lower half of the vagina is supported by fusion of the vaginal endopelvic fascia to the perineal bod posteriorly, the levator ani laterally and the urethra anteriorly

Question 6

What makes up the pelvic floor

Answer 6

 Predominantly by the levator ani muscles.
 Urogenital diaphragm/perineal membrane
 Perineal body
 Perineal muscles
 Posterior compartment

Question 7

Describe the levator ani muscles

Answer 7

 These form a broad U-shaped sheet
 Stretches backwards and inwards from either side of
the pelvis to meet in the middle line
 encircles the urethra, vagina and the rectum and reaching the coccyx.
 Originate from the back of the body of the pubic bone, the white line over the obturator internus muscle and
the medial aspect of the ischial spines.  Some of the fibres are inserted as they encircle the urethra, some are inserted as they encircle the vagina,
where they take part in forming the perineal body
 some fibres are inserted as they encircle the rectum and the rest are inserted in the lower part of the coccyx
and anococcygeal raphe

Question 8

What are the 3 levator ani muscles

Answer 8

 pubococcygeus  puborectalis  iliococcygeus

Question 9

Wha are the perineal muscles

Answer 9

 Next layer after the levator ani
 Superficial
 Most commonly involved in perineal trauma- accidental, sexual and obstetric.
Note: transverse perineus, bulbospongiosus

Question 10

What is the urigenital diaphragm

Answer 10

 triangular sheet of dense fibrous tissue
 Spans the anterior half of the pelvic outlet
 Arises from the inferior ischiopubic ramus
 Attaches medially to the urethra, vagina and perineal body
 Thereby supporting the pelvic f loor

Question 11

What is the perineal body

Answer 11

 Occupies a central position (and role) on the pelvic f loor, between the vagina and rectum
 Point of insertion of the levator ani muscles
 Attached posteriorly to the external anal sphincter (EAS) and the coccyx
 Support of the perineal structures rely on it

Question 12

Describe teh blood supply, innervation, venous drainage and lymphatics to the pelvic floor

Answer 12

 Blood supply –  the internal and the external pudendal arteries and
drains through corresponding veins.  Lymphatic drainage-  via the inguinal lymph nodes.  Nerve supply-  branches of the pudendal nerve, which derives its
fibres from the ventral branches of the second, third
and fourth sacral nerve

Question 13

What can happen as a result of pelvic floor dysfunction

Answer 13

 Pelvic organ prolapse (POP)
 Incontinence- urinary (stress)
 Posterior compartment pelvic f loor dysfunction

Question 14

What are other pelvic floor syfucniton

Answer 14

 Obstetric trauma including episiotomy  FGM  Vaginismus  Vulval pain syndromes

Question 15

What. Is pop

Answer 15

Pelvic Organ Prolapse (POP)
 refers to loss of support for the uterus, bladder, colon or rectum, leading to prolapse of one or more of these organs into the vagina.
 common, up to 40% of women experence a degree of pelvic organ prolapse in their lifetime
 Although not life-threatening, has a significant impact on the quality of life, perception of body image and can
cause depressive symptoms.

Question 16

What functional disturbances is pop associated with

Answer 16

 is more than an anatomical defect  Associated with significant functional disturbances
including:  anorectal,  urinary  sexual

Question 17

Describe the classification of pop

Answer 17

 Anterior compartment-
This is commonly described as a cystocele, urethrocoele or cystourethrocoele

 In the middle compartment or vaginal apex, the uterus may
prolapse - uterine prolapse.
 If it’s the entire uterus- procidentia
 Following a hysterectomy, the apex may still prolapse

Posterior compartment
 The rectum may prolapse into the posterior part of the vagina-rectocele
 Loops of bowel may prolapse into the rectovaginal space (Pouch of Douglas)- enterocele

Question 18

What are the causes/risk factors of opp

Answer 18

 Aetiology is complex  Risk factors:
 Age
 Parity - carrying a weight eg fetus
 Vaginal delivery- 4x increased risk after 1st child; 11x increase after >/= 4 deliveries
 Postmenopausal oestrogen deficiency
 Obesity and causes of chronic raised intra-abdominal pressure
 Neurological e.g.. Spina bifida, muscular dystrophy  Genetic connective tissue disorder e.g.. Marfan’s,
Ehlers Danlos.

