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Pelvic Floor Physical Therapy > Pelvic Floor Anatomy > Flashcards

Pelvic Floor Anatomy Flashcards

1
Q

There is an inseparable relationship between structure and function of pelvic floor and

A

lower urinary tract

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2
Q

the _________ and _________ of the bladder and urethra are important factors in continence, but they are dependent on their attachments to the bony pelvis and pelvic floor.

A

position and mobility

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3
Q

The pelvic floor:

A

all visceral, neurovascular, and myofascial structures contained in the bony pelvis from pubis to coccyx and between lateral ischial walls

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4
Q

Describe the pelvic floor deep to superficial

A
  • Peritoneum
  • Endopelvic fascia - pelvic viscera or viscerofascial layer
  • Smooth muscle sphincter
  • Levator Ani muscles - pelvic diaphragm, levator ani
  • Urogenital diaphragm - perineal membrane
  • Superficial perineal muscles - Superficial/external genital muscles, superficial genital muscles and anal sphincter
  • Vulvar skin
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5
Q

Bony pelvis

A
  • dynamic link between the spine and upper/lower limbs
  • major mechanism for transmitting weight
  • transmits torque of different speeds and directions from trunk through pelvis to the limbs
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6
Q

Describe the innominate bones

A

Ilium
Ischium
Pubis

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7
Q

Ilium

A
  • ilial hiatus shorter and wider female vs male
  • the anterior superior iliac spine (ASIS) and the posterior superior iliac spine (PSIS) are important landmarks for ilial position
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8
Q

Ischium

A
  • ischial tuberosity farther apart female vs male

- ischial spines project posterioly from medial surface of the ischium at the level of S5

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9
Q

Pubis:

A
  • pubic symphysis is thinner in females vs males
  • fibrocartilaginous disc between pubic bones
  • lies in the same vertical plane as the ASIS
  • superior pubic rami forms a portion of the obturator foreman
  • inferior pubic rami travels inferior from the medical aspect of the superior pubic rami and lateral meeting the ischial tuberosities below the obturator foreman
  • pubic arch is created by the pubic symphysis and the inferior pubic rami –> 90-100 deg in women and 70-75 deg in men, –> adductor muscles attach along pubic arch
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10
Q

Sacrum

A
  • 5 fused vertebrae
  • sacral base/sacral promontory is superior and articulates with the last lumbar vertebra
  • alae are the lateral projections that articulate with the ilium forming the right and left sacroiliac joints (SIJ)
  • Sacral sulci are lateral depression next to the PSIS
  • lower half of sacrum forms the ILA (inferior lateral angle)
    sacral apex articulates with coccyx at the sacrococcygeal joints
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11
Q

SIJ

A
  • synovial joints supported by strong ligaments

- self-locking mechanism of SIJ

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12
Q

Describe form closure of SIJ

A

joint surface congruency enhances joint stability

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13
Q

Describe force closure

A

muscle and ligaments augment from closure to enhance joint stability during load transfer from trunk to lower limbs

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14
Q

Joint surface in women is smaller than men

A
  • leading to less potential form closure, increasing potential for increased mobility and decreased stability
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15
Q

hormonal changes and pelvis can affect???

A

force closure resulting in changes in joint mobility

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16
Q

Coccyx

A
  • 3-5 fused bones –> generally smaller in females
  • sacrococcygeal joint: the articulation b/w the convex surface of the sacral apex and the concave surface of the coccygeal base –> fibrocartilagenous disc, anterior, posterior, and lateral sacrococcygeal
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17
Q

pelvic inlet

A
  • boundary between the abdominal cavity and the pelvic cavity
  • posterior = the anterior margin of the sacral base/promontory
  • anterior = the upper margins of the pubic symphysis
  • lateral = the iliopectineal lines
  • broader and rounder in women to allow engagement of the fetal head
  • in standing, the plane of the inlet makes an angle of 50-60 deg with the horizontal plane
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18
Q

pelvic outlet boundaries

A

Boundaries:

  • posterior = the apex of the coccyx and the inferior margins of the sacrotuberous ligaments
  • anterior = the pubic arch
  • lateral = the ischial tuberosities
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19
Q

pelvic outlet info

A
  • larger in women to allow for delivery –>may predispose to female PFM weakness
  • in standing, the plane of the outlet makes an angle of 15-20 deg with horizontal plane
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20
Q

