Pelvic floor muscles Flashcards
What are the functions of the pelvic floor?
- control of defeacation and micturition
- maintain intra-abdominal pressure during sneezing, coughing, laughing etc
- maintan continence
- facilitate childbirth
A main function of pelvic floor is support of pelvic organs. What are the 3 mechanisms of support?
- suspension
- attachment
- fusion
What is suspension?
“holding up the muscles” - maintains an anti-gravity position by providing strong vertical support
What structures allow suspension?
cardinal and uterosacral and round ligaments
What does the cardinal ligament do?
holds the cervix and upper vagina in place
What does the uterosacral ligament do?
holds the back of the verve and upper vagina laterally
What does the round ligament do?
maintains the anteverted position of the uterus
What is the attachment mechanism?
the support that comes from attachments on the pelvic organs
What is significant about the endopelivc fascia?
it stretch like a hammock and the urethra lies anterior and above it so when intra abdominal pressure increases., urethra is compressed - important for urinary continence
What is the fusion mechanism?
support that arises from fusion of different tissues e.g. urogenital diaphragm and perineal body
What are the deep muscles of the pelvic floor?
the levator ani muscles -they encircle the urethra, vagina and rectum
What are the muscles of elevator ani?
iliococcygeus
puborectali
pubococcygeus
What is the midpoint of these attachments?
perineal body (central point between the vagina and the rectum)
What are the superficial muscles?
bulbospongiosus
ischiocavernosus
superficial transverse perineal
Which muscles are most commonly involved in injury and what is the mechanism of injury?
the superficial muscles - perineal trauma - accidental, sexual or obstetric (during childbirth)
What is the urogenital diaphragm?
triangular sheet of dense fibrous tissue that spans half of the pelvic outlet and support the pelvic floor
What is the blood supply to the pelvic floor muscles?
pudendal arteries and drainage through pudendal veins
What is the lymph drainage of the pelvic floor muscles?
inguinal lymph nodes
What is the nerve supply to the pelvic floor muscles?
the pudendal nerve (S234)
What is pelvic floor dysfunction?
refers to a wide range of symptoms and conditions that can arise as a result of problems to do with the pelvic floor
What type of pelvic floor dysfunctions can you get?
- pelvic organ prolapse
- urinary incontinence
- posterior compartment pelvic floor dysfunction
- obstetric trauma including episiotomy
- FGM
- vulval pain syndromes
What is pelvic organ prolapse?
loss of support for the uterus, bladder, rectum, colon - prolapses into vagina
What disturbances can POP cause?
anorectal, urinary and sexual function issues
How are POP classified?
by the compartment that the prolapse has occurred
What is an anterior compartment prolapse related to?
bladder (cystoceole)
urethra (urethrocoele)
Both - cystourethrocoele
What is a middle compartment prolapse related to?
the uterus prolapsing into the vagina -uterine prolapse entire uterus (procidential)
Can the uterus prolapse after a hysterectomy? WHY?
the apex may still prolapse - the supportive ligament have to be cut when removing the uterus
What is a posterior prolapse related to?
the rectum prolapsing into the posterior part of the vagina (rectocele)
- loops of bowel may prolapse into the rectovaginal space (pouch of douglas) (enterocoele)
What are the causes and risk factors of POP?
AGE! - weight and mode of delivery (these 3 are most common)
- connective tissue disorders
- lack of oestrogen
- neurological
- chronic cough (increased intra abdominal pressure)
What mode of delivery is more commonly associated with POP?
vaginal delivery
What is the typical symptoms associated with POP?
feeling a lump down below and feeling “something coming down”
-constipation
What is the management for POP?
- need to consider nature of symptoms/severity/how is it impacting the patient
- sexual activity
- future pregnancies
- fitness for surgery
- work/physical activity
What are the non-surgical options?
pessaries (hold up pelvis and organs)
What is the surgical management?
- removal of uterus
- mesh suppor in a vault prolapse
What is stress urinary incontinence?
incontinence affect by the dysfunction of the pelvic floor causing the urethral sphincter to allow leakage
What is urge incontinence?
problems with the bladder not the pelvic floor
What are the risk factors for stress incontinence?
-age and oestrogen deficiency
What are typical symptoms of stress incontinence?
-passing urine on coughing/laughing/vomiting
What is the management for stress incontinence?
pelvic floor muscle training
surgical intervention to create slings to support urethral sphincter
What vulval problems can you get?
patients can experience pain with no obvious finding on examination - often related to tension of the levator ani
What is vaginismus?
taut pelvic floor and muscle spasms that won’t let anything in or out - have painful sex
What is FGM?
All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or non-therapeutic reasons
What is type 1 FGM?
-partial or total removal of the clitoris
What is type 2 FGM?
- partial or total removal of the clitoris and labia majora
What is type 3 FGM?
Narrowig of the vaginal orifice with creation of a covering seal by sewing together the labia minor and majora
What is type 4 FGM?
all other harmful procedures to the female genitalia for non-medical purposes
What are the consequences and complications of FGM?
Haemorrhage -septic shock and infection
Sexual difficulties/fertility issues/urinary outflow obstruction
Obstetric - fear of childbirth, PPH
Psychological - PTSD, flashbacks
What is posterior compartment pelvic floor dysfunction?
presents as - constipation, incomplete evacuation, anal incontinence, vaginal or rectal lump
What are the causes of posterior compartment pelvic floor dysfunction?
structural, drugs (opiates), dehydration, pregnancy, immobility
What is the commonest cause of faecal incontinence in women?
obstetric anal sphincter injury
