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Pelvic floor

Pelvic Floor- Sekgoma Memorial Hospital, Botswana country

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Pelvic floor

  2. 2. For obstetrical purposes, the pelvis is divided by the pelvic brim into two parts: – The False Pelvis – The True Pelvis
  3. 3. Levator Ani Muscles  Most important muscle in the pelvic floor  Represents a critical component of pelvic organ support  Physiologically, normal levator ani muscles maintain a constant state of contraction  Provide a solid floor that supports the weight of the abdominopelvic contents against intra-abdominal forces.
  4. 4. Pubococcygeus Pubovaginalis  No direct attachment to urethra, the muscle fibres that attach to vagina are responsible to elevate urethra during a pelvic muscle contraction– contributing to urinary continence Puboperinealis  Draws the perineal body towards pubic symphysis Puboanalis  Elevates the anus All the muscle fibres of levator ani keep the urogenital hiatus narrowed
  5. 5. U-shaped sling  Draws the anorectal junction towards pubis  Contributes to anorectal angle  Part of anal sphincter complex contributing for fecal continence Puborectalis
  6. 6.  Primary support  Arises from arcustendineous and ischial spines  Fibres from either side fuse at anococcygeal raphe forms a supportive shelf on which  rectum  Upper vagina  Uterus rest Iliococcygeus
  7. 7. Perineum  Diamond-shaped area between  Bounded deeply by the inferior fascia of the pelvic diaphragm and superficially by the skin  Boundaries of the perineum are the same as those of the bony pelvic outlet: the pubic symphysis anteriorly, ischiopubic rami and ischial tuberosities anterolaterally, coccyx posteriorly, and sacrotuberous ligaments posterolaterally  An arbitrary line joining the ischial tuberosities divides the perineum into the anterior or urogenital triangle and a posterior or anal triangle
  8. 8. Anterior (Urogenital) Triangle  Content-external genitalia  superficial transverse perineal muscles forms base of triangle  Triangle can be further divided into a superficial and a deep pouch or space by the perineal membrane
  9. 9. Superficial Perineal Space  Closed compartment that lies between Colles fascia and the perineal membrane  Contents-  Ischiocavernosus –maintain clitoral erection  Bulbocavernosus- contributes to the release of secretions from bartholin glands  Superficial transverse perineal muscles- contribute to perineal body  Bartholin glands  Vestibular bulbs  Clitoris  Branches of the pudendal vessels and nerve  Urethra and vagina traverse this space
  10. 10. Deep Perineal Space  space is continuous superiorly with the pelvic cavity  Contents-  Compressor urethrae  Urethrovaginal sphincter muscles  External urethral sphincter  Parts of urethra and vagina  Branches of the internal pudendal artery  Dorsal nerve and vein of the clitoris.
  11. 11. Perineal Membrane  Trilaminar, triangular urogenital diaphragm- main component of the deep perineal pouch  Contents-deep transverse perineal muscles and sphincter urethrae muscles  Clinical Correlation  The perineal membrane attaches to the lateral walls of the vagina approximately at level of the hymen  It provides support to the distal vagina and urethra by attaching these structures to the bony pelvis
  12. 12. Posterior (Anal) Triangle  Contents-  ischioanal fossa  anal canal  anal sphincter complex  branches of the internal pudendal vessels  pudendal nerve  Bounded deeply by the fascia overlying the inferior surface of the levator ani muscles and laterally by the fascia overlying the medial surface of the obturator internus muscles  A splitting of the obturator internus fascia in this area- pudendal or Alcock canal which allows passage of the internal pudendal vessels and pudendal nerve whoose terminal branches supply the vulva and perineum
  13. 13. Ischiorectal Fossa  Fills the majority of the anal triangle  Contents-  adipose tissue  occasional blood vessels  anal canal  anal sphincter complex lie in the center of this fossa  Bounded  superomedially -inferior fascia of the levator muscles  anterolaterally -fascia covering obturator internus muscles and the ischial tuberosities  posterolaterally -gluteus maximus muscles and sacrotuberous ligaments. At a superficial level- bounded anteriorly by the superficial transverse perineal muscles  deeper level, there is no fascial boundary between the fossa and the tissues deep to the perineal membrane  Posterior to the anus, the contents of the fossa are continuous across the midline except for the attachments of the external anal sphincter fibers to the coccyx. The continuity of the ischioanal fossa across perineal compartments allows fluid, infection, and malignancy to spread from one side of the anal canal to the other, as well as into the perineal compartment deep to the perineal membrane.
