Lecture 4: Pelvic floor

Question 1

What are the functions of the pelvic floor?

Answer 1

• Support of the pelvic organs (vagina, uterus, ovaries, bladder, rectum)
• facilitate micturition (urination) and defecation and maintain urinary/faecal continence
• maintains a high intra-abdominal pressure during sneezing, laughing, coughing
• contributes to the birth canal and facilitates childbirth

Question 2

What are the three levels of support in the pelvic floor?

Answer 2

• suspension
• attachment
• fusion

Question 3

How does suspension support the pelvic organs?

Answer 3

Maintains an ‘anti-gravity’ position by providing a strong verticle support, from the cardinal ligaments and uterosacral ligaments

Question 4

How does attachment support the pelvic organs?

Answer 4

Comes from attachments on the pelvic organs

e.g. vagina is supported by its attachment to endopelvic fascia, levator ani muscles, and the perineal body

Question 5

How does fusion support the pelvic organs?

Answer 5

Arises from fusion of different tissues

e.g. urogenital diaphragm abd perineal body

Question 6

What is the composition of the pelvic floor?

Answer 6

Deep muscles:
Levator ani muscles make up majority of pelvic floor: set of U-shaped muscles acting like a sling, thereare three muscles
-pubococcygeus
-puborectalis
-iliococcygeus

Superficial muscles:

• bulbospongiosus
• ischiocavernosus
• superficial transverse perineal

Question 7

What structures do the levator ani muscles encircle?

Answer 7

-urethra
-vagina
-rectum
It provides support for these organs

Question 8

What is the midpoint of the attachments for the levator ani muscles?

Answer 8

Perineal body

Question 9

What superficial muscles can undergo iatrogenic damage during childbirth?

Answer 9

Bulbospongiosus and the transverse perineal muscles undergo iatrogenic damage in a medio-lateral episiotomy in childbirth (cutting vagina)
-this is to avoid damage to the perineal body as it is an integral role in pelvic floor support as site of attachment

Question 10

Why is an episiotomy done?

Answer 10

If the baby is large/ there is a difficult delivery/ use of forceps in delivery. It is done to prevent further perineal damage

Question 11

What complications can an episiotomy cause?

Answer 11

• infection
• haemorrhage
• damage to anal sphincter
• dyspareunia (pain during sex)

Question 12

What is the perineal body?

Answer 12

Central point between the vagina and the rectum. Its main function is to act as a site of attachment for pelvic floor muscles and other structures providing support

Question 13

What is the urogenital diaphragm?

Answer 13

Sheet of dense fibrous tissue that spans the anterior half of the pelvic floor

Question 14

What is the innervation of the pelvic floor?

Answer 14

Pudendal nerve

Question 15

What is pelvic organ prolapse?

Answer 15

Loss of support for the uterus/bladder/colon can result in a prolapse of any of these organs into the vagina

• implications on quality of life due to its disturbance to anorectal, urinary and sexual function
• can also cause altered sense of body image, leading to depressive symptoms
• source of pain and infection

Question 16

How can pelvic organ prolapse be classified?

Answer 16

By the compartment the prolapse has occured in, and the organ that has prolapsed

Anterior compartment (bladder/urethra)

• cystoceole (bladder)
• urethrocoele (urethra)
• cystourethrocoele (both)

Middle compartment
-uterus prolapses into the vagina, various degrees depending on how far the prolapse was

Posterior compartment (bowel/surrounding structures)

• rectocoele (rectum)
• enterocoele (loops of bowel entering rectouterine pouch)

Question 17

What is a vault prolapse?

Answer 17

Apex of the vagina (vault) can prolapse

Can occur after a hysterectomy as the supportive ligaments have been cut when removing the uterus

Question 18

What are the risk factors for pelvic organ prolapse?

Answer 18

• age
• parity (no. of times a woman has given birth)
• mode of delivery (particularly vaginal delivery)
• oestrogen deficiency (post/peri-menopausal)
• chronic increased abdominal pressure
• connective tissue/neurological disorders

Question 19

What symptoms does a patient present with in pelvic organ prolapse?

Answer 19

• feeling a lump down below
• something ‘coming down’
• symptoms relating to where the prolapse is occuring e.g. constipation

Question 20

How do you manage a pelvic floor prolapse?

Answer 20

Centered on how much the prolapse is interfering with the patients quality of life, the severity of the prolapse, and how fit they are for surgical procedure
Non-surgical:
-use of pessaries (ring pessaries)
Surgical: depends of prolapse type
-removal of uterus (hysterectomy)
-mesh support for a vault prolapse

Educate patients that prolapses can reoccur

Question 21

What does dysfunction of the pelvic floor usually result in?

Answer 21

Stress incontinence
-increased abdominal pressure causes ‘leaks’ of urine, as the support to the urethral sphincter via the pelvic floor is inadequate

Question 22

What are the risk factors for developing stress incontinence?

Answer 22

Same as those for pelvic floor prolapse, especially: age and oestrogen deficiency

Question 23

What are the symptoms of stress incontinence?

Answer 23

• passing urine on laughing/coughing/activities increasing intraabdominal pressure
• may not be much to see on examination other than an obvious injury to the pelvic floor
• urodynamic studies can be used to investigate further

Question 24

How do you manage urinary incontinence?

Answer 24

• pelvic floor muscle training

- surgical intervention can be used to create ‘slings’ to support the urethral sphincter

Question 25

What are some vulval problems?

Answer 25

Patients experience pain with no finding on examination

-related to tension of the levator ani muscles

Question 26

What is FGM?

Answer 26

Female genital mutilation (illegal in UK, reported and safeguarding if <18yo)

• damaging female external genitalia
• significant consequences such as severe pain, sepsis, haemorrhage
• long term complications include psychological effects, sexual dysfunction, difficulty conceiving, chronic pain, menstrual disorders

Question 27

What is posterior compartment pelvic floor dysfunction?

Answer 27

Range of conditions affecting the posterior part of the pelvic floor.
The anal sphincter is attached to levator ani muscles, so any damage can lead to loss of voluntary control of defecation
-can get constipation/incomplete evacuation/anal incontinence