The Pelvic Flaw Flashcards
What are the functions of the pelvic floor?
Support the pelvic organs -vagina, uterus, ovaries, bladder and rectum.
Maintain intra-abdominal pressure during coughing, vomiting, sneezing and laughing.
Facilitate defaection and micturition.
Maintain urinary and faecal continence
Facilitate childbirth
How does the pelvic floor support?
3 mechanisms:
Suspension
Attachment
Fusion
What does it mean by suspension of the pelvic floor?
Vertical support
Working against gravity
Strength required
The cardinal ligaments - holding the cervix and upper vagina in place
The uterosacral ligaments - holding the back of the cervix and upper vagina
The round ligament - maintain the anteverted position of the uterus
What does it mean by attachment of the pelvic floor?
Provided by the:
- Arcus tendinous fascia pelvis (ATFP) -also known as the white line.
- Endopelvic fascia - stretches like a hammock from the while line laterally, to the vaginal wall medially.
Urethra lies anterior and above it, this hey compressed against it during increased intra-abdominal pressure. Important in maintaining urinary continence.
What does it mean by fusion?
Implies link, connection, inseparable.
Involves the urogenital diaphragm and the perineal body.
The lower half of the vagina is supported by fusion of the vaginal endopelvic fascia to the perineal body posteriorly, the elevator ani laterally and the urethra anteriorly.
What is the composition of the pelvic floor?
Mainly elevator ani muscles
Urogenital diaphragm / perineal membrane
Perineal body
Perineal muscles
Posterior compartment.
What are the levator ani muscles?
They encircle the urethra, vagina and rectum and reach the coccyx forming a broad, U-shaped sheet that stretches backwards and inwards from either side of the pelvis to meet in the midline.
what are the three levator ani muscles?
Pubococcygeus
Puborectalis
Iliococcygeus
What are the perineal muscles?
Bulbospongiosus
Ischiocavernosus
Superficial transverse perineal
Next layer after the elevator ani
Superficial
Most commonly involved in perineal trauma - accidental, sexual or obstetric
What is the urogenital diaphragm?
Triangular sheet of dense fibrous tissue
Spans the anterior half of the pelvic outlet.
Arises from the ischiopubic ramus
Attaches medially to the urethra, vagina and perineal body.
Thereby supporting the pelvic floor.
What is the perineal body?
Occupies a central position (and role) on the pelvic floor, between the vagina and rectum.
Point of insertion of the elevator ani muscles
Attaches posteriorly to the external anal sphincter (EAS) and the coccyx.
Support of the perineal structures rely on it.
What is the blood supply?
External and internal pudental arteries and drains through the corresponding veins.
What is the lymphatic drainage?
Inguinal lymph nodes
What is the nerve supply?
Branches of pudental nerve, which derives its fibres form ventral branches of the second, third and fourth sacral nerve
What is a pelvic organ prolapse?
Loss of support for the uterus, bladder, colon or rectum, leading to prolapse of one or more of these organs into the vagina.
Common - up to 40% of women experience a degree of pelvic organ prolapse in their lifetime.
Although not life-threatening, has a significant impact on the quality of life, perception of body image can cause depressive symptoms.
How do you classify pelvic organ prolapse?
Anterior compartment - cystocele, urethrocoele or cystourethralcoele
Middle compartment - uterus prolapse into vagina
Posterior component - rectum may prolapse in the posterior part of the vagina - rectocele. Loops of bowel may prolapse into the rectovaginal space (pouch of Douglas) - enterocoele
What are some risk factors for pelvic organ prolapse?
Age
Parity
Vaginal delivery (more = higher risk)
Post menopausal oestrogen deficiency
Obeisity and causes of chronic raised intra-abdominal pressure
Neurological - spina bifida, muscular dystrophy
Genetic connective tissue disorders - Marfan’s Ehlers Danlos
How do you assess POP?
History
Examination
POP-Q system
What things need to be considered when planning management of POP?
Nature of symptoms and degree of bother
Extent of prolapse
Completion of family and future pregnancies
Sexual activity
Fitness for surgery, anaesthesia
Incontinence symptoms
Goals
How do you manage pelvic organ prolapse
Pessaries - especially when not fit for surgery, patients wishes or while waiting for surgery.
Surgery - definitive treatment, risk of reoccurrence and potential for complications.
What is OASIS?
Obstetric Anal Sphincter Injuries ..
How do you prevent OASIS?
Episiotomy
Care then giving birth - don’t push when baby is in the wrong position.
What is FGM?
Defined as 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 non-therapeutic reasons.
What are the different types of FGM?
Type 1 - clitoral removal
Type 2 - removal of clitoris and lbia minor +/- labia majora (excision)
Type 3 - Narrowing of vaginal orrifice with creating of a covering seal by cutting and apportioning the lava minor and/or the labia majora with or without excision of the clitoris. (infibulation)
Type 4 - All other harmful procedures to the female genitalia for non medical purposes. e.g. piercing.
What are the acute consequences of FGM?
Haemorrhage -severe and lead to shock
Sepsis -severe infection, hepatitis, HIV
Death
What are the late consequences of FGM?
Sexual difficulties
Chronic pain
Dysmenorrhea
Urinary outflow obstruction, labial fusion
Difficult cytological screening and evaluation following miscarriage
PTSD
What are some obstetric consequences of FGM?
Fear of childbirth
Increase likelihood of C section
Postpartum haemorrhage (PPH), severe vaginal lacerations
What are the psychological consequences of FGM?
Flashbacks
Feeling of betrayal -young age
Loss of control and violation
Anger, trust issues, relationship difficulties
Sense of self-esteem affected, shame, self-worth
Is FMG legal in the UK?
NO! it is illegal.
If the female is under 18, it is a safeguarding issue.
How can posterior compartment pelvic floor dysfunction present?
Vaginal / rectal bulge / lump
Constipation
Incomplete evacuation
Dyssynergic defecation
Anal incontinence.
What are some causes of posterior compartment pelvic floor dysfunction?
Structural - rectocele, rectal prolapse
Drugs - opiates, iron supplements
Dehydration
Immobility
Pregnancy
Postoperative pain
