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WACS > Anatomy of Pelvic Floor and Prolapse > Flashcards

Anatomy of Pelvic Floor and Prolapse Flashcards

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1
Q

Passive support of the pelvic floor

A

Fascia and ligaments

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2
Q

Active support of the pelvic support

A

Muscles of the pelvic floor (levator ani)

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3
Q

3 layers of the pelvic floor from superior to inferior

A

The pelvic fascia
The pelvic diaphragm
The urogenital diaphragm

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4
Q

Muscles of the anal sphincter complex

A

Internal anal sphincter
Conjoined longitudinal muscle
External anal sphincter

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5
Q

T/F: Internal anal sphincter is extension of the circular muscle layer of the rectum

A

T

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6
Q

T/F: Internal anal sphincter is under constant maximal contraction

A

T

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7
Q

% of resting anal tone provided by the internal anal sphincter

A

50 - 85%

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8
Q

Autonomic innervation of the internal anal sphincter

A

Parasympathetic…..S2-4
Sympathetic……..thoracolumbar ganglia (L5)

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9
Q

T/F: Suggested that both parasympathetic and sympathetic innervation cause inhibition of contraction

A

T

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10
Q

Formation of the conjoined longitudinal muscle

A

Extension of the longitudinal muscle layer of the rectum, along with levator ani muscle fibers

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11
Q

Structural support, anchoring the anorectum to the pelvis

A

Conjoined longitudinal muscle

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12
Q

T/F: External anal sphincter comprises a single layer of striated muscles

A

F. Multiple layers of striated muscle

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13
Q

% of resting anal tone provided by the external anal sphincter

A

25 - 30%

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14
Q

Somatic innervation of the external anal sphincter

A

Somatic innervation from the inferior rectal branch of the pudendal nerve (S2-3) and the perineal branch of S4

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15
Q

Levator ani muscles

A

Ischiococcygeus

Iliococcygeus

Pubococcygeus
Puborectalis Lig
Pubovaginalis Lig
Pubovesical Lig.

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16
Q

Origin and insertion of ischiococcygeus

A

Arises from the tip of the iscial spine close to the origin of obturator internus

Inserted into the coccyx and lower part of the sacrum

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17
Q

What forms the arcus tendineus

A

Arcus tendinous is a fibrous band formed by the fascia of the obturator internus

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18
Q

The iliococcygeus originates from what part of the arcus tendineus

A

posterior half of the arcus tendinous

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19
Q

The 2 insertion points of the iliococcygeus

A

Inserted into the side of the coccyx and ano-coccygeal raphe

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20
Q

The muscle arising from the anterior half of the arcus tendineus

A

Pubococcygeus

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21
Q

3 origins of the pubococcygeus

A

Arises from the anterior half of arcus tendineus, side and posterior surface of the pubis