Gender differences in bony pelvis - female:

A
  • ilial height shorter, wider
  • ischial tubes further apart
  • pubic symphysis thinner
  • pelvic arch/angle = 90-100 deg
  • pelvic inlet = broad, rounder, 50% have a gynecoid pelvis (30% of women have heart shaped pelvis)
  • pelvic outlet = larger
  • SIJ joint surface smaller
  • coccyx - smaller
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21
Q

Gender differences in bony pelvis - male:

A
  • ilial height taller, narrow
  • ischial tubes closer together
  • pubic symphysis thicker
  • pelvic arch/angle = 70-75 deg
  • pelvic inlet = heart-shaped(30% of women have heart shaped pelvis)
  • pelvic outlet = smaller
  • SIJ joint surface larger
  • coccyx - larger
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22
Q

Name the major supportive pelvic ligaments

A
  • Sacrospinous: ischial spine to sacrum - posterior to coccygeus muscle, but anterior to sacrotuberous ligament (Not so much to touch) – with ST ligament, divides the greater and lesser sciatic foreman
  • Sacrotuberous: ischial tuberosity to lower portion of sacrum/ILA – fascial extension of biceps femoris mm – very strong lig– YOU CAN TOUCH
  • Sacroiliac: thin ventral portion – thicker interosseus portion – dorsal portion is inseparable from interosseus but evident posteriorly
  • Anterior Longitudinal Ligament (ALL) and PLL
  • Iliolumbar ligament: transverse process of L5 to ilium and sacrum – prevents anterior translation of L5
  • Superior and inferior pubic ligaments
  • Sacrococcygeal ligament - ligamentous laxity allows for flexibility with bowel movements and childbirth
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23
Q

Name the non-supportive pelvic ligaments

A
  • iliopectineal (Cooper’s) ligament

- ilioinguinal ligament

24
Q

Other pelvic ligaments

A

Visceral ligaments:

  • consist of smooth muscle, fibrous tissue, and loose areolar tissue (meshwork of collagen, elastin, and reticular fibers)
  • act as mesenteries (encasing blood vessels, lymphatic structures and nerves) and may not contribute to support
  • allow a high degree of movement between structures
25
Q

Name the Superficial Perineal structures:

A
  • Urogenital triangle

- anal triangle

26
Q

Structure in Urogenital triangle

A

Created by the pubic arch anterior/superiorly and the superficial transverse perineal muscles posteriorly/inferiorly

  • mons pubis - fat pad cover over pubic bone covered by hair after puberty
  • vulva - includes labia mijora, minora, and clitoris
  • clitoris - glans, erectile tissue
  • prepuce - the clitoral hood made up of folds of smooth skin from the labia minora
  • frenulum - superior conjoining of labia minora just below clitoris
  • urethral meatus - external opening of the urethra - located below the frenulum and above the introitus
  • labia majora: outer labia from mons pubis to perineum with hair follicles and adipose tissue
  • Labia minora: inner labia that merge superiorly to form the frenulum and the prepuce, no hair follicles or adipose tissue
  • vestibule:
  • Hart’s line
  • Hymen
  • Introitus
  • posterior fourchette
  • Glands within vestibule
  • perineal body
27
Q

Pelvic floor muscle functions:

A
  1. composed of both slow (type I) and fast twitch fibers (type II)
  2. sphincteric/continence control
  3. supportive to all pelvic floor structures
  4. play a role in stability and posture (hodges 2007)
  5. coordinate with respiration (Talasz 2011)
  6. sexual function
28
Q

Superficial PFM

A
  • Superficial = sexual
  • responsible for sexual function
  • similarities male vs female
  • muscles: bulbocavernosus (female)/bulbospongiosus (male), Ischiocavernosus, Superficial transverse perineal
29
Q

Perineal Membrane was previously known as

A

Urogenital diaphragm

30
Q

Perineal membrane

A
  • dense fibromuscular tissue spanning the opening of the anterior pelvic outlet superior to the superficial PFM
  • 2 distinct regions:
    • ventral (anterior) = a 3D layer with structures imbedded in the fascia including the urethrovaginal sphincter and compressor urethrae muscles (previously known as the deep transverse perineal muscle); this layer is continuous with the insertion of the arcus tendinous fascia pelvis at the pubic symphysis
  • -Dorsal (posterior) = dense fibrous tissue that supports the distal urethral urethra and vagina by attachments to the bony pelvis; attaches laterally to the ischiopubic rami, medially to the distal third of the urethra and vagina, and posteriorly to perineal body
31
Q

