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Pelvic Floor Anatomy and Pelvic Organ Prolapse

Tevfik Yoldemir, MD

Marmara University Department of Obstetrics and Gynecology

Division of Reproductive Endocrinology and Infertility

Abdomino-pelvic cavity

• Respiratory diaphragm

• Vertebral column

• Abdominal muscles

• Pelvic floor

• Intra-abdominal pressure

• Visceral weight & Gravity in erect body

• Maintain visceral function

Genital Support

• Pelvic floor- Pelvic visceral attachment to pelvic walls through endopelvic fascia

• Levator ani muscles- a pelvic diaphragm with a cleft in anterior portion

• Urogenital diaphragm connects perineal body to ischiopubic rami

• Bulocavernous, ischiocavernous, sup.transverse perineal, anal sphincter m.

Levator ani muscles

• Pelvic diaphragm composed of levator ani,

coccygeus, obturator internus, and

piriformis muscles

• Levator ani consists of medial

pubococcygeus and lateral iliococcygeus

muscles

• Pelvic diaphragm composed of levator ani,

coccygeus, obturator

The Pelvic Diaphragm The Urogenital Diaphragm

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The Function of Pelvic Floor

• Support pelvic and abdominal organs

during stress of increased abdominal

pressure

• Allow for opening of the pelvic floor to

accommodate excretory functions and

parturition

• Endopelvic fascia and visceral ligaments

contains smooth muscles

The Pelvic Floor Attachments

• Pelvic floor support depends on its

connection to the pelvic bones

• An evolutionary solution for support of visceral organs

• Pelvic floor muscles oppose gravity and

increased abdominal pressures

Prevention of Prolapse Attachments of Pelvic Floor

• Tendinous arch of pelvic fascia-

pubocervical fascia arises

• Tendinous arch of levator ani- levator ani muscles arise

• Pubourethral ligaments

• Pubovesical ligaments

Attachments of Pelvic Floor Pelvic Floor Dysfunction

• A variety of fascial and anatomic defects

• Cystocele, rectocele, uterine prolapse,

enterocele, vault prolapse

• Adequate diagnosis and staging of pelvic

floor dysfunction is essential

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Diagnosis of Pelvic Floor Dysfunction

• Detailed physical examination

• Pelvic ultrasound

• Fluoroscopy of rectum & bladder

• Magnetic resonance imaging (MRI)

Normal Anatomy

The axes of pelvic support

• Three support axes

• Upper vertical axis (cardinal-uterosacral ligament complex)

• Horizontal axis leads to lateral and paravaginal supports– Two platforms pubocervical fascia and

rectovaginal septum

• Lower vertical axis supports the lower third of the vagina, urethra and anal canal

DeLancey’s three levels of vaginal support

• Apical suspension– Upper paracolpium suspends apex to pelvic walls and sacrum

– Damage results in prolapse of vaginal apex

• Midvaginal lateral attachment– Vaginal attachment to arcus tendineus fascia and levator ani

muscle fascia

– Pubocervical and rectovaginal fasciae support bladder and anterior rectum

– Avulsion results in cystocele or rectocele

• Distal perineal fusion– Fusion of vagina to perineal membrane, body and levators

– Damage results in deficient perineal body or urethrocele

Normal anterior anatomy Anterior compartment defects

• Urethral hypermobility

– Distal 4 cm of anterior vaginal wall

– Cotton swab test

– If describes an arc greater than 30 degrees

from horizontal with valsalva

– Results in genuine stress incontinence

• Cystocele

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Cystocele

• Main support of urethra and bladder is the pubo-vesical-cervical fascia

• Essentially a hernia in the anterior vaginal wall due to weakness or defect in this fascia– Midline weakness allows bladder to descend causing central

cystocele

– Tearing of endopelvic fascial connections from lateral sulci to arcus tendinii causes lateral or displacement cystocele

– Detachment of pubocervical fascia from pericervical ring causes a transverse or apical cystocele

• Symptoms include pelvic pressure and bulge or mass in the vagina

Cystocele

• Classified as Grade I, II, or III

• Grade III is prolapse outside the introitus

• Surgical repair is treatment of choice

– Anterior Colporrhaphy

– Paravaginal repair

– Colpocleisis

• Vaginal pessary

Evaluation of a cystourethrocele Anterior defect

Cystocele Bladder neck descent

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Bladder neck descent Cystocele

• Most Gr 1 and 2 cystoceles are asymptomatic

• High grade cystoceles are associated with vaginal buldging, vaginal pressure, dyspareunia, UTI, obstructive voiding, urinary retention

