Week 4 - F - Anatomy 5 - Anatomy of Urinary Incontinence and Prolapse

Question 1

What does the pelvic floor separate? What does it play an important role in?

Answer 1

The pelvic floor separates the pelvic cavity from the perineum The pelvic floor plays an important role in: * Providing support to the pelvic organs * Maintaining urinary and faecal continence

Question 2

What are the three layers that make up the pelvic floor? (deepest to most superficial)

Answer 2

Pelvic diaphragm Muscles of perineal pouches - have a deep and superficial perineal pouch Perineal membrane

Question 3

There is a superficial and deep perineal pouch Which pouch forms part of the pelvic floor?

Answer 3

The deep perineal pouch forms part of the pelvic floor (2nd layer)

Question 4

The pelvic diaphragm is the deepest layer of the pelvic floor What are the two muscle groups which make up the pelvic diaphragm? (some books may say pelvic floor and diaphragm are the same but pelvic floor technically has the muscles of perineal pouches and the perineal membrane)

Answer 4

Two muscle groups The two muscle groups are the levator ani and the coccygeus

Question 5

What appearance does the pelvic diaphragm have? - this is the layer consisting of levator ani and coccygeus

Answer 5

The pelvic diaphragm has a sling like appearance

Question 6

Deepest layer of pelvic floor- generally known as levator ani but actually two muscle groups here. Anterior aspect- levator ani. Little part at the back is called coccygeus muscle. Pretty much lies over the sacrospinous ligament- What are the attachments of the coccygeus muscle? What is the anterior gap in the musculature of the levator aani known as? What passes through here?

Answer 6

Coccygeus - basically runs over the sacrospinous ligament Attaches from the ischial spine and comes back towards the sacrum/coccyx The anterior gap in the musculature of the levator ani is the urogenital hiatus - the urethra, dorsal vein of clitoris/penis and vagina pass here

Question 7

The levator ani forms the majority of the pelvic diaphargm What three muscles make up the levator ani?

Answer 7

Puborectalis Pubococcygeus Iliococcygues

Question 8

What is the most medial muscle of the levator ani? What is the gap between the anteromedial borders of the levator ani and what passes through here?

Answer 8

The most medial muscle of the levator ani is the puborectalis

The gap between the antero medial borders of the puborectalis is the urogenital hiatus

Urethra, dorsal vein of clitoris/penis and in women, the vagina pass through the urogenital hiatus

Question 9

What is the nerve supply to the levator ani? What are the nerve roots?

Answer 9

Nerve to the levator ani - S3,4 Pudendal nerve - S2,3,4 Levator ani has a dual nerve supply

Question 10

What are the different attachments of the muscles of the levator ani?

Answer 10

Puborectalis - attaches to pubic bone and forms a sling around the rectum Pubococcygeus - thinner and wider running from pubic bone back towards coccyx Iliococcygeus - runs from ilium to coccyx All three sling round - sort of crescent shaped

Question 11

The levator ani is tonically contracted What must happen to allow for urination / defecation?

Answer 11

To allow for urination / defection, the muscles of the levator ani must relax Can see how the obturator internus muscle lies over the obturator foramen (obturator membrane is superficial to the muscle) and there is a small opening known as the obturator canal

Question 12

A lot of additional support to the muscles is the endopelvic fascia. Main job is providing areas for expansion e.g. when the bladder is filling up- it expands into here. What are the ligaments running close to the endopelvic fascia which provide additional support to the pelvic organs?

Answer 12

The uteroscaral ligament The tendinous arch of the pelvic fascia The tendinous arch of the levator ani The ligament of the bladder These ligaments are formed from fibrous parts of endopelic fascia that have started to condense forming ligaments

Question 13

One of the ligaments not shown on the previous diagram is the transverse cervical ligament which is located at the base of the broad liggament of the uterus WHat is the transverse cervical ligament also known as?

Answer 13

The transverse cervical ligament is also known as the cardinal ligament

Question 14

WHat is the middle layer of the pelvic floor? What is found in this layer?

Answer 14

Ths is the deep perineal pouch containing: * Dorsal vein of the clitoris/penis * Part of the vagina in females * Part of the urethra * External urethral sphincter & compressor urathrae * Deep transverse perineal muscle * Extensions of the ischioanal fat pads & muscles:

Question 15

What is the slight difference between the deep transverse perineal muscle in males and females? What is the function of the compressor urathrae and the external urethral sphincter?

