The Pelvic Floor

Question 1

What is the pelvic floor?

Answer 1

Muscular and fibrous tissue diaphragm
Fills the lower part of the pelvic canal
Closes the abdominal cavity
Defines the upper border of the perineum
Supports the pelvic organs

Pierced by the urethral, vagina and rectum

Question 2

What are the general contents of the pelvic floor?

Answer 2

Obturator membrane
Obturator internus
Pudendal nerve
Levator ani
Rectum, uterus, bladder
Perineal body
Perineal muscles

Question 3

What makes up the pelvic side wall?

Answer 3

Ischium of pelvis
Sacrospinous and sacrotuberous ligaments
Obturator membrane
Obturator nerve
Obturator internus
Piriformis and coccygeus
Branches of sacral plexus
Fascia; includes arcus tendineus
Levator ani muscles
Internal iliac vessels and branches
Ureters

Question 4

What are the muscles of levator ani?

Answer 4

Puborectalis
Pubococcygeus
Iliococcygeus

Question 5

What does the fascia overlying the obturator internus supply?

Answer 5

The origin of the levator ani muscles

Question 6

Which blood vessels and nerves are important in the pelvic floor?

Answer 6

Branches of the posterior trunk of the internal iliac artery:
- Pudendal artery
- Vaginal artery
- Inferior rectal artery
Pudendal nerve
- S2,3 & 4
- "keeps your guts of the floor"

Question 7

What is the perineum?

Answer 7

Fibromuscular sheet which closes the pelvic outlet
Lower limit of perineal space
Perineal space continuous with ischiorectal fossa
Perineal muscles
Perineal body

Question 8

What is the perineum comprised of?

Answer 8

Urogenital diaphragm (fibrous membrane)
Transverse perineal muscles
Ischiocavernosus    Involved in clitoris enlargement, and
Bulbospongiosus        erection.
Perineal body

Question 9

What is the perineal body?

Answer 9

Connective tissue mass in centre of perineum
Anchors the perineal muscles
Anchors the rectum
Central fulcrum for pelvic support

Question 10

How is the perineum divided?

Answer 10

Into the:
Anterior triangle
- Lateral borders - inferior pubic rami down to ischial
tuberosities
Posterior triangle
- Lateral borders - from ischial tuberosities to coccyx

Question 11

What does the posterior triangle of the perineum contain?

Answer 11

Pararectal fat

Question 12

How many endopelvic fascia-levels of support is there?

Answer 12

3

Question 13

What are the three endopelvic fascia-levels of support?

Answer 13

Level 1 - Uterosacral ligaments
Level 2 - Arcus tendineus fascia
Level 3 - Perineal body and associated structures

Question 14

What does the pelvic floor do?

Answer 14

Supports the pelvic organs
- Retains uterus and bladder in correct position

Contributes to continence
- Sphincter mechanism directly and indirectly

Contributes to the process of childbirth

Contributes to “truncal stability” (For lifting things)

Question 15

What are the effects of childbirth on the pelvic floor?

Answer 15

Stretch of pudendal nerve
- Neuropraxia and muscle weakness
Stretch and damage of pelvic floor and perineal muscles
- Muscle weakness
Stretch/rupture of ligaments supports of muscles
- Ineffective muscle action

Question 16

What are the consequences of pelvic floor damage?

Answer 16

Prolapse

Incontinence

Question 17

What are factors that contribute to pelvic floor damage and the results thereof?

Answer 17

Age
Menopause 
- Atrophy of tissues after oestrogen withdrawal
Obesity
Chronic cough
Intrinsic connective tissue laxity
- Defined conditions 
- Constitutional

Question 18

What is the treatment for pelvic floor consequences?

Answer 18

Pelvic floor muscle exercise
- Easy, safe and effective
- Cure of incontinence in 50-75% patients
- Will prevent or delay worsening of prolapse
Surgery

Question 19

What continence procedures are there?

Answer 19

Increase support to sphincter mechanism and prevent descent of bladder neck
- Colposuspension
- Tension-free vaginal tape
Effective
- Cure rate 85%-90%
Side effect
- Voiding difficulty/retention
- Overactive bladder disease (obstruction)

Question 20

What prolapse procedures are there?

Answer 20

Remove prolapsed organs
Restore connective tissue supports
Maintain function

Side effects

• Recurrence
• New incontinence
• Dyspareunia