The Pelvic Floor Flashcards
Functions of the pelvic floor
SUPPORT the pelvic organs (e.g. vagina, uterus, ovaries, bladder, rectum)
MAINTAIN intra-abdo PRESSURE (coughing/ vomiting/ sneezing/ laughing)
facilitate DEFECTION & MICTURITION
maintain urinary/ faecal CONTINENCE
facilitate CHILDBIRTH
3 mechanisms of support and structures involved in each
SUSPENSION- vertical support e.g. cardinal ligaments hold cervix/ upper vagina, uterosacral ligaments hold back cervix/ upper vagina laterally, round ligament maintains anteverted uterus
ATTACHMENT- archus tendinosus fascia pelvis (white line), endopelvic fascia (white line to vagina medially) urethra anterior and above so gets compressed increased pressure = urinary continence
FUSION- urogenital diaphragm and perineal body, lower half of vagina supported by fusion vagina endopelvic fascia to perineal body posteriorly, levator ani laterally and urethra anteriorly
What makes up the pelvic floor?
Mostly levator ani muscles (puborectalis, pubococcygeous, iliococcygeous)
Urogenital diaphragm/ perineal membrane
Perineal body
Perineal muscles (transverse superficial & deep, bulbospongiosus)
Posterior compartment
What are the levator ani muscles? What are their names?
U- shaped sheet, stretches backwards and inwards from either side of the pelvis to meet in middle line, encircled urethra, vagina, rectum and coccyx
PuborecTALIS
PubococcyGEUS
iliococcyGEUS (ilium-> coccyx)
What are the perineal muscles? What are 2 of particular note?
Next layer after levator ani, superficial, most commonly involved in perineal trauma (accidental, sexual, obstetric)
Transverse perineal muscles (superficial and deep) - horizontal to vagina
Bulbospongiosus/ bulbocavernous - around vagina/ urethral orifice/ clitoris
What is the urogenital diaphragm?
Triangular sheet of dense fibrous tissue, spans anterior half of pelvic outlet, inferior ischiopubic ramus -> urethra/ vagina/ perineal body
Supports the Pelvic floor
What is the perineal body?
Central position between vagina and rectum, insertion point of levator ani muscles, posteriorly attached to external anal sphincter and coccyx
Supports perineal structures
What’s the blood supply and drainage to the pelvic floor by?
Internal and external pudendal arteries and drains through corresponding veins
Lymphatic drainage of the pelvic floor
Inguinal lymph nodes
Nerve supply to pelvic floor and nerve roots
Branches of the pudendal nerve, from ventral branches of S2-S4
What is pelvic organ prolapse? How common is it? How serious is it?
Loss of support for uterus/ bladder/ colon/ rectum -> vagina
Common, up to 40% of women experience a degree
Not life-threatening but can lead to functional disturbances: anorectal, urinary, sexual, body image
Types of pelvic organ prolapse in the anterior, middle and posterior compartments
Anterior: cystocele (bladder), urethrocele (uterus)/ cystourethrocoele (both)
Middle (vaginal apex): uterine, procidentia (whole uterus), post-hysterectomy vault (vaginal apex) prolapse
Posterior: rectocele (rectum into posterior vagina), enterocele (loops of bowel into rectovaginal space)
Risk factors for pelvic organ prolapse
Older ( weaker tissue)
Higher Parity (number of pregnancies)
Higher BmI
Chronic cough
Postmenopausal oestrogen deficiency
Neurological e.g. spina bifida/ muscular dystrophy
Genetic CT disorder e.g. Marfan’s, Ehlers Danlos
Assessment of pelvic organ prolapse
History- dragging sensation, lump
Examination
POP-Q universal assessment
What factors need to be considered when planning management?
Nature of symptoms Extent of prolapse Family planning Sexual activity Fitness for surgery Work Physical activity
Management options: surgical and non-surgical
Non-surgical: pessaries (ring, shelf and gelhorn) holds up pelvis, between 2 bones of pelvis
Surgical:
Anterior/ posterior repair (colporrhaphy), vaginal hysterectomy
What is an obstetric anal sphincter injury (OASIS)? What are the different types?
Perineal tears involving the anal sphincter complex
Types: 3rd and 4th degree
Can results in significant morbidity
Perineal tears: 1st degree- skin under vagina torn 2nd- perineal muscles torn 3rd- anal sphincter torn 4th- rectum torn
How do you prevent OASIS?
Episiotomy- surgical incision of perineum and vaginal wall to enlarge opening for baby to pass through and prevent perineal tear
Perineal protection at crowning
Encouraging mother not to push when head is crowning
Types of urinary incontinence and management
Stress incontinence - dysfunction of pelvic floor
Urge incontinence- problems with bladder
Pelvic floor muscle exercises 1st line
Surgical treatment (colposuspension)
What is vestibulodynia and Vaginismus? What’s a possible cause.
Vestibulodynia- painful vulva
Vaginismus- pain on vaginal penetration by involuntary muscle spasm
Possible cause: tight vagina opening from taut pelvic floor
What is female genital mutilation?
Partial/ total removal of external female genitalia or other injury to female genital organs whether for cultural or other non-therapeutic reasons
- mistaken religious practice
- culture
- social acceptance
Types of FGM
1- partial/ total removal clitoris &/or prepuce (clitoridectomy)
2- partial/ total removal clitoris, labia minora with/ without excision of labia majora (excision)
3- narrowing of vagina orifice with creation of a covering seal by cutting and appositioning the labia minora/ majora, with/ without excision of clitoris (infibulation)
4- all other harmful procedures e.g. pricking, piercing, incising, scraping, cauterising
Complications of FGM
Acute: haemorrhage-> sepsis, blood-bourne infections
Late: sexual difficulties, fertility issues, chronic pain, urinary outflow obstruction, difficulty with cytological screening & evacuation following miscarriage
Obstetric: fear childbirth, increased chances C/S, postpartum haemorrhage, sever vagina lacerations
Psychological
Posterior compartment pelvic floor dysfunction
Presentation and causes
Vaginal/ recital bulge, constipation, incomplete evacuation, dyssynergic defecation (problem nerves and muscles), anal incontinence
Cause:
Structural (rectocele), drugs (opiates, iron supplements), dehydration, immobility, pregnancy, postoperative pain
What is anal/ faecal incontinence and what are some causes?
Involuntary loss of flatus, liquid or solid stools e.g. from obstetric anal sphincter injury, rectum prolapse/ hypersensitivity, pudendal nerve injury, stroke, diabetes mellitus, Ms, CES