Answer 15

Deep transverse perineal muscles in females is smooth muscle and involuntary In males this muscle is skeletal and voluntary The compressor urethrae wraps around the external urethral sphincter - when both contract, the lumen of the urethra closes

Question 16

What is located in the deep perineal pouch in males around the deep transverse perineal muscle that lubricates the urethra? WHere is this located in females?

Answer 16

This is the Bulbourethral glands (Cowper’s gland) In females it is known as Bartholin’s gland located in the superficial pernieal pouch - lteral vagina/labia minora Also known as greater vestibular gland in females

Question 17

What is the final layer of the pelvic floor? Most superficial What are its attachments?

Answer 17

This is the perineal membrane It attaches laterally to the sides of the pubic arch closing the urogenital triangle

Question 18

The triangle formed by the deep perineal pouch muscles isnt completely closed- the perineal membrane fills these gaps (apart from vagina and urethra). Basically the last layer (with the perineal body) of passive support of the pelvic cavity. Label the diagram from top to bottom

Answer 18

Top to bottom:

• Extension of ischioanal fat pad and the dorsal vein of the clitoris (this is a female)
• Perineal membrane
• Compressor urethrae and external urethral sphincter
• Levator ani - pubococygeus, iliococcygeus puborectalis
• Obturator internus
• Tendinous arch of the levator ani
• Coccygeus
• Gluteus maximus

Question 19

The superficial perineal pouch is next , it lies inferior to the perineal membrane (remember the pelvic floor from deep (superior) to superficial (inferior) if lying down (standing) Superficial perineal pouches- not part of the pelvic floor. Perineum- space between levator ani and skin- thin area split into two pouches. Split by perineal membrane. Deep pouch- between levator ani and perineal membrane. Superficial- between perineal membrane and skin What are the 3 tubes in the superficial perineal pouch?

Answer 19

have the two crura - corpus cavernosum - and one bulb - corpus spongiosum

Question 20

Two crura- pass up either side of ischiopubic ramis. They are made from corpus cavernosum. The bulb is an individual tube of erectile tissue What does the bulb attach to? Which tube does the urethra pass through? When do the two crura join together? do they fuse?

Answer 20

The bulb attaches tightly to the perineal membrane at its base The urethra passes within the bulb (corpus spongiosum - hence spongy/penile urethra) The two crura come together at the pubic symphysis but do not fuse

Question 21

Fascia surrounding the corpus spongiosum is very expandable so as to not compress the urethra. There are muscles that lie over the top of the erectile tissue- in the superficial perineal pouch. What are these muscles known as? WHat is the muscle at the base of the penis giving a firmer base for erection?

Answer 21

The muscles covering the crura (corpus spongiosum) - ischiocavernosus

The muscles covering the bulb of the penis (corpus spongiosum) - bulbiospongiosus

This is the superficial transverse perineal muscle

Question 22

The superficial perineal contents differ more than the deep in males and females

In deep, only have the difference in skeletal/smooth for deep transverse pernieal muscle and the Bulbourethral glands

The superficial pernieal pouch in females also contains female erectile tissue and associated muscle

• What are the erectile different tissue and associated muscle in females?

Answer 22

Erectile tissue

• Clitoris and crura - corpus cavernosum
• Bulbs of vestibule - corpus spongiosum

Associated Muslce

• Ischiocavernosus - covering the crura and clitoris
• Bulbiospongiosus covering the bulbs of the vestibule

Question 23

How is the clitoris formed? How does it differ in males? In both males and females, where do all the superficial perineal muscles come together to join?

Answer 23

Clitoris is formed by the fusing of the crura (corpus cavernosum - covered by ischiocavernosus muscle) In males the crura do not fuse Perineal body is the attachment site

Question 24

What are the glands, homologous to Cowper’s glands in males in the females? Where are they located?

Answer 24

These are the greater vestibular glands (Bartholin’s glands) located at the base of the bulbs of the vestibule - lubricating the vagina

Question 25

Where is the perineal body located?

Answer 25

The perineal body is located midway between the vagina and rectum - or in males between the base of the bulb and the anus

Question 26

What are the functions of the pelvic floor?