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22
Q

2 insertion points of the pubococcygeus

A

Inserts into the tip of the coccyx and ano-coccygeal raphe

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23
Q

The 3 groups formed by the anterior fibres of the pubococcygeus

A

Puborectalis
Pubovaginalis
Pubo-vesical ligament

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24
Q

The anorectal angle is formed by which muscle

A

Puborectalis

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25
The U-shaped and medial most part of the levator ani
Puborectalis
26
Origin and insertion of puborectalis
From the back of pubic bone & inserted into the ano-rectal junction
27
Origin and insertion of the pubovaginalis
Arises from the back of the pubis and inserted into the vagina and the perineal body
28
T/F: Tearing of the pubovaginalis results in 3rd degree perineal tear
T
29
The most anterior group of the pubococcygeus
Pubovesical ligament
30
Origin and insertion of the pubovesical ligament
It arises from the back of the pubic bone Inserts into the junction between the bladder and the urethra
31
The muscle that helps in raising pelvic diaphragm when it is necessary to raise intra-abdominal pressure: During defaecation During micturition During coughing During sneezing During vomiting and forced expiration
Pubococcygeus
32
The muscle that during parturition helps to support the head of the baby, guide the head towards the vaginal canal and helps in the expulsion of the fetus
Pubococcygeus
33
The muscle that during sexual relationship helps to tighten the phallus to contribute to orgasm in the female
Pubococcygeus
34
The muscle that allows for gross fecal continence
Puborectalis and the anorectal angle
35
The muscle that relieves pressure from the sphincter process
Puborectalis and the anorectal angle
36
What is responsible for gas and liquid continence
The sphinter complex
37
Defecation occurs with the relaxation of the -- and contraction of the other levator muscles
Puborectalis
38
The most common pelvic organ prolapse
Cystocele
39
The 2 anterior compartment prolapse
1. Bladder prolapse called cystocele (most common pelvic organ prolapse) 2. Urethral prolapse called urethrocele
40
The 2 middle compartment prolapse
Uterine prolapse Vaginal vault prolapse
41
The 2 posterior compartment prolapse
1. Small bowel prolapse called enterocele. 2. Rectal prolapse called rectocele
42
T/F: With normal tone of the levator ani the anorectal angle is acute and the levator plate is horizontal
T
43
Loss of tone in the levator ani results in --, -- and --
1. Change in the vaginal axis 2. Sagging of the levator plate 3. Enlargement of the urogenital hiatus
44
Strongest support of the uterus
Transverse cervical/Mc Kenrodt Ligament
45
Runs from the pubis to the fundus of the cervix
Pubocervical ligament
46
Arises from the back of the uterus and attaches to the sacrum on either side
Uterosacral ligament
47
5 causes of prolapse
1. Injury sustained during child birth: C. During instrumental vaginal delivery especially with forceps and there is exertion of traction on the support. 2. Respiratory problems e.g in bronchitis 3. Post-hysterectomy 4. Congenital weakness 5. Aging (menopause) due hypoeostrogen state
48
9 precipitating factors for prolapse
Chronic constipation Chronic cough Lifting of heavy objects Manual work Straining for long period Large intra-abdominal tumour Ascites Pregnancy obesity
49
4 determinants of incidence of prolapse
Level of obstetric care Parity of the patient Pelvic anatomy Cultural factors e.g farming
50
6 clinical features of prolapse
History of something coming out of the vaginal Reducible or not More prominent on standing or reduces on lying down down Dragging sensation or pelvic discomfort Backache Abnormal vaginal discharge or bleeding due to ulceration of the prolapsed area Urinary symptoms- urinary retention or urgency Difficulty indefaecation
51
How many degrees of uterovaginal prolapse
4 degrees
52
1st degree UV prolapse:
Descent of the cervix to below the level of the Ischial spine but does not protuse through the introitus
53
2nd degree UV prolapse:
Descent of the cervix to the introitus.
54
The clinically commonest degree of UV prolapse
2nd degree
55
3rd degree UV prolapse:
The entire uterus comes out of the introitus
56
4th degree UV prolapse
The entire length of vaginal wall comes out along with the uterus (procidentia):
57
7 differential diagnoses of prolapse
Vulva tumour Polypoid tumour Cervical polyp Hypertrophied or elongated cervix Vaginal cyst Peri-urethral cyst Diverticulum of the urethra
58
3 complications of UV prolapse
