Pelvic Floor

Question 1

What are the functions of the pelvic floor

Answer 1

Support pelvic organs

Maintain intra-abdominal pressure

Facilitate defaecation and micturition

Maintain urinary and faecal continence

Facilitate childbirth

Question 2

Name and describe how support of the pelvic organs is maintained

Answer 2

Suspension - vertical support working against gravity. Cardinal, uterosacral and round ligaments help keep pelvic organs in right place

Attachment - arcus tendinosus fascia pelvis and endopelvic fascia serve as attachment points for muscles and ligaments

Fusion - fusion at urogential diaphragm and perineal body helps to support pelvic organs

Question 3

What forms the pelvic floor

Answer 3

Levator ani muscles

Urogential diaphragm/perineal membrane

Perineal body

Perineal muscles

Posterior compartment

Question 4

Describe the levator ani muscles

Answer 4

These muscles form a sheet that stretches backwards and inwards from either side of pelvis to meet in midline

Muscles originate from back of pubic bone, white line over obturator internus and medial aspect of ischial spines

Question 5

Where do fibres of levator ani muscles insert

Answer 5

Some insert into urethra

Some insert into vagina

Some insert into rectum

Some insert into lower coccyx and anococcygeal raphe

Fibres inserting into urethra and vagina help form perineal body

Question 6

Which muscles form the levator ani

Answer 6

Pubococcygeus

Puborectalis

Iliococcygeus

Question 7

What are the perineal muscles and which are the two to note

Answer 7

Layer of muscles superficial to levator ani

Most commonly involved in perineal trauma

Two to note are:

Transverse perineal muscles - superifical and deep

Bulbospongiosus

Question 8

What is the urogential diaphragm

Answer 8

Triangular sheet of dense fibrous tissue that spans anterior half of pelvic outlet

Arises from inferior ischiopubic ramus -> attaches medially to urethra, vagina and perineal body

Question 9

Describe the perineal body

Answer 9

Central point of insertion of levator ani muscles

Attached posteriorly to external anal sphincter and coccyx

Supports perineal structures

Question 10

What is the blood supply, innervation, venous and lymphatic drainage of the pelvic floor

Answer 10

Blood supply - internal and external pudendal arteries and veins

Lymphatic drainage - inguinal lymph nodes

Innervation - pudendal nerve

Question 11

What are the types of pelvic floor dysfunction

Answer 11

Pelvic floor prolapse

Incontinence

Posteiror compartment pelvic floor dysfunction

FGM

Vaginisums

Vulval pain syndrome

Question 12

What is vulval pain syndrome

Answer 12

Where patient experiences pain without having any obvious findings on examination

Question 13

Describe POP

Answer 13

Loss of support for uterus, bladder, colon or rectum leading to prolapse of one or more of these organs into the vagina

Has an anatomical, functional and mental impact on patient

Classified as either: cystocele, middle compartment or rectocele - can have post-hysterectomy vault prolapse

Question 14

What are the symptoms of a POP

Answer 14

Feeling of fullness/pressure in pelvis

Feeling of incomplete empyting of bladder/bowel

Repeated bladder infections

Pain/urinary leakage during coitus

Vaginal bleeding or discharge

Urinary incontinence

Rectal pressure/fullness

Difficulty with bowel movements

Question 15

What risk factors are assocaited with POP

Answer 15

Age - wear and tear on pelvic floor muscles

Parity - increases risk, espically vaginal delivery

Obesity and other causes of chronically raised intra-abdominal pressure

Neurological

Genetic CT disorders

Post-menopausal oestrogen deficiency

Question 16

How is POP managed

Answer 16

Non-surgical management - pessaries. Used before surgery or if patient cannot undergo surgery

Surgical management - definitive treatment but risk of recurrence and complications. E.g. anterior/posterior repair, vaginal hysterectomy

Question 17

What are obstetric anal sphincter injuries, what they can cause and how can they be prevented

Answer 17

Perianal tears involving anal sphincter complex

Can result in significant morbidity - incontinence

Can be prevented during childbirth by performing a episiotomy, perinel portection at crowning and encourage mother not to push when head is crowning

Question 18

What is an episiotomy

Answer 18

Where a cut is made through the bulbospongiosus and transverse perineal muscles to give the baby more room during childbirth and prevent damage to the perineal body

Question 19

Describe the type of urinary incontinence that occurs due to pelvic floor dysfucntion and how it is treated

Answer 19

Stress urinary incontinence is caused by pelvic floor dysfunction as there is an inability of the external urethral sphincter to close -> increased pressure on bladder allows urine to flow

Management is through pelvic floor exercises -> surgical treatment if symptoms persist - colpususpension

Question 20

What is female genital mutilation

Answer 20

All procedures involving partial or total removal or external female genitalia or other injury to the female gential organs, whether for cultural or other non-therapeutic reasons

Question 21

What are the types of FGM

Answer 21

1. Partial or total removal of clitoris or prepuce
2. Partial or total removal of clitoris and labia minor, with or without excision of labia majora
3. Narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning labia minora and/or labia majora, with or without excision of clitoris
4. All other harmful procedures to female genitalia for non-medical purposes

Question 22

What are the consequences of FGM

Answer 22

Acute - haemorrhage, shock, infection, sepsis, death

Late - sexual difficulties, relationship issues, fertility issues, chronic pain, PTSD, urinary outflow obstruction, difficult cytological screening, dysmenorrhoea

Obstetric - fear of childbirth, increased chance of C/S, post-partum haemorrhage

Psychological - trust issues, flashbacks, feeling betrayed, anger issues, sense of shame

Question 23

Describe the presentation and causes of posterior compartment pelvic floor dysfunctoin

Answer 23

Presentation: vaginal/rectal bulge, constipation, incomplete evacuation, dyssynergic defaecation, anal incontinence

Causes: structural, drugs, dehydration, immobility, pregnancy, pos-operative pain