The Pelvic Floor

Question 1

Give some of the functions of the pevlic floor

Answer 1

• Supports the pelvic organs- (vagina, uterus, ovaries, bladder & rectum)
• maintains intra-abdominal pressure in coughing, laughing, vomiting etc.
• facilitate defaecation and micturition (urination)
• maintains urinary and faecal continence
• facilitate childbirth

Question 2

What are the 3 mechanism by which the pelvic floor provides support?

Answer 2

1. Suspension
2. Attachment
3. Fusion

Question 3

Which ligaments of the pelvic floor provide support via suspension

Answer 3

• cardinal ligament - holds cervix and vagina in place
• uterosacral ligament- holds back of cervix and upper vagina laterally
• round ligament- maintains anteverted postion of uterus

Question 4

Which 2 forces act on the pelvic floor?

Answer 4

1. Gravity
2. Intra-abdominal pressure

Question 5

What ligaments provide attachment for the pelvic floor?

Answer 5

• Arcus tendinosus fascia pelvis (ATFP) or ‘white line’
• Endopelvic fascia (stretches from white line laterally → vaginal wall medially)

Question 6

Explain how the pelvic floor supports the peritoneal contents by fusion

Answer 6

The lower half of the vagina is supported by fusion of the vaginal endopelvic fascia to the perineal body posteriorally, urethra anerioraly and levator ani laterally

Question 7

What are the different muscles of levator ani?

Answer 7

• Puborectalis
• Pubococcygeus
• Iliococcygeus

Question 8

What is the perineal body?

Answer 8

Area between vagina and rectum where all levator ani muscles insert

Question 9

What are the 2 types of perineal muscle?

Answer 9

• Transverse perineal (superficial and deep)
• Bulbospongiosus - around the vagina

Question 10

Which muscles of the pelvic floor are most commonly involved in perineal trauma?

Answer 10

The Perineal muscles

Question 11

What is the urogenital diaphragm?

Answer 11

• a triangular sheet of dense fibrous tissue
• spans anterior half of pelvic outlet
• Supports the pelvic floor

Question 12

Describe the blood supply of the pelvic floor

Answer 12

Internal and external pudenal arteries supply muscles

Deoxygenated blood drains via pudenal veins

Question 13

What is the lymphatic drainage of the pelvic floor muscles?

Answer 13

Inguinal lymph nodes

Question 14

What nerves supply the muscles of the pelvic floor?

Answer 14

Pudenal nerve

(arises from S2, S3 and S4)

Question 15

What is Pelvic Organ Prolapse?

Answer 15

Loss of support of the uterus, bladder, colon or rectum leading to prolapse into the vagina

Question 16

What is the incidence of pelvic organ prolapse?

Answer 16

~40% of women will have some degree of POP in their lifetime

Question 17

What is a cystocele (or anterior prolapse)?

Answer 17

Where the bladder prolapses into the vagina

Question 18

What is a urethrocele?

Answer 18

Where the urethra prolapses into the vagina

Question 19

What is cystourethrocoele?

Answer 19

Where both the bladder and the urethra prolapse into the vagina

Question 20

What is middle compartment prolapse?

Answer 20

Prolapse of the uterus into the vagina

Question 21

What is post hysterectomy vault prolapse and how does it happen?

Answer 21

Where the apex of the vagina prolapses into the vagina

Occurs because the supporting ligaments have been removed when the uterus was removed

Question 22

What is an enterocele?

Answer 22

Where the rectum prolapses into the rectovaginal space

Question 23

Give some of the risk factors that increase risk of prolpase

Answer 23

• Age
• Having been pregnant
• Vaginal delivery (x4 increase after 1 child, x11 increase >4 children)
• Obestity
• Chronic raised intra abdominal pressure
• Post menopausal oestrogen deficiency
• neurological
• genetic connective tissue disorder

Question 24

What are the surgical and non-surgical options for treating someone with prolapse?

Answer 24

Non-surgical: pessaries - hold the pelvic organs between 2 bones

Surgical: definitive treatment

Question 25

What are obstetric anal sphincter injuries and what is the risk?

Answer 25

Perineal tears of the anal sphincter complex during childbirth

Can cause significant morbidity

Question 26

What can be done to prevent obstetric anal sphincter injuries?

Answer 26

Episiotomy - reduced risk by 50% of a 3rd degree tear

Involves cutting bulbospongiosus and transverse perineal muscles

Also… encourage mother not to push when head is crowning

Question 27

What is stress incontinence?

Answer 27

Weakness of muscles of the pelvic floor meaning external urethral sphnicter does not close when intra-abdominal pressure is raised

Question 28

What is vestibulodynia?

Answer 28

A painful vulva

Question 29

What is vaginismus and what are the implications?

Answer 29

Pain on vaginal penitration due to involuntary muscle spasm

-cannot have sex or insert tampons

Question 30

Define FGM

Answer 30

Femal Genital Mutilation

All procedues involving partial or total removal of external female genitalia or other injury to the female genital organs

Question 31

What are the 4 types of FGM?

Answer 31

Question 32

What are some of the complications of FGM?

Answer 32

• Haemorrhage
• Sepsis/ Infection
• Sexual difficulties
• Fertility issues
• chronic pain
• fear of childbirth
• psychological flashbacks

Question 33

How does posterior compartment pelvic floor dysfunction present?

Answer 33

• Vaginal/ rectal lump
• constipation
• incomplete evacuation
• dyssynergic defecation
• anal incontinence

Question 34

What can cause posterior compartment pevlic floor dysfunction?

Answer 34

• rectocele
• drugs (opiates, iron supplements)
• dehydration
• immobility
• pregnancy
• post-op pain