Repro5 - The Pelvic Floor

Question 1

4 functions of the pelvic floor

Answer 1

1. ) Support - of the pelvic organs, mainly the vagina, uterus, ovaries, bladder, and rectum
2. ) Pressure Maintenance - intra-abdominal pressure during coughing, vomiting, sneezing and laughing
3. ) Continence - urinary and faecal continence
4. ) Childbirth

Question 2

What are the 3 mechanisms for support of the pelvic organs?

Suspension (3 ligaments)
Attachment
Fusion

Answer 2

1. ) Suspension - vertical support against gravity and intra-abdominal pressure
   - cardinal ligaments holds the cervix and vagina in place
   - uterosacral ligaments holds the cervix and vagina laterally
   - round ligament - keeps anteverted position of uterus
2. ) Attachment - provided by the:
   - arcus tendinosus fascia pelvis (ATFP)
   - endopelvic fascia stretches like a hammock from the ATFP laterally to the vaginal wall medially
3. ) Fusion - of the vaginal endopelvic fascia to other structures supports the lower half of the vagina
   - posteriorly = perineal body, laterally = levator ani, anteriorly - urethra

Question 3

What 4 structures is the pelvic floor composed of?

Answer 3

1. ) Deep Levator Ani Muscles
2. ) Superfical Perineal Muscles - superficial and deep transverse, bulbospongiosus, ischiocavernous
3. ) Perineal Body - central between vagina and rectum
   - site of attachment for pelvic floor muscles and other structures supporting the pelvic floor
4. ) Urogenital Diaphragm/Perineal Membrane - sheet of dense fibrous tissue spanning the anterior half of the pelvic floor
   - attaches to the urethra, vagina, and perineal body

Question 4

What are the 3 levator ani muscles

Answer 4

1. ) Puborectalis - encircles the rectum
2. ) Pubococcygeus - encircles the vagina
3. ) Iliococcygeus - ishcium –> coccyx

Question 5

Neurovasculature of the Pelvic Floor

Answer 5

1. ) Blood Vessels - internal and external pudendal arteries and veins
2. ) Nerve Supply - pudendal nerve (S2-S4)
3. ) Lymphatic Drainage - inguinal lymph nodes

Question 6

5 features of a pelvic organ prolapse (POP)

Definition
Causes and Risk Factors x7
Consequences
Assessment
Management

Answer 6

1.) Definition - loss of support of pelvic organs leading to their prolapse into the vagina

2. ) Causes and Risk Factors - main ones are:
   - age, parity (being pregnant), and vaginal delivery,
   - others: oestrogen deficiency, chronic increased abdominal pressure (obesity), neurological or CT disorders e.g. Marfan’s

3.) Consequences - not life threatening but has impact on QoL, body image and cause depressive symptoms

4. ) Assessment - POP-Q system, examination
   - patients present with dragging sensation or lump
5. ) Management - non-surgical or surgical
   - non-surgical is use of pessaries
   - surgical includes anterior/posterior repair, vaginal hysterectomy + others

Question 7

3 compartments of pelvic organ prolapse

Answer 7

1. ) Anterior Compartment - bladder and/or urethra
   - Cystoceole - bladder prolapse into vagina
   - Urethrocoele - urethra prolapse into vagina
   - Cystourethrocoele - bladder and urethra prolapse
2. ) Middle Compartment - uterus prolapse into the vagina
   - the vaginal apex (vault) can prolapse when the supportive ligaments are cut after a hysterectomy
3. ) Posterior Compartment - bowel or rectum
   - Rectocoele - rectum prolapse,a small hook can be created which can trap faeces in rectum
   - Enterocele - loops of bowel prolapse into the rectouterine pouch

Question 8

What are obstetric anal sphincter injuries (OASIS) and how can they be prevented?

Answer 8

1.) Definition - perineal tears involving the anal sphincter complex. - occur mainly during pregnancy

2. ) Prevention - episiotomy (widening vagina wall)
   - this can lead to damage of the bulbospongiosus and transverse perineal muscles
   - encouraging the mother not to push when the head is crowning

Question 9

5 features of female genital mutilation (FGM)

Definition
Types
Acute Consequences x3
Late Consequences x3 
Other Consequences x2

Answer 9

1.) Definition - partial or total removal of the external female genitalia or other injury to the female genital organs for non-therapeutic reasons

2. ) Types - 4 types of FGM, Type 1: clitoridectomy
   - Type 2: excision of clitoris and labia minora
   - Type 3: infibulation (stiching edges of vulva together)
   - Type 4: other harmful procedures to female genitalia
3. ) Acute Consequences - haemorrhage, sepsis, death
4. ) Late Consequences - infertility, chronic pain, urinary outflow obstruction
5. ) Other Consequences - psychological impacts and obstetric issues

Question 10

4 other conditions caused by dysfunction of the pelvic floor

Answer 10

1. ) Urinary (stress) Incontinence - increased abdominal pressure causes leaks of urine due to weak pelvic floor muscles
   - same risk factors as POP
   - 1st line management is pelvic floor exercises,
   - surgical (colposuspension) fixation if symptoms persist
2. ) Anal (faecal) Incontinence - impairment of QoL
   - in women, caused mainly by OASIS
3. ) Vulval Problems - vestibulodynia (painful vulva),
   - vaginismus (tight vaginal opening) causing pain on vaginal penetration
4. ) Posterior Compartment (anorectal) Dysfunction
   - caused by structural defects e.g. rectocele, drugs, dehydration, immobility, pregnancy, post-op
   - presents as vaginal or rectal lump, constipation, incomplete evacuation, anal incontinence