Session 3: Pelvic Floor Anatomy Flashcards
Give functions of the pelvic floor.
Support (this is the main support) of the pelvic organs Continence to maintain urinary and faecal continence Maintain high intra-abdominal pressure Child birth Sexual function
Which are the main pelvic organs that are supported by the pelvic floor?
The vagina, uterus, ovaries, bladder and rectum
There are three levels of support, which?
Suspension Attachment Fusion
Explain suspension support.
This is an ‘anti-gravity’ support to prevent vertical collapse of the pelvic organs. This is done mainly by the cardinal ligaments, the uterosacral ligaments and to a lesser extent also the round ligament.
Role of the cardinal ligaments.
Holding the cervix and upper vagina in place.
Role of the uterosacral ligaments.
Holding the back of the cervix and upper vagina laterally
Role of the round ligament.
Maintain the anteverted position of the uterus. It originates from the uterus and attaches into labia majora.
Explain attachment support.
Pelvic organs are attached by several structure such as; endopelvic fascia, levator ani muscles and the perineal body as well as arcus tendinosus fascia pelvis.
Explain fusion support.
Fusion of different tissue support the pelvic organs. Examples are the urogenital diaphragm and the perineal body.
Composition of the pelvic floor.
Muscles (deep and superficial muscles) Perineal body Urogenital diaphragm
What are the deep muscles of the pelvic floor?
The levator ani muscles.
What are the levator ani muscles function?
To encircle the urethra, vagina and the rectum to provide support for respective organs.
Which are the levator ani muscles?
Pubococcygeus
Puborectalis
Iliococcygeus

What is the midpoint of attachment of the levator ani muscles?
The perineal body
What are the superficial muscles (also called the perineal muscles) of the pelvic floor?
Bulbopongiosus
Ischiocavernosus
Superficial transverse perineal

When might the bulbospongiosus and transverse perineal muscles be damaged?
During medio-lateral episiotomy in childbirth.
Why is medio-lateral episiotomy done in childbirth?
Can be done if the baby is large, during a difficult delivery or using instruments such as forceps during a delivery.
It is done to avoid damage to the perineal body because of its critical role in providing pelvic floor support as a site of attachment.
Complications of medio-lateral episiotomy.
Damage to bulbospongiosus and transverse perineal muscles
Infection
Haemorrhage
Dyspareunia (painful intercourse)
Damage to anal sphincter
However it is done to prevent 2nd or 3rd degree tears.

What is the perineal body?
A central point found between the vagina and the rectum or between the scrotum and rectum in men.
A site of attachment for the pelvic floor muscles and other structures that provide support for the pelvic floor.
It has a central role in the support of the pelvic organs.
What is the urogenital diaphragm?
A sheet of dense fibrous tissue that is found and spans the anterior half of the pelvic floor.
Attaches to the urethra, vagina and perineal body.
It provides support to the pelvic organs.
Main innervation of the pelvic floor.
Pudendal nerve
Main branches of the pudendal nerve
Inferior rectal nerve
Perineal nerve
Dorsal nerve of the penis
What does the perineal nerve innervate?
Bulbospongiosum
Ischiocavernosus
Levator ani muscles
What can damage to the pudendal nerve cause?
Problems with pelvic floor support as the levator ani muscles will be weaker. They will not stop functioning all together because they still have innervation directly from the S4 nerve root’s anterior ramus.
Also the inferior rectal nerve will be damaged causing urinary and faecal incontinence.
Impotence (dorsal nerve of the penis)
Main blood supply of the pelvic floor.
Internal and external pudendal arteries and their veins
Lymphatic drainage of the pelvic floor.
Inguinal lymph nodes
Nerve roots of the pudendal nerve.
S2-S4
Mnemonic for the sacral part of the lumbosacral plexus and their nerve roots.
Salmon Is So Perfectly Pink
Superior gluteal nerve (L4, L5, S1)
Inferior gluteal nerve (L5, S1, S2)
Sciatic nerve (L4, L5, S1, S2, S3)
Posterior femoral nerve (S1, S2, S3)
Pudendal nerve (S2, S3, S4)
Give examples of pelvic floor dysfunctions.
Pelvic organ prolapse
Vaginismus
Urinary incontinence
Vulval pain syndrome
What are pelvic organ prolapses?
It’s the loss of support of a pelvic organ. Most commonly uterus, bladder or colon.
They can prolapse into the vagina.
Complications of pelvic organ prolapses.
Quality of life problems
Anorectal, urinary and sexual dysfunction
Disturbed sense of body image
Depressive symptoms
Source of infection and/or pain
Pelvic organ prolapses can be classified into categories.
Which?
Based on which organ prolapse and where it prolapse to.
Divided into:
Anterior compartment
Middle compartment
Posterior compartent
Give examples of anterior compartment POPs.
Explain them.
Cystocoele relates to bladder
Urethrocoele relates to urethra
Cystourethrocoele relates to both

Give examples of middle compartment POPs.
Explain them.
Uterine prolapse - Uterus prolapse into vaginal apex
Uterus procidentia - if the entire uterus prolapse into the vagina
Vault prolapse - the apex of the vagina prolapse into the vaginal canal

How can a vault prolapse occur?
During a hysterectomy the supportive ligaments have to be cut.
This can lead to a vault prolapse.

Give example of posterior compartment POPs.
Explain them.
Rectocoele - when the rectum prolapses
Enterocoele - when loops of bowel involved enter the pouch of douglas.

Causes and risk factors of pelvic organ prolapses.
Age
Parity
Mode of delivery
Oestrogen deficiency
Chronic increased abdominal pressure (obesity)
Connective tissue disorders (EDS, Marfan’s)
Neurological problems like damage to pudendal nerve, Spina bifida and muscular dystrophy
How will patients present with a POP.
Saying they feel a lump down below
‘Something coming down’
Constipation
Management of POPs.
Depend on quality of life, severit of prolapse and how fit they are for surgical intervention.
Non-surgical options include:
Pessaries like ring pessaries.
Surgical options include:
Hysterectomy
Mesh support in a vault prolapse
What type of urinary incontinence can come about with dysfunction of the pelvic floor.
Stress incontinence.
Explain stress incontinence.
Increased abdo pressure causes leaks of urine because the support to the urethral sphincter via the pelvic floor is not adequate.
Risk factors of stress incontinence.
Same as those of POPs.
Age and oestrogen deficiency mainly.
How may patients present with stress incontinence.
Passing urine during any sort of increased abdo pressure like coughing and sneezing.
Management of stress incontinence.
Muscles training
Surgical intervention if appropriate which involves creating ‘slings’ of support to the urethral sphincter.
Most common cause of Vulval pain syndromes.
Often related to tension of the levator ani muscles.
Explain female genital mutilation and its complications.
A cultural practice of damaging the female external genitalia.
Severe pain, potential sepsis or haemorrhage. Psychological effects, sexual dysfunction and difficulty conceiving. Chronic pain and menstrual disorders.
Types of female genital mutilations.
Type 1: Clitoridectomy (partial or total removal of clitoris)
Type 2: Excision (partial or total removal of the clitoris and the labia minora)
Type 3: Infibulation (Narrowing of the vaginal orifice by a seal made by cutting and appositioning the labia minora and/or labia majora)
Type 4: All other harmful procedures to the female genitalia like pricking, piercing, incising, scraping and cauterising.

Main complications of posterior compartment pelvic floor dysfunction.
Constipation
Incomplete evacuation
Anal incontinence
Loss of voluntary control of defecation.