Question 19

Scribe the history and examination of pop

Answer 19

 History- dragging sensation
 Examination
 The POP-Q system, the universal method of assessing
a prolapse

Question 20

What factors need to be considered for the management of pop

Answer 20

 Factors that need to be considered: 
 nature of symptoms and degree of bother 
 nature and extent of prolapse 
 completion of family and future pregnancy plans 
 sexual activity 
 fitness for surgery and anaesthesia 
 associated incontinence symptoms 
 woman's goals

 work, physical activity and domestic circumstances
 previous management and outcome
 surgical experience and familiarity with different surgical procedures
 having realistic expectations about outcomes, in the light of history and examination.

Question 21

Describe non surgical management for op

Answer 21

 Pessaries  Especially useful in cases where patient is not fit for
surgery, patient’s wishes, while awaiting surgery  Different types and different indications for choosing
e.g. sexually active or not  Types include- ring, shelf and gelhorn pessaries

Question 22

Describe surgical management for pop

Answer 22

 offers a more definitive treatment  There’s risk of recurrence and the potential for

complications.  Can be performed vaginally, abdominally or
laparoscopically.  Include:  Anterior /posterior repair (anterior /posterior
colporrhaphy) , vaginal hysterectomy etc.

Question 23

What are oasis

Answer 23

Obstetric Anal Sphincter InjurieS (OASIS)
 Perineal tears involving the anal sphincter complex  Types- 3rd and 4th degree tears  Can result in significant morbidity  Demonstrates the functions of the pelvic f loor-
continence and support

Question 24

Describe the preventataion of oasis

Answer 24

 Thinking about episiotomy (risk groups and correct
angle) i.e. restrictive use  For every 6° the episiotomy is made away from the
midline, there is a 50% reduction in third-degree tear.  Perineal protection at crowning can be protective  Encouraging the mother NOT to push when the head
is crowning

Question 25

Describe stress incontinence

Answer 25

Urinary incontinence
 Stress incontinence, affected by dysfunction of the
pelvic f loor  Other types of incontinence- urge incontinence due to
problems with the bladder not the pelvic f loor  The management ref lects this- pelvic f loor muscle
exercises is 1st line treatment  Surgical treatment, only if symptoms persist -
colposuspension

Question 26

What is fgm

Answer 26

Female genital mutilation is defined as all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other non-therapeutic reasons
 Varied  Mistaken as a religious practice, a form of
“circumcision”, across board- Muslims, Christians etc.  Culture- “ purification”, tradition, rite of passage-
attainment of womanhood  Social acceptance, family honour- especially for
marriage  Fear of social exclusion  etc.

Question 27

What are the types of fgm

Answer 27

Ss

Question 28

Whar are acute consequences of fgm

Answer 28

 less likely for these to be seen here in the UK  Haemorrhage- can be severe, leading to shock  Sepsis- severe infection, hepatitis, HIV  Death

Question 29

What are late consequences of fgm

Answer 29

 Sexual difficulties- fertility issues, relationship issues, vicious cycle
 Chronic pain
 Dysmenorrhoea (including haematocolpos)
 Urinary Outf low Obstruction, labial fusion
 Difficult cytological screening and evacuation following miscarriage
 PTSD

Question 30

What are obstetric onsequences o fgm

Answer 30

 Fear of childbirth
 Increased likelihood of C/S
 Postpartum haemorrhage {PPH}, severe vaginal lacerations

Question 31

What are psychological consequences of fgm

Answer 31

 Flashbacks
 Feelings of betrayal, usually at a young age
 Feeling of loss of control and violation
 Anger, trust issues, relationship difficulties
 Sense of self- esteem affected, shame, self-worth

Question 32

What are the legal aspects of fgm

Answer 32

S

Question 33

What is posterior compartment pelvic floor dysfunction

Answer 33

 affecting the posterior compartment presents as:  a vaginal or a rectal bulge/lump  constipation  incomplete evacuation  dyssynergic defecation (anismus)  anal incontinence

Question 34

What are the causes f posterior compartment pelvic floor dysfunction

Answer 34

 Structural, e.g. Rectocele, rectal prolapse  Drugs e.g.. Opiates, Iron supplements  Dehydration  Immobility  Pregnancy  Postoperative pain

Question 35

Descrbe fetal incontencance

Answer 35

 Faecal incontinence: involuntary loss of liquid or solid
stools that is a social or hygienic problem.  Anal incontinence: involuntary loss of f latus, liquid or
solid stools that are a social or hygienic problem.  Causes both physical and psychological distress and
leads to significant impairment of quality of life (Rao
SS et al 2004).  The most common cause of faecal incontinence in
women is obstetric anal sphincter injury.