The pelvic floor Flashcards
What are the functions of the pelvic floor?
- Pelvic organ support
- Maintains intra-abdominal pressure during coughing, vomiting, sneezing and laughing
- Facilitates defecation and urination
- Maintains urinary and faecal continence
- Facilitates childbirth
- Sexual function
In what ways does the pelvic floor provide support?
- Suspension
- Attachment
- Fusion
How does suspension allow the pelvic floor to provide support?
- Maintains pelvic organs in pelvic cavity
- Provides strong sling-like support of inferiorly in pelvis
How does attachment allow the pelvic floor to provide support?
- Vagina is supported by attachments to endopelvic fascia, levator ani muscles, and perineal body
- Important in maintaining urinary continence - urethra is compressed by attachments when intra-abdominal pressure is raised
How does fusion allow the pelvic floor to provide support?
- Interplay between muscles, fascia and ligaments helps keep pelvic structures in correct place
- Urogenital diaphragm and perineal body fuse
Which structures make up the pelvic floor?
- Levator ani muscles
- Urogenital diaphragm/perineal membrane
- Perineal body
- Perineal muscles
What are the levator ani muscles?
- Puborectalis - originates from pubis symphysis
- Pubococcygeus - originates from pubis symphysis and inserts onto coccyx pubis
- Iliococcygeus - originates from ischium and inserts onto coccyx pubis
What are the deep muscles of the pelvic floor?
- Levator ani muscles
- U-shaped
- Encircle vagina, urethra, and rectum
- Spread in fan shape
- Act like a sling to support pelvic organs
What key structure do the levator ani muscles form?
- Perineal body - muscle fibres insert as they encircle vagina/urethra to form this
What are the superficial muscles of the pelvic floor?
- Perineal muscles
- Most commonly involved in perineal trauma (accidental, sexual, and obstetric)
What are the names of the perineal muscles?
- Bulbospongiosus (encircles labia/base of penis)
- Ischiocavernosus (along line of ischium)
- Superficial transverse perineal muscle
What is the function of the perineal muscles?
- Aid in continence
What are the ligaments of the pelvis?
- Cardinal ligaments
- Pubocervical ligaments
- Uterosacral ligaments
Describe the anatomical location of the cardinal ligaments
- Situated along inferior border of broad ligament of uterus
- Arise from side of cervix and lateral fornix of vagina
- Attach to lateral pelvic wall at level of ischial spine
Describe the anatomical location of the pubocervical ligaments
- Attach from cervix to posterior surface of pubic symphysis
Describe the anatomical location of the uterosacral ligaments
- Attach cervix to sacrum
- Support uterus
What is the urogenital diaphragm?
- Triangular sheet of dense fibrous tissue
- Spans anterior half of pelvic outlet
- Arises from inferior ischiopubic ramus
- Attaches medially to urethra, vagina and perineal body
- Supports pelvic floor
What is the perineal body?
- Central position between vagina and rectum
- A number of ligaments and muscles coalesce here
- Levator ani muscles insert here
- Attached posteriorly to external anal sphincter and coccyx
- Support of perineal structures rely on it
What is the blood supply to the pelvic floor?
- Internal and external pudendal arteries (drains through corresponding veins)
What is the innervation of the pelvic floor?
- Pudendal nerve (S2, S3, S4)
What is the lymphatic drainage of the pelvic floor?
- Inguinal lymph nodes
What are some common causes of pelvic floor dysfunction?
- Pelvic organ prolapse
- Vaginismus
- Urinary incontinence
- Female Genital Mutilation
What is pelvic organ prolapse?
- Refers to loss of support for uterus, bladder, colon or rectum
- Leads collapse of one of these organs into vagina
What are the side effects of POP?
- Decrease in quality of life
- Anorectal, urinary, sexual functional disturbances
- Pain
- Infection
- Depressive symptoms
How are prolapses classified?
- Anterior
- Central
- Posterior
Describe a prolapse of the anterior compartment
- Cystocoele - bladder prolapses into vaginal space
- Urethrocoele - urethral collapse
- Cystourethrocoele - bladder and urethra both prolapse
What is a central prolapse?
- Uterus collapses down into vaginal space
- If entire uterus prolapses = procidentia
- Can still occur after hysterectomy = vault prolapse
Describe a prolapse of the posterior compartment
- Rectocoele - rectum prolapses into vaginal space
- Enterocoele - loops of bowel prolapse into Pouch of Douglas
What are the risk factors for prolapse?
- Increased age
- Parity
- Oestrogen deficiency
- Increased abdominal pressure (e.g. due to obesity)
- Neurological (spina bifida, muscular dystrophy)
- Genetic connective tissue disorder (Marfan’s, Ehler Danlos)
Outline perineal trauma and obstetric anal sphincter injuries (OASIS)
- Can involve any of the perineal muscles
- OASIS involves the anal sphincter complex
- 3rd and 4th degree tears
- Can result in significant morbidity
How can we help prevent tearing while a woman is giving birth?
- Episiotomy
- Perineal protection at crowning
- Encouraging the mother not to push when the head is crowning
What are the symptoms of prolapse?
- History of a dragging sensation or a lump
- Feeling of incomplete emptying of the bladder
- Double voiding
How do we manage pelvic floor prolapse?
- Pessaries provide additional support
- Topical oestrogen
- Pelvic floor exercises
- Hysterectomy, mesh supports
What is stress urinary incontinence?
- Urine leaks from bladder during episodes of high intra-abdominal pressure
- Occurs if pelvic organs are inadequately supported by pelvic floor
What is female genital mutilation?
- All procedures involving partial or total removal of external female genitalia or other injury to female genital organs, whether for cultural or other non-therapeutic reasons
What are the types of FGM?
- Type 1 - partial or total removal of clitoris and/or prepuce
- Type 2 - partial or total removal of clitoris and labia minora. May or may not excise labia majora.
- Type 3 - narrowing of vaginal orifice with creation of a covering seal by cutting and appositioning labia minora/majora with or without excision of clitoris
- Type 4 - all other harmful procedures to female genitalia for non-medical purposes
What are some of the consequences and complications of FGM?
- haemorrhage, shock, sepsis, blood-borne infections, death
- sexual difficulties, fertility issues, chronic pain
- increased risk of C-section, post-partum haemorrhage, fear of childbirth
- PTSD, flashbacks
