4 Pelvic Floor Anatomy

Question 1

What are the functions of the pelvic floor? (4)

Answer 1

• Support (main function)
• Continence
• Intra-abdominal pressure
  
  • maintenence of high intra-abdominal pressure
• Childbirth

Question 2

How does the pelvic floor support the pelvic organs? (Vagina, bladder, uterus, ovaries, bladder, rectum) (3)

Answer 2

1. Suspension
   
   1. Strong vertical support
      
      1. Cardinal ligaments
         
         1. hold cervix and upper vagina in place
      2. Uterosacral ligaments
         
         1. holding back of cervix and upper vagina in place
      3. Round ligament
         
         1. Maintain anteverted position of uterus
2. Attachment
   
   1. ​eg Vagina attached to: endopelvic fascia, levatator ani muscles, perineal body
3. Fusion
   
   1. ​eg fusion of urogenital diaphragm and perineal body
   2. Lower half of vagina- supported by fusion of endopelvic fascia to perineal body, levatator ani and urethra

Question 3

Name the deep muscles of the pelvic form and the collective term for them.

Answer 3

Levatator ani muscles:

1. Pubococcygeus
2. Puborectalis
3. Iliococcygeus

Question 4

Fill in the missing labels in the diagram:

Answer 4

Question 5

Name the 3 superficial muscles found in the pelvic floor (these are found in men and women) and identify them on the following diagram:

Answer 5

• Ischiocavernous
• Bulbospongiosus
• Superficial transverse perineal

Question 6

Why would a medio-lateral episiotomy be carried out during childbirth and which muscles may be damaged as a result?

Answer 6

• Avoid damage to perineal body (eg 2nd and 3rd degree tears)
• If baby large
• Difficult delivery
• Using forceps during delivery

Muscles: transverse perineal muscle, bulbocavernosus muscle

Question 7

What complications can an episiotomy cause?

Answer 7

Infection, haemorrhage, dyspareunia (difficult/painful intercourse), damage to anal sphincter

Question 8

Describe the 4 degrees of perineal tears:

Answer 8

Question 9

Where is the perineal body on the following image and what is its function?

Answer 9

Main function: site of attachment for pelvic floor muscles and other structures providing support

Question 10

What is the urogenital diaphragm?

Answer 10

Sheet- dense fibrous tissue- spans anterior half of pelvic floor

Attaches urethra, vagina, perineal body

Arises from inferior ischiopubic ramus

Question 11

What nerve supplies the pelvic floor muscles?

Answer 11

S2,3 and 4

Pudendal nerve

Question 12

What complications can a pelvic organ prolapse cause?

Answer 12

Disturb anorectal, urinary and sexual function

Depressive symtoms

Pain

Infection

Question 13

How do we classify pelvic organ prolapses?

Answer 13

Compartment and organ which has prolapsed

ANTERIOR

Bladder/urethra

MIDDLE

Uterus into vagina

POSTERIOR

Rectum

Loops of bowel entering pouch of douglase

Question 14

What is a ‘vault’ prolapse?

Answer 14

After hysterectomy

Supportive ligaments cut to remove uterus

Apex of vagina can prolapse

Question 15

What causes/risk factors are there for pelvic organ prolapses?

Answer 15

Age- post menopause- less oestrogen

Parity

Pregnancy (esp vaginal delivery)

(Pregnancy still risk factor even if caesarian)

Oestrogen deficiency

Chronic increased abdominal pressure eg obesity

CT/ Neurological disorder

eg muscular dystrophy

eg marfans, ehlers danlos

Question 16

How should a prolapse be managed? Give examples of non-surgical and surgical ways to manage it.

Answer 16

Depends on:

• Nature of symptoms, degree of bother
• Nature and extent of prolapse
• Future pregnacy plans
• Sexual activity
• Fitness for surgery

1. Non-surgical
   
   1. Pessaries
2. Surgical
   
   1. Hysterectomy
   2. Mesh (vault prolapse)

Question 17

What is ‘stress incontinence’?

Answer 17

Increased abdominal pressure causes leaks of urine as support of urethral sphincter= inadequate

(risk factors same as developing prolapse)

Question 18

How might a patient with stress incontinence present?

Answer 18

Passing urine whilst: coughing, laughing etc

Question 19

How should stress incontinence be managed?

Answer 19

Pelvic floor muscle training

Surgical intervention eg slings to support urethral sphincter

Question 20

What are the potential long term consequences of FGM?

Answer 20

• Psychological effects
• Sexual dysfunction
• Difficulty conceiving
• Chronic pain
• Menstrual disorders

(FGM is illegal in UK- must be reported. Safeguarding issue for under 18s)

Question 21

What arteries does the pelvic floor receive its blood supply from and where is its lymphatic drainage?

Answer 21

Pudendal arteries (venous drainage is corresponding veins to pudendal arteries)

Inguinal lymph nodes

Question 22

What is vaginismus?

Answer 22

Vaginal opening closed- pelvic floor muscles so tight

Question 23

Describe a cystocele prolapse

Answer 23

Supportive tissue between a woman’s bladder and vaginal wall weakens and stretches, allowing the bladder to bulge into the vagina

Will be symptomatic

Question 24

What does OASIS stand for? How can this be prevented?

Answer 24

Obstetric Anal Sphincter Injuries

Prevention:

Episiotomy

Perineal protection at crowning

Encouraging mother NOT to push when head= crowning

Question 25

What does vestibulodynia mean?

Answer 25

Painful vulva

hypersensitive nerve endings or an overgrowth of nerve fibers in the vestibule area of the vulva

Question 26

What are the different types of FGM?

Answer 26

Question 27

How might a posterior pelvic floor dysfunction present?

Answer 27

Vaginal/rectal bulge/lumConstipation

Incomplete evacuation

Anal incontinence

Question 28

Name some causes of posterior compartment pelvic floor dysfunction:

Answer 28