Keratinization due to exposure and repeated abrassion and thickening Decubitus ulcers on the cervix due to kinking of the blood vessels with relative ischaemia leading to oedematous cervix, abrassions Obstructive lesions of the urinary tract
59
4 ways of preventing prolapse
Well supervised labour Postnatal exercises Good surgical technique at hysterectomy Small family size
60
2 modes of treatment of prolapse
Non-surgical and surgical
61
8 determinants of surgical treatment of prolapse
Age of patient Marital status Reproductive career Plan about future sexual relationship Degree of prolapse including symptoms Other associated problems Patient’s clinical condition Patient’s desire
62
6 non-surgical treatment of prolapse
Physiotherapy especially in post natal period and in minor degree prolapse Lifestyle changes, such as avoiding certain activities. Faradism: application of heat to the muscles to ake them contract Hormone replacement therapy in minor degree prolapse especially in old and post-menopausal patients Treatment of decubitus ulcers involves packing the vaginal with antiseptic-containing gauze ( moistined with acriflavine or hibitane) Use of pessaries
63
2 antiseptics for vaginal packing
acriflavine or hibitane
64
3 materials for making pessaries
Plastic, rubber and silicone
65
5 indications for pessary use
Pregnancy Puerperium Patients who desire to get pregnant soon after consultation Surgery contra-indicated To allow healing of decubitus ulcers
66
Follow-up protocol after pessary insertion:
Give antibiotics See every 3-6 months Change every 6 months
67
How often should pessaries be changed
Every 6 months
68
How often should the patient be seen following pessary insertion
3 - 6 months
69
3 examples of pessaries
Inflatable Doughnut Gellhorn
70
11 preoperative investigations/measures
Pap smear Biopsy of decubitus ulcer Urine for m/c/s Renal function test especially when there is repeated infections Chest x-ray especially in history of cough Cystoscopy to look at the interior lining of the bladder and the urethra. Intravenous pyelogram (IVP) to show the size, shape, and position of the kidneys, bladder, ureters, and urethra. Computed tomography scan (CT scan) to produce detailed pictures of structures inside the pelvic area. Urodynamic studies to see how your body stores and releases urine. Weight reduction in obese patient Treatment of chest infections and other other medical conditions if present
71
6 surgical procedures for prolapse
1. Colporrhaphy 2. Vaginal hysterectomy and colporrhaphy 3. Manchester (Forthergil) operation 4. Partial (Defort’s) colpoclesis 5. Complete colpoclesis 6. Vaginal wall suspension
72
Repair of the vaginal wall
Colporrhaphy
73
2 types of colporrhaphy
anterior as for cystourethrocoele posterior as for rectocoele
74
Muscles tightened in colporrhaphy
It involves opening the vaginal wall and tightening the appropriate muscles: Pubovesical in Cystourethrocoele puborectalis in Rectocoele
75
2 indications for vaginal hysterectomy and colporrhaphy
In uterovaginal prolapse In women who have no wish to bear children
76
Manchester or --- operation
Fothergil
77
Manchester (Forthergil) operation is useful in which degree of prolapse
2nd degree prolapse
78
T/F: Manchester (Forthergil) operation is for patients who still want to get pregnant
T
79
4 components of Manchester (Forthergil) operation
Anterior colporrhaphy to remove the cystourethrocoele Shortening of the cervix Shortening of the transverse cervical ligament Posterior colpoperineorrhaphy (optional)
80
The optional component of the Manchester (Forthergil) operation
Posterior colpoperineorrhaphy
81
Partial colpocleisis is also known as
Defort's colpocleisis
82
Type of colpocleisis for women still menstruating
Partial (Defort's)
83
Occlusion of the vagina with spaces at the sides
Partial (Defort's) colpocleisis
84
Type of colpocleisis indicated in old women and women that are not sexually active
Complete colpocleisis
85
2 types of colpocleisis
Partial (Defort's) Complete
86
Done for post hysterectomy prolapse
Vaginal wall suspension
87
Attaching the vaginal vault to the sacrum
Vaginal wall suspension
88
T/F: vaginal wall suspension is done through the abdominal approach
T
89
3 post operative care following prolapse surgery
Urethral catheterisation to prevent urinary retention and to rest the bladder Vaginal packing to reduce bleeding Antibiotics as necessary
90
11 complications of surgery for prolapse
Urinary retention Haemorrhage Thromboembolic disease Infection Stress incontinence Dyspareunia Apareunia Recurrence of prolapse Cervical incompetence in Manchester operation Gynaetresia Cervical cancer in neglected decubitus ulcer
91
Which surgery for prolapse can be complicated with cervical incompetence
Manchester operation

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