S2 L2 The Pelvic Floor

Question 1

Function of the pelvis floor

Pelvic Floor Functions

Answer 1

If patient has any of these - Consider if it is due to a pelvic floor problem?!

1. Pelvic Organ Support
2. Bladder and Bowel Control
3. Passing of Urine and Faeces
4. Sexual Function
5. Breathing
6. Pregnancy and childbirth

Question 2

Label the sagittal view of the pelvis

What happens if one of the pelvic floor structure is dysfunctional?

Answer 2

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Question 3

How do the Pelvic floor muscle maintain support

Answer 3

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Question 4

1. Suspension
   - What is this?
   - What does it work against?
   - Structures involved?

Answer 4

These ligament work against gravity and sudden changes in intra-abdominal pressure e.g. by sneezing, coughing…

Question 5

2. Attachment
   - Provided by what structures
   - Importance for urethra…

Answer 5

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Question 6

3. Fusion

- Which structures are involved?

Answer 6

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Question 7

Composition of the pelvic floor?

Label structure

Answer 7

— Predominantly by the levator ani muscles.
— Urogenital diaphragm/perineal membrane
— Perineal body
— Perineal muscles
— Posterior compartment

Question 8

The Levator Ani muscles

• Name three muscle
• Origins and insertions (roughly)
• What organs do they encircle?

Answer 8

Deep muscle (Forms a U-shaped sheet)

• Puborectalis (pubic tubercle and wraps around the retum)
• Pubococcygeus (pubic bone to coccyx)
• Iliococcygeus (ishcial spine to coccyx)
• Encircles the urethra, vagina and the rectum and
  reaching the coccyx.

Question 9

Recap -
Levator Ani muscles

Where they originate?
Where they insert?
Encircle which organs?
Form which structure?

Answer 9

Originate: Back of the body of the pubic bone, the white line over the obturator internus muscle and medial aspect of the ischial spines
Insert: Some of the fibres are inserted as they encircle the
urethra, some are inserted as they encircle the vagina, some fibres are inserted as they encircle the rectum
and the rest are inserted in the lower part of the coccyx
and anococcygeal raphe
Encircle: Urethra, vagina, rectum
Form: Perineal body

Question 10

Perineal muscles

• Which layers?
• Clinical consideration…
• 4 main muscle and location

Answer 10

Superficial layer (next layer after the levator ani)

Most commonly involved in perineal traumaaccidental,
sexual and obstetric

Question 11

Label

Answer 11

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Question 12

Urogenital diaphragm

• What is this?
• Which muscles make up this
• Origins
• Insertions
• Role

Answer 12

The urogenital diaphragm consists of the deep transverse perineal muscle with the superior and inferior fascia
Triangular sheet of dense fibrous tissue
Spans the anterior half of the pelvic outlet
Origin: Arises from the inferior ischiopubic ramus
Insertion: Attaches medially to the urethra, vagina and perinealbody
Role: Thereby supporting the pelvic floor

Question 13

Perineal Body

• Location
• Point of insertion for which muscles
• Role

Answer 13

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Question 14

Label

Answer 14

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Question 15

Blood supply, innervation, venous and lymphatic drainage for the levator ani and perineal muscles

Answer 15

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Question 16

Label

Answer 16

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Question 17

Pelvic Organ Prolapse

• What is this?
• How common?
• Life-threatening?
• Other risk factors

Answer 17

Associated with significant functional disturbances including:

• Anorectal
• Urinary
• Sexual

Other risk factors:
— Age (muscles weaken over time)
— Parity (pregnancy)
— Vaginal delivery- 4x increased risk after 1st child; 11x increase after >/= 4 deliveries
— Obesity and causes of chronic raised intra-abdominal pressure
— Postmenopausal oestrogen deficiency
— Neurological e.g.. Spina bifida, muscular dystrophy
— Genetic connective tissue disorder e.g.. Marfan’s,
Ehlers Danlos

Question 18

POP Anterior compartment

• 3 types
• In a diagram - what could this look like?

Answer 18

• Cystocele (only bladder)
• Urethrocoele (only urethra)
• Cystourethrocoele (both bladder and urethra)

Question 19

POP Middle compartment

don’t look at Q flashcard pic yet

Answer 19

• Uterine prolapse
  —In the middle compartment or vaginal apex, the uterus
  may prolapse -uterine prolapse.
  — If it’s the entire uterus- procidentia
  — Following a hysterectomy, the apex may still prolapse-
  Post-hysterectomy vault prolapse (see pic on Q flashcard)

Question 20

POP Posterior Compartment

- 2 types

Answer 20

—The rectum may prolapse into the posterior part of the
vagina-rectocele
— Loops of bowel may prolapse into the rectovaginal
space (Pouch of Douglas)- enterocele

Question 21

Management of POPS:

- Non-surgical and surgical

Answer 21

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Question 22

Perineal trauma and Obstetric Anal Sphincter InjurieS (OASIS

• What is perineal trauma?
• Degrees of tears?
• Functions of the pelvic floor?

Answer 22

— Perineal trauma involve any of the perineal muscles
— OASIS are those involving the anal sphincter complex
— Types- 3rd and 4th degree tears
— Can result in significant morbidity
— Demonstrates the functions of the pelvic floor continence
and support

Question 23

Prevention of OASIS

• For childbirth
• One recommendation to tell mum at crowning

Other risk factors

Answer 23

— Thinking about episiotomy (risk groups and correct
angle) i.e. restrictive use
— Perineal protection at crowning can be protective
— Encouraging the mother NOT to push when the head
is crowning
Episiotomy - cut the perineal space between the vagina and anus - to elevate pressure and provide space

Question 24

Urinary incontinence

- 2 types

Answer 24

— Stress incontinence, affected by dysfunction of the
pelvic floor
— Other types of incontinence- urge incontinence due to
problems with the bladder not the pelvic floor

Question 25

FGM: - Defintion - Why it happens? - Types

Answer 25

All procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs, whether for cultural or other nontherapeutic reasons Why it happens: — Mistaken as a religious practice, a form of “circumcision”, across board; Muslims, Christians etc. — Culture- “ purification”, tradition, rite of passageattainment of womanhood — Social acceptance, family honour- especially for marriage — Fear of social exclusion

Question 26

FGM - Consequences and complications - Legal aspects

Answer 26

— Acute- Haemorrhage- can be severe, leading to shock, sepsis, blood-borne infections, death — Late - Sexual difficulties- fertility issues, chronic pain, urinary outflow obstruction, difficulty with cytological screening and evacuation following miscarriage — Obstetric- fear of childbirth, increased likelihood of C/S, postpartum haemorrhage (PPH), severe vaginal lacerations — Psychological- flashbacks, self-esteem/worth issues, PTSD FGM is illegal in the UK- FGM Act 2003. Prison sentence of up to 14 years

Question 27

More clinical correlations: - Polycystic ovaries - Endometriosis - Episiotomy

Answer 27

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Question 28

Recap of location of: | - Perineal Muscles

Answer 28

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Question 29

Recap of: | - Other structures around these

Answer 29

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Question 30

Recap of location of: | - Levator Ani muscles

Answer 30

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