Striated urogenital sphincter complex

A
  • superior to perineal membrane
  • comprised of striated urethral sphincter (also known as the sphincter urethrae or the external sphincter)
  • primarily slow twitch fibers that fuse with the trigone of the bladder and encircle the upper 2/3 of the urethra
  • the lower 1/3 division into the urethrovaginal sphincter and the compressor urethrae
  • provides a majority of the striated muscle compression at the urethra and 1/3 of urethral closure resting pressure
32
Q

Innervation of Perineal membrance

A

Levator Ani Nerve (S3-4)

Perineal Branch of Pudendal nerve (S2-3)

33
Q

Function of Perineal membrane:

A
  • composed mostly of slow twitch muscle fibers and assist in urethral closure
  • The superior surface of the Perineal membrane has been shown to have direct connections to the levator ani muscles, suggesting that it may play a greater role in supporting the pelvic floor than previously thought
34
Q

Name the 2 major parts of the perineal membrane:

A

1) Compressor urethrae
2) Urethrovaginal Sphincter (UVS)
…make up the Striated Urogenital Sphincter complex

35
Q

Pelvic Diaphragm

A

Contains the levator ani muscles and coccygeus muscles which are invested by superior and inferior fascial layers

36
Q

Levator Ani muscles

A
  • term usually refers to the group of Deeper pelvic floor muscles (PFM) that have differing origins and insertions and are critical in support of the pelvic floor
  • comprised of 70% slow twitch and 30% fast twitch muscle fibers
  • in a constant state of activity/resting “tone”
  • active support to the weight of the abdominal contents and pelvic viscera against intra-abdominal contents and pelvic viscera against intra-abdominal pressures
  • prevents constant strain of connective tissue
  • narrows the urogenital hiatus
  • draws the distal urethra, vagina, and rectum toward the pubic symphysis
  • acts as a postural stabilizer contracting prior to or with most movements to assist with core stabilization (Hodges 2007)
37
Q

T/F: LA muscles can be voluntarily contracted.

A

Yes, with PFM exercises, as originally described by Arnold Kegel (1948)

38
Q

T/F: Full relaxation can occur in PFM

A

Yes, only intermittently during defecation, voiding, and parturition (Corton, 2009)

39
Q

Components of LA

A
  • Pubococcygeus (AKA pubovisceral -PV muscle d/t significant attachments to the walls of pelvic viscera)
  • Puborectalis
  • Iliococcygeus
40
Q

Describe location of Pubococcygeus:

A
  • origin = posterior surface of pubic symphysis on either side
  • insertion to visceral walls assisting with elevation of those structures: pubovaginalis - medial fibers of the PV to the lateral walls of vagina, puboperinealis - PV fibers attaching to the perineal body, puboanalis - PV fibers attaching to the anus at the intersphincteric groove b/w the internal and external anal sphincters
41
Q

Puborectalis

A
  • originates on one side of the posterior inferior pubic bone and travels posteriorly, inferiorly, and medially forming a U shaped sling around the rectum just above the external anal sphincter, attaching to the other side of the posterior inferior pubic rami
  • draws the anorectal junction toward the pubic symphysis thereby contributing to the anorectal angle and bowel continence.
  • contributes to the vaginal high pressure zone on manometry d/t compression of the anal canal, vagina, and urethra against the posterior pubic symphysis (Raizada, 2008)
42
Q

Iliococcygeus

A
  • arises from posterior 1/2 of the arcus tendinous levator ani and the ischial spine to fuse at the anococcygeal raphe and inner surface of the coccyx
  • most posterior and thinnest portion of the LA, relatively horizontal
  • provides a supportive shelf
43
Q

Innervation of LA:

A
  • controversial
  • pudendal nerve S2-5
  • recent studies show = Levator Ani nerve S3-5
44
Q

Describe Urethral vascular tissue

A
  • submucusal vasculature is well developed and very prominent
  • assists in forming a “water-tight” seal of the mucosal surfaces (called “coaptation”)
  • appears to be hormone sensitive
45
Q