Answer 26

Provides support to the pelvic organs - normally tonically contracted and actively contracts when coughing/sneezing/vomiting Also plays an important role in helping maintain urinary and faecal continence

Question 27

Any time you raise Intra abdominal pressure- it actively contracts. It tries to work against the raised pressure, when you raise it the organs will want to move down so the pelvic floor resists this. They also help to maintain continence. What helps maintain urinary continence?(which muscles) What muscles help maintain faecal continence?

Answer 27

Urinary continence Compressor urethrae, external urethral sphincter and the levator ani Faecal continence The puborectalis tonically contracts bending the rectum anteriorly Active contraction of the muscles (external anal sphincter, puborectalis) when rectum fills helps maintain continence

Question 28

Name 5 causes of injury to the pelvic floor?

Answer 28

Pregnancy Childbirth - stretching/tearing or pudendal nerve damage Obesity Heavy lifting Chronic constipation Coughing or sneezing Menopause

Question 29

Urinary incontinence is the involuntary loss of urine There are different types, what are they?

Answer 29

Urge incontinence Stress incontinence Mixed Overflow incontinence

Question 30

What is the most common type of incontinence and what gender is it in?

Answer 30

This would be stress incontincne in woman

Question 31

Pelvic floor damage can cause stress incontinence What are three non-pharmacological interventions to treat stress incontinence?

Answer 31

Weight loss Stop smoking Pelvic floor exercises

Question 32

Which drug is useful in stress incontinence mangement? Surgery is the mainstay however, what surgery is carried out for stress incontinence?

Answer 32

Pseudoephidrine or duloxetine Colosuspension is the mainstay however to hold the bladder in a retropubic position

Question 33

Prolapse is a common gyaencological disorder What can a prolapse involve?

Answer 33

It can involve uterus, bladder, vagina, rectum

Question 34

A prolapse is usually due to weakness of the pelvic floor and pelvic ligaments The herniation of urethra, bladder, rectum or rectouterine pouch through supporting fascia presents as a lump in vaginal wall If the lump is felt in the anterior wall, what may have prolapsed?

Answer 34

If the lump is felt anteriorly, the urethra or bladder may have prolapsed into the vaginal wall

Question 35

What is a bladder or urethral prolapse known as?

Answer 35

Bladder - cystocele Urethre - urethrocele anterior prolapse (cystocele) – where the bladder bulges into the front wall of the vagina

Question 36

If the bulge is on top of the vagina, what is thought to be the problem?

Answer 36

The uterus and cervix are thought to have prolapsed into the top of the vagina

Question 37

If the prolapse is felt on the posterior wall of the vagina, what is though to be the cause?

Answer 37

Rectal prolaspe - rectocele or Small intestine prolaspe into the pouch of douglas (rectouterine pouch) - enterocele

Question 38

A uterine prolapse is different from the other vaginal prolapses (where organs prolapse into the vaginal wall) The uterine prolapse is graded based on its descent Describe the 3 degrees of uterine prolapse? CLue - introitus is an opening, vaginal introitus is the opening leading into the vaginal canal

Answer 38

1st degree - slippage of the cervix slightly further into the vagina 2nd degree - the exteernal os is visible at the introitus but the uterus remains inside the vagina 3rd degree - the uterus lies outside of the vagina

Question 39

What are the symptoms of a uterine prolaspe? Symptoms of vaginal prolaspe may include: a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back discomfort during sex problems passing urine

Answer 39

Uterine prolapse - dragging sensation, feeling of a lump, urinary incontinence - similar to vaginal prolapse

Question 40

What is the surgical treatment of a uterine prolapse?

Answer 40

Sacrospinous fixation (sacrospinous ligament suspension of the vagina) is carried out where the vagina is sutured to the sacrospinous ligament to prevent further prolaspe

Question 41

What nerves are at risk of injury during a sacrospinous fixation?

Answer 41

The sciatic and the pudendal nerve are at risk of injury here

Question 42

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Answer 42

2 - sacrospinous ligament B - Important for sacrospinous fixation for vagina in a vaginal vault prolapse

Question 43

Research is being done into incontinence surgery by carrying out a trans-obturator approach How does this work?

Answer 43

A small incision is made on the wall of the vagina and the permanent tape is introduced via the vagina to sit under the urethra. The needles used to place the tape are introduced through small incisions at both sides of your upper inner thigh (see picture). The tape used is a permanent mesh, - it wont dissolve