Week 8 (POP)

Question 1

What is a pelvic floor?

Answer 1

A collective working of bony structures (pelvis), connective tissues (ligaments and tendons), and muscles (superficial and deep), that provide a floor to pelvic viscera

Provide constrictor functions:

• urethra
• vagina
• anus

Question 2

Superficial layers of pelvic floor

Answer 2

• external anal sphincter
• perineal body
• puboperineal (or tranverse perinei) muscles

Question 3

Deep layers of pelvic floor

Answer 3

• Levator Ani
  
  • pubococcygeus
  • iliococcygeus
  • puborectalis

Question 4

Stress Urinary Incontinence (SUI)

Answer 4

Involuntary urine leakage with effort or exertion (ex: sneezing, coughing, jumping, valsalva)

Question 5

Pelvic Organ Prolapse

Answer 5

Descent, protrusion, or herniation of one or more of the pelvic organs (uterus, vagina, bladder, or bowel) through the levator hiatus into or out of the vaginal canal)

Question 6

Types of POP

Answer 6

• Uterine
• Cystocele (bladder)
• Rectocele (rectum)
• Enterocele (vaginal vault, after hysterectomy)

Question 7

Classifications of Prolapse

Answer 7

Stage I: Vaginal wall bulges down to three centimeters inside the opening of the vagina

Stage II: Vaginal wall comes to or slightly outside the vaginal canal

Stage III: Vaginal wall protrudes several centimeters outside of the vagina

Stage IV: The entire vagina protrudes outside the vaginal canal

Question 8

Measurement tools

Answer 8

Palpation: POP-Q, Brinks strength test

Speculum

Vaginal dynamometer

MRI

Question 9

Symptoms of POP

Answer 9

Mechanical symptoms- pelvic heaviness and vaginal bulging

Bladder symptoms- stress and urge incontinence, straining to void

Bowel symptoms- straining to void, increase IAP

Sexual symptoms

Question 10

Pelvic nerve innervation

Answer 10

Innervated through:

sacral plexus: S2, S3, S4, pudendal nerve

Coccygeal plexus

Question 11

Levator Ani Innervation

Answer 11

Myogenic tone (intrinsic property of vascular smooth muscle that contracts in response to stretch) largely supplied through:

parasympathetic system
pelvic nerve - levator ani
ach
mediated by muscarinic receptors

Question 12

Neuropathy

Answer 12

During pregnancy and delivery the pelvic and pudendal nerves can be crushed or expanded to the point of necrosis.

Age-related nerve density decrease

Question 13

Levator Ani trauma

Answer 13

One of the most important pelvic support muscle groups

Common tearing during vaginal delivery (15-35%)

• puborectal tearing
• often unknown mechanism

Often undiagnosed (MRI needed)

20% of nulliparous women have a visible defect of levator ani muslces

Question 14

Difficulties in examining levator hiatus and levator ani

Answer 14

MRI needed

Positional difficulty

Question 15

Vascular dysfunction caused by…

Answer 15

smoking

atherosclerosis/hypertension (poor diet)

diabetes

Inconclusive results on whether these affect pelvic floor function.

Question 16

Treatment/prevention

Answer 16

Surgical repair

pessary

exercise

• kegal exercises
• moderate/vigorous physical activity

Question 17

Pelvic floor “kegal” exercises

Answer 17

Highly beneficial for the prevention and treatment of SUI, especially postpartum

Inconclusive for POP

No sig increase in RMR