S2 L2 The Pelvic Floor Flashcards
Function of the pelvis floor
Pelvic Floor Functions
If patient has any of these - Consider if it is due to a pelvic floor problem?!
- Pelvic Organ Support
- Bladder and Bowel Control
- Passing of Urine and Faeces
- Sexual Function
- Breathing
- Pregnancy and childbirth
Label the sagittal view of the pelvis
What happens if one of the pelvic floor structure is dysfunctional?
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How do the Pelvic floor muscle maintain support
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- Suspension
- What is this?
- What does it work against?
- Structures involved?
These ligament work against gravity and sudden changes in intra-abdominal pressure e.g. by sneezing, coughing…
- Attachment
- Provided by what structures
- Importance for urethra…
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- Fusion
- Which structures are involved?
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Composition of the pelvic floor?
Label structure
Predominantly by the levator ani muscles. Urogenital diaphragm/perineal membrane Perineal body Perineal muscles Posterior compartment
The Levator Ani muscles
- Name three muscle
- Origins and insertions (roughly)
- What organs do they encircle?
Deep muscle (Forms a U-shaped sheet)
- Puborectalis (pubic tubercle and wraps around the retum)
- Pubococcygeus (pubic bone to coccyx)
- Iliococcygeus (ishcial spine to coccyx)
- Encircles the urethra, vagina and the rectum and
reaching the coccyx.
Recap -
Levator Ani muscles
Where they originate?
Where they insert?
Encircle which organs?
Form which structure?
Originate: Back of the body of the pubic bone, the white line over the obturator internus muscle and medial aspect of the ischial spines
Insert: Some of the fibres are inserted as they encircle the
urethra, some are inserted as they encircle the vagina, some fibres are inserted as they encircle the rectum
and the rest are inserted in the lower part of the coccyx
and anococcygeal raphe
Encircle: Urethra, vagina, rectum
Form: Perineal body
Perineal muscles
- Which layers?
- Clinical consideration…
- 4 main muscle and location
Superficial layer (next layer after the levator ani)
Most commonly involved in perineal traumaaccidental,
sexual and obstetric
Label
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Urogenital diaphragm
- What is this?
- Which muscles make up this
- Origins
- Insertions
- Role
The urogenital diaphragm consists of the deep transverse perineal muscle with the superior and inferior fascia
Triangular sheet of dense fibrous tissue
Spans the anterior half of the pelvic outlet
Origin: Arises from the inferior ischiopubic ramus
Insertion: Attaches medially to the urethra, vagina and perinealbody
Role: Thereby supporting the pelvic floor
Perineal Body
- Location
- Point of insertion for which muscles
- Role
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Label
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Blood supply, innervation, venous and lymphatic drainage for the levator ani and perineal muscles
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Label
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Pelvic Organ Prolapse
- What is this?
- How common?
- Life-threatening?
- Other risk factors
Associated with significant functional disturbances including:
- Anorectal
- Urinary
- Sexual
Other risk factors:
Age (muscles weaken over time)
Parity (pregnancy)
Vaginal delivery- 4x increased risk after 1st child; 11x increase after >/= 4 deliveries
Obesity and causes of chronic raised intra-abdominal pressure
Postmenopausal oestrogen deficiency
Neurological e.g.. Spina bifida, muscular dystrophy
Genetic connective tissue disorder e.g.. Marfan’s,
Ehlers Danlos
POP Anterior compartment
- 3 types
- In a diagram - what could this look like?
- Cystocele (only bladder)
- Urethrocoele (only urethra)
- Cystourethrocoele (both bladder and urethra)
POP Middle compartment
don’t look at Q flashcard pic yet
- Uterine prolapse
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-
Post-hysterectomy vault prolapse (see pic on Q flashcard)
POP Posterior Compartment
- 2 types
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
Management of POPS:
- Non-surgical and surgical
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Perineal trauma and Obstetric Anal Sphincter InjurieS (OASIS
- What is perineal trauma?
- Degrees of tears?
- Functions of the pelvic floor?
Perineal trauma involve any of the perineal muscles
OASIS are those involving the anal sphincter complex
Types- 3rd and 4th degree tears
Can result in significant morbidity
Demonstrates the functions of the pelvic floor continence
and support
Prevention of OASIS
- For childbirth
- One recommendation to tell mum at crowning
Other risk factors
Thinking about episiotomy (risk groups and correct
angle) i.e. restrictive use
Perineal protection at crowning can be protective
Encouraging the mother NOT to push when the head
is crowning
Episiotomy - cut the perineal space between the vagina and anus - to elevate pressure and provide space
Urinary incontinence
- 2 types
Stress incontinence, affected by dysfunction of the
pelvic floor
Other types of incontinence- urge incontinence due to
problems with the bladder not the pelvic floor
FGM:
- Defintion
- Why it happens?
- Types
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 nontherapeutic
reasons
Why it happens:
Mistaken as a religious practice, a form of
“circumcision”, across board; Muslims, Christians etc.
Culture- “ purification”, tradition, rite of passageattainment
of womanhood
Social acceptance, family honour- especially for
marriage
Fear of social exclusion
More clinical correlations:
- Polycystic ovaries
- Endometriosis
- Episiotomy
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Recap of location of:
- Perineal Muscles
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Recap of:
- Other structures around these
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Recap of location of:
- Levator Ani muscles
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