Describe Urethral glands:

A
  • periurethral glands, Skene’s glands
  • found in submucosa, located along vaginal side of urethra and most concentrated in the distal 2/3 of urethra
  • provides lubrication during female sexual arousal and orgasm
46
Q

Innervation of lower urinary tract

A
  • sympathetic input from the hypogastric plexus via inferior mesenteric ganglion = T11- L2/3
  • Parasympathetic input from sacral plexus via pelvic splanchnic nerves (S2-4)
47
Q

Describe the parts of the Uterus

A
  • Fundus = lies superior
  • The body
  • the cervix = lies inferior and connects to the top of the vagina
48
Q

Describe the cell layers of the Uterus

A
  • Endometrium = the inner layer, the most active, responds to cyclic ovarian hormone changes and is highly specialized and essential to menstrual and reproductive function
  • Myometrium = the middle layer, makes up most uterine volume and is the muscular layer, comprised primarily of smooth muscle cells (involuntary)
  • Parametrium = The outer layer, a thin layer of tissue made of epithelial cells that envelop the uterus
49
Q

Describe the Uterine connective tissue/ligaments:

A

Endopelvic/visceral fascia =

  • differs from parietal fascia (organized arrangement of collagen) that invests striated muscle within the pelvis (obturator internus, piriformis, levator ani, coccygeus)
  • consists of a loose arrangement of collagen, elastin, and adipose tissue intimately associated with the walls of the viscera and allows for expansion and contraction of pelvic organs
  • acts as a mesentery that encase blood vessels, lymphatic vessels, and nerves

Parametrium:

  • endopelvic fascia attached to uterus
  • cardinal ligament (transverse cervical or Mackenrodt’s ligament) which attaches the cervix to the lateral pelvic wall and ATFP on either side at the base of the broad ligament and invests the uterine artery and vein
  • Uterosacral ligament attaches the cervix posteriorly to the sacrum froming the lateral boundaries of the Pouch of Douglas (rectouterine pouch, posterior cul de sac of Douglas)
  • Broad ligament = attaches the uterus and fallopian tubes to lateral pelvic wall
  • Round ligament = attaches the anterior uterus to symphysis pubis anteriorly into labia
50
Q

Uterine innervation:

A
  • sympathetic input from hypogastric plexus via inferior mesenteric ganglion = T11, L2-3
  • parasympathetic input from sacral plexus via pelvic splanchnic nerves = S2-4
51
Q

Vagina details:

A
  • averages = 7.5-10 cm in length, muscular and fibrous tissue
  • vaginal connective tissue: the main support of anterior and posterior vaginal walls is provided by the interaction between the levator ani muscles and the connective tissue that attaches to the lateral vaginal walls to the pelvic walls and ATFP
52
Q

T/F there is a fascial connection between the anterior vaginal wall and the bladder

A

False, previously called “pubocervical fascia”

53
Q

T/F There is a layer of tissue between the posterior vaginal wall and the rectum

A

True, itattaches to the perineal body inferiorly and rises approximately 2-3cm above the perineal body

54
Q

Describe Paracolpium

A
  • endopelvic fascia that is attached to the vagina
  • continuation of the
    parametrium
55
Q

Innervation of the vagina:

A
  • sympathetic input from the hypogastric plexus via inferior mesenteric ganglion (T11, L2/3)
  • parasympathetic input from sacral plexus via pelvic splanchnic nerves (S2-4)
  • sensory fibers arise from pudendal nerve and pain fibers arise from sacral nerve roots
  • Sensitive to deep pressure, pain and temperature
56
Q

Perineal Clock Structures

A

12 o clock = pubic symphysis/clitoris
1 o clock = inferior pubic rami, ischiocavernosus muscles
2 oclock= bulbocavernosus muscle
3 oclock = superficial transverse perineal muscle
4-5 oclock = ischiorectal fossa, levator ani muscles (deep)
6 oclock = perineal body
7-8 oclock = ischiorectal fossa, levator ani muscles (deep)
9 o clock = superficial transverse perineal muscle
10 o clock = bulbocavernosus muscle
11 o clock = inferior pubic rami, ischiocavernosus muscle

Pelvic Floor Physical Therapy (11 decks)

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