The Pelvic Floor

Question 1

Functions of the pelvic floor

Answer 1

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

Question 2

3 mechanisms of support and structures involved in each

Answer 2

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

Question 3

What makes up the pelvic floor?

Answer 3

Mostly levator ani muscles (puborectalis, pubococcygeous, iliococcygeous)
Urogenital diaphragm/ perineal membrane
Perineal body
Perineal muscles (transverse superficial & deep, bulbospongiosus)
Posterior compartment

Question 4

What are the levator ani muscles? What are their names?

Answer 4

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)

Question 5

What are the perineal muscles? What are 2 of particular note?

Answer 5

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

Question 6

What is the urogenital diaphragm?

Answer 6

Triangular sheet of dense fibrous tissue, spans anterior half of pelvic outlet, inferior ischiopubic ramus -> urethra/ vagina/ perineal body

Supports the Pelvic floor

Question 7

What is the perineal body?

Answer 7

Central position between vagina and rectum, insertion point of levator ani muscles, posteriorly attached to external anal sphincter and coccyx

Supports perineal structures

Question 8

What’s the blood supply and drainage to the pelvic floor by?

Answer 8

Internal and external pudendal arteries and drains through corresponding veins

Question 9

Lymphatic drainage of the pelvic floor

Answer 9

Inguinal lymph nodes

Question 10

Nerve supply to pelvic floor and nerve roots

Answer 10

Branches of the pudendal nerve, from ventral branches of S2-S4

Question 11

What is pelvic organ prolapse? How common is it? How serious is it?

Answer 11

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

Question 12

Types of pelvic organ prolapse in the anterior, middle and posterior compartments

Answer 12

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)

Question 13

Risk factors for pelvic organ prolapse

Answer 13

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

Question 14

Assessment of pelvic organ prolapse

Answer 14

History- dragging sensation, lump

Examination

POP-Q universal assessment

Question 15

What factors need to be considered when planning management?

Answer 15

Nature of symptoms 
Extent of prolapse 
Family planning 
Sexual activity 
Fitness for surgery 
Work 
Physical activity

Question 16

Management options: surgical and non-surgical

Answer 16

Non-surgical: pessaries (ring, shelf and gelhorn) holds up pelvis, between 2 bones of pelvis

Surgical:
Anterior/ posterior repair (colporrhaphy), vaginal hysterectomy

Question 17

What is an obstetric anal sphincter injury (OASIS)? What are the different types?

Answer 17

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

Question 18

How do you prevent OASIS?

Answer 18

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

Question 19

Types of urinary incontinence and management

Answer 19

Stress incontinence - dysfunction of pelvic floor
Urge incontinence- problems with bladder

Pelvic floor muscle exercises 1st line

Surgical treatment (colposuspension)

Question 20

What is vestibulodynia and Vaginismus? What’s a possible cause.

Answer 20

Vestibulodynia- painful vulva

Vaginismus- pain on vaginal penetration by involuntary muscle spasm

Possible cause: tight vagina opening from taut pelvic floor

Question 21

What is female genital mutilation?

Answer 21

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

Question 22

Types of FGM

Answer 22

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

Question 23

Complications of FGM

Answer 23

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

Question 24

Posterior compartment pelvic floor dysfunction

Presentation and causes

Answer 24

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

Question 25

What is anal/ faecal incontinence and what are some causes?

Answer 25

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