SM_224b: Pelvic Floor Disorders and Urogyn / Uro

Question 1

Describe the bony pelvis

Answer 1

Bony pelvis

Question 2

Describe ligaments of the pelvis

Answer 2

Ligaments of the pelvis

Question 3

____ is the primary support of pelvic viscera and is composed of ____, ____, and ____

Answer 3

Levator ani is the primary support of pelvic viscera and is composed of puborectalis, pubococcygeus, and iliococcygeus

• Sling around rectum, vagina, and urethra

Question 4

Pelvic diaphragm is composed of ____ and ____

Answer 4

Pelvic diaphragm is composed of levator ani muscles and coccygeus muscle

Question 5

Describe the levels of pelvic organ support

Answer 5

Levels of pelvic organ support

• Level I: uterosacral and cardinal ligaments, apical support
• Level II: arcus tendineuous fascia pelvis, lateral / longitudinal support
• Level III: perineal muscles, distal support

Question 6

Describe nerves of inguinal region

Answer 6

Nerves of inguinal region

• Dorsal nerve to clitoris
• Perineal nerve
• Inferior rectal nerve

Question 7

Endopelvic fascia is ____ anchored to ____

Answer 7

Endopelvic fascia is loose connective tissue anchored to parietal fascia of muscles

• Collagen, elastin, smooth muscle

Question 8

Describe muscle fibers and innervation of levator ani muscles

Answer 8

Muscle fibers and innervation of levator ani muscles

• Type I fibers: slow twitch, baseline tone
• Type II fibers: fast twitch, voluntary contractions
• Innervation: anterior roots of S2-4, no pudendal contribution

Question 9

Parietal fascia is ____, has a ____ vascular supply, covers ____, and provides attachment to ____

Answer 9

Parietal fascia is dense connective tissue, has a limited vascular supply, covers pelvic muscle, and provides attachment to the bony pelvis

Question 10

Visceral fascia suspends ____ and is a conduit for ____

Answer 10

Visceral fascia suspends viscera over the pelvic floor and is a conduit for nerves, vessels, and lymph system

Question 11

Pelvic floor is ____

Answer 11

Pelvic floor is muscles, ligaments, and connective tissue in the lowest part of the pelvis

• Supports internal organs: bladder, uterus, rectum, vagina

Question 12

Describe pelvic floor disorders

Answer 12

Pelvic floor disorders

• Prolapse of pelvic organs: vagina, bladder, rectum
• Urinary control problems: urinary incontinence
• Bowel control problems: fetal incontinence

Question 13

Risk factors for pelvic floor disorders are ____, ____, ____, ____, and ____

Answer 13

Risk factors for pelvic floor disorders are aging, obesity, constipation, childbirth, and smoking

Question 14

Risk factors for pelvic organ prolapse are ____, ____, and ____

Answer 14

Risk factors for pelvic organ prolapse are genetic predisposition, aging tissue, and pelvic floor injury (childbirth, chronic illness, overweight, tobacco use)

Question 15

Pelvic organ prolapse symptoms are ____, ____, ____, and ____

Answer 15

Pelvic organ prolapse symptoms are bulge, urinary incontinence or voiding difficulties, bowel problems, and sexual discomfort

• Straining, stool trapping, fecal incontinence

Question 16

Surgical treatment of pelvic organ prolapse involves concepts of ____ or ____

Answer 16

Surgical treatment of pelvic organ prolapse involves concepts of reconstructing a functional vagina and obliterating the vaginal canal / closing the genital hiatus

• Surgical choices: reconstructive (native tissue, mesh augmented), obliterative

Question 17

___ is a common surgical technique for pelvic organ prolapse

Answer 17

Sacrocolpopexy is a common surgical technique for pelvic organ prolapse

• Mesh from vagina to sacrum
• Anatomic superiority, durability, increased complications compared to vaginal approach

Question 18

Minimally invasive surgery options for pelvic organ prolapse are ____, ____, and ____

Answer 18

Minimally invasive surgery options for pelvic organ prolapse are uterosacral ligament suspension, sacrospinous ligament suspension, and colpocleisis

Question 19

___ innervates the striated muscle of the urethral sphincter

Answer 19

Pudendal nerve (S2-4) innervates the striated muscle of the urethral sphincter

• Neuromuscular injury can lead to stress urinary incontinence

Question 20

Urinary urgency usually with frequency and nocturia and leakage with urgeny are ___

Answer 20

Urinary urgency usually with frequency and nocturia and leakage with urgeny are overactive bladder / urge incontinence

Question 21

Urgency urinary incontinence results from ____ and ____, leading to ____

Answer 21

Urgency urinary incontinence results from loss of CNS control and activation of muscarinic receptors on the bladder, leading to spontaneous bladder contraction

Question 22

Describe common surgeries for stress incontinence

Answer 22

Stress incontinence

• Burch colposuspension
• Autologous fascial sing
• Minimally invasive midurethral slings
• Pessary

Question 23

Describe management of urgency incontinence

Answer 23

Urinary incontinence management

• Tier 1: conservative management (bladder retraining, fluid management)
• Tier 2: medications (antimuscarinic, B3 agonist)
• Tier 3: sacral neuromodulation, intravesical onobotulinum toxin

Question 24

Risk factors for fecal incontinence are ____, ____, ____, and ____

Answer 24

Risk factors for fecal incontinence are female, age, poor overall health, and physical limitations

Question 25

Describe the anatomic sites and reflexes involved in anal continence

Answer 25

Anatomic sites and reflexes involved in anal continence

• Rectosigmoid junction: rectosigmoid junction guarding reflex
• Anus: rectoanal inhibitory reflex
• Anal sphincter complex: internal anal sphincter, external anal sphincter

Question 26

Describe the rectosigmoid junction guarding reflex

Answer 26

Rectosigmoid junction guarding reflex

1. GI contents stop in terminal sigmoid colon: reservoir for fluid absorption
2. As filling continues, the rectosigmoid junction pressure increases
3. Pressure builds until a threshold maximum
4. Rectosigmoid junction opens
5. Contents flow from sigmoid into rectum for evacuation

Question 27

Describe the recto-anal inhibitory reflex

Answer 27

Recto-anal inhibitory reflex

• Internal anal sphincter relaxes and samples contents: gas, liquid, solid
• If defecation desired: puborectalis relaxes -> anorectal angle increases -> external anal sphincter relaxes -> stool passes
• If defecation not desired: external anal sphincter contracts -> doubles pressure in anal canal -> puborectalis muscle contracts -> stool is maintained in rectum

Question 28

Compare and contrast the internal anal sphincter and external anal sphincter

Answer 28

Internal anal sphincter and external anal sphincter

• Internal anal sphincter: circular smooth muscle, enteric nervous system, involuntary, contributes 80-85% resting tone
• External anal sphincter: striated muscle, somatic innervation, voluntary, contributes 15-20% resting tone

Question 29

Fecal incontinence can result from ____ or ____

Answer 29

Fecal incontinence can result from functional abnormalities or structural abnormalities

• Functional abnormalities: constipation / fecal impaction, stool characteristics, physical mobility, drugs, cognitive impairment
• Structural abnormalities: anal sphincter muscle injury, rectal abnormalities, pudendal nerve injury, CNS injury

Question 30

____ via ____ or ____ is the most common treatment for fecal incontinence resulting from functional abnormalities

Answer 30

Altering stool consistency via daily psyillium-husk fiber supplement or low dose loperamide prn is the most common treatment for fecal incontinence resulting from functional abnormalities