Pelvic floor Flashcards
What are teh fucntions of the pelvic floor muscles
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.
Wat are the 3 mechanisms in which the pelvic floor muscles provide support
Via are 3 mechanisms: 1. Suspension 2. Attachment 3. Fusion
What is suspension
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
Describe attachment
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
What Is fusion
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
What makes up the pelvic floor
Predominantly by the levator ani muscles.
Urogenital diaphragm/perineal membrane
Perineal body
Perineal muscles
Posterior compartment
Describe the levator ani muscles
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
What are the 3 levator ani muscles
pubococcygeus puborectalis iliococcygeus
Wha are the perineal muscles
Next layer after the levator ani
Superficial
Most commonly involved in perineal trauma- accidental, sexual and obstetric.
Note: transverse perineus, bulbospongiosus
What is the urigenital diaphragm
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
What is the perineal body
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
Describe teh blood supply, innervation, venous drainage and lymphatics to the pelvic floor
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
What can happen as a result of pelvic floor dysfunction
Pelvic organ prolapse (POP)
Incontinence- urinary (stress)
Posterior compartment pelvic f loor dysfunction
What are other pelvic floor syfucniton
Obstetric trauma including episiotomy FGM Vaginismus Vulval pain syndromes
What. Is pop
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.
What functional disturbances is pop associated with
is more than an anatomical defect Associated with significant functional disturbances
including: anorectal, urinary sexual
Describe the classification of pop
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
What are the causes/risk factors of opp
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.
Scribe the history and examination of pop
History- dragging sensation
Examination
The POP-Q system, the universal method of assessing
a prolapse
What factors need to be considered for the management of pop
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.
Describe non surgical management for op
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
Describe surgical management for pop
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.
What are oasis
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
Describe the preventataion of oasis
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
Describe stress incontinence
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
What is fgm
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.
What are the types of fgm
Ss
Whar are acute consequences of fgm
less likely for these to be seen here in the UK Haemorrhage- can be severe, leading to shock Sepsis- severe infection, hepatitis, HIV Death
What are late consequences of fgm
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
What are obstetric onsequences o fgm
Fear of childbirth
Increased likelihood of C/S
Postpartum haemorrhage {PPH}, severe vaginal lacerations
What are psychological consequences of fgm
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
What are the legal aspects of fgm
S
What is posterior compartment pelvic floor dysfunction
affecting the posterior compartment presents as: a vaginal or a rectal bulge/lump constipation incomplete evacuation dyssynergic defecation (anismus) anal incontinence
What are the causes f posterior compartment pelvic floor dysfunction
Structural, e.g. Rectocele, rectal prolapse Drugs e.g.. Opiates, Iron supplements Dehydration Immobility Pregnancy Postoperative pain
Descrbe fetal incontencance
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.