• A high grade cystocele may mask urethral hypermobility and stress incontinence

Physical examination of Cystocele Enterocele

• Simple enterocele

• Complex enterocele- associated with vault

prolapse and anterior or posterior vaginal prolapse

• Cause vaginal pressure, dyspareunia, low

back pain, constipation, symptoms of

bowel obstruction

Physical examination of Vaginal Cuff Prolapse Posterior compartment defects

• Rectocele

• Perineal deficiency– Bulbocavernous and superficial transverse

muscle heads retracted

• Perineal descent– Sagging and funneling of the levator ani

around the perineum such that anus becomes most dependent

– Difficulty with defecation

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Rectocele

• Chiefly a hernia in the posterior vaginal

wall secondary to weakness or defect in

the rectovaginal septum or fascia of

Denonvilliers

• Symptoms include difficulty evacuating

stool, a vaginal mass, and fullness

sensation

• Rectovaginal exam confirms diagnosis

Rectocele

• Damage generally due to excessive

pushing in childbirth or chronic

constipation

• Surgical treatment if symptomatic

– Posterior Colporrhaphy

– Laxatives and stool softeners

• Temporary relief

• Pessary not helpful

Evaluation of a rectocele Rectocele

• Defect of prerectal and pararectal

fascia,and rectovaginal septum

• Present in 80% asymptomatic patients

• Vaginal mass,vaginal pressure,

dyspareunia,constipation

Physical examination of Rectocele Uterine Prolapse

• Laxity of uterosacral ligaments

• May present with vaginal mass,

dyspareunia, urinary retention, back pain

• Grade 4 prolapse is associated with

ureteral obstruction

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Physical examination of Uterine Prolapse

Complete Uterovaginal procidentia

Bladder descent Apical defect

Pelvic Floor Relaxation

• Associated with damage to

pubococcygeus muscle

• The muscle is lax, atrophied, poor tone

• Urinary stress incontinence

• Genital prolapse

• Sexual Problem

• Rectal stasis

Muscular Component of Pubococcygeus muscle

• Large diameter slow twitch type I fibers

predominant- provide static visceral

support

• Fast twitch type II fibers- assists in active

closure of pelvic visceral organs

• 40% of women have lost function or

coordination of this muscle

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The Structures supporting Bladder and Urethra

• Arcus tendineus fascia pelvis

• Levator ani (pubococcygeus muscles)

• Pubovesical muscles or ligaments

• Vaginal muscle attachments to fascia and

levator ani

Physical examination of Pelvic Floor Dysfunction

• General examination- cancer screen, stool OB, urinalysis, physical examination

• Neurological examination- paresthesia of dermatome, bulbocavernous reflex, voluntary contraction of anal sphincter

• Pelvic examination- cystocele, rectocele,uterine prolapse, vault prolapse

• Urinary incontinence by Valsalva maneuver or coughing

Patient position for evaluating pelvic floor defects

Staging of Pelvic Organ Prolapse

• Stage 0 - no prolapse

• Stage I - the most distal portion is >1cm above level of hymen

• Stage II - The most distal portion is <1cm proximal or distal to plane of hymen

• Stage III - The most distal portion is >1cm below plane of hymen, but < total vaginal length - 2 cm

• Stage IV - complete eversion of total length of lower genital tract, the distal portion is > TVL-2 cm, i.e. cervix or vaginal cuff

Evaluation of Pelvic Floor Muscle Function

• Assessing patient’s ability to contract and

relax pelvic muscles separately

• Measuring the force of contraction

• Palpation of thickness of pelvic floor

musculatures

• Electromyography

• Pressure recording

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Measurement of Bladder Base Descent (The Q-tip Test)

Lower Urinary Tract Symptoms caused by Pelvic Organ Prolapse

• Stress incontinence

• Frequency, urgency, urge incontinence

• Hesitancy, weak stream, incomplete

empty

• Manual reduction of prolapse for voiding

• Positional change to start or complete

voiding

Incontinence Assesment

Bowel Symptoms caused by Pelvic Organ Prolapse

• Difficulty with defecation

• Incontinence of flatus

• Incontinence of liquid stool

• Incontinence of solid stool

• Fecal staining of underwear

• Digital manipulation to complete defecation

• Feeling of incomplete evacuation

• Rectal protrusion during or after defecation

Sexual symptoms caused by Pelvic Organ Prolapse

• Vaginal coitus?

• Frequency of vaginal coitus?

• Painful coitus?

• Satisfaction with sexual activity?

• Change in orgasm?

• Incontinence experienced during sexual

activity?

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Local symptoms caused by Pelvic Organ Prolapse

• Vaginal pressure or heaviness

• Vaginal or perineal pain

• Sensation or awareness of tissue

protrusion from vagina

• Low back pain

• Abdominal pressure or pain

• Observation or palpation of a mass

Principles of reconstructive pelvic surgery

• Site-specific repair

• Rebuild weakened endopelvic fascia,

repair fascial tears, and reattach prolapsed tissues to stronger sites

• Goal is a vagina of normal depth, width

and axis

• Denervation or muscle trauma cannot be corrected surgically

Cystocele Repair Cystocele Repair

Burch Lateral defects

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PVR Burch + PDR

Colposuspension

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Rectocele

Rectocele Rectocele

Pelvic Muscle Exercises Medications

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Pessaries