  14. 14. Anal Sphincter Complex  Contents  Two sphincters  Puborectalis muscle
  15. 15. External Anal Sphincter  Surrounds the distal anal canal  Consists of a superficial and a deep portion  The deep fibers blend with the lowest fibers of the puborectalis muscle  Innervated by branch of the pudendal nerve  Responsible for the squeeze pressure of the anal canal
  16. 16. Internal Anal Sphincter  Thickening of the circular smooth muscle layer of the anal wall  Innervated by autonomic nervous system  Responsible for 80 percent of the resting pressure of the anal canal
  17. 17. Perineal Body  mass of fibromuscular tissue  found between the distal part of the posterior vaginal wall and the anus  formed by the attachment of several structures.  Contributions  Bulbocavernosus  superficial transverse perineal  external anal sphincter muscles At deeper level –  perineal membrane  levator ani muscles and covering fascia  urethrovaginal sphincter muscles  distal part of the posterior vaginal wall  The anterior-to-posterior as well as the superior-to-inferior extents of the perineal body measure approximately 2 to 4 cm.
  18. 18. Clinical Correlation During episiotomy and other vaginal laceration repairs and with pelvic reconstructive procedures, particular attention should be paid to reconstruction of the perineal body in an effort to prevent pelvic organ prolapse and other pelvic floor dysfunction.
  19. 19. Pelvic Floor Innervation  The pelvic diaphragm muscles -second through the fifth sacral nerve roots (S2-5) (POP)  The perineal or inferior surface is supplied by branches of the pudendal nerve (incontinence)
  20. 20.  Uterine organ prolapse  Urinary incontinence  Faecal incontinence  Complete perineal tear Pelvic floor dysfunction
  21. 21. Classification of Perineal Tears • First degree: laceration of the vaginal epithelium or perineal skin only. • Second degree: first degree with muscles and fascia but not the anal sphincter. • Third degree: second degree with involvement of anal sphincter muscles 3a: Less than 50% of external anal sphincter (EAS) thickness torn 3b: More than 50% of EAS thickness torn 3c: Both EAS and internal anal sphincter (IAS) torn • Fourth degree: a third degree tear with disruption of the anal epithelium. • Rectal mucosal tear (buttonhole) without involvement of the anal sphincter is very rare and not included in the above classification.
  24. 24. PREVENTIVE OF COMPLETE PERINEAL TEAR  Delivery of the head by early extension is to be avoided  Controlled delivery of the flexed head in between uterine contractions  Timely and judicious mediolateral episiotomy specially on primigravida, occipito posterior, face , breech or instrumental delivery
  25. 25. Pelvic floor muscle training exercises • Women with urinary stress incontinence • People who have fecal incontinence • A pelvic floor muscle training exercise is like pretending that you have to urinate, and then holding it • You relax and tighten the muscles that control urine flow. It's important to find the right muscles to tighten • The next time you have to urinate, start to go and then stop. Feel the muscles in your vagina, bladder, or anus get tight and move up. These are the pelvic floor muscles. If you feel them tighten, you've done the exercise right
  26. 26. If you are still not sure Women: Insert a finger into your vagina. Tighten the muscles as if you are holding in your urine, then let go. You should feel the muscles tighten and move up and down. Men: Insert a finger into your rectum. Tighten the muscles as if you are holding in your urine, then let go. You should feel the muscles tighten and move up and down. These are the same muscles you would tighten if you were trying to prevent yourself from passing gas. It is very important that you keep the following muscles relaxed while doing pelvic floor muscle training exercises: Abdominal Buttocks (the deeper, anal sphincter muscle should contract) Thigh
  27. 27. PERFORMING PELVIC FLOOR EXERCISES: 1. Begin by emptying your bladder. 2. Tighten the pelvic floor muscles and hold for a count of 10. 3. Relax the muscles completely for a count of 10. 4. Do 10 repititions, 3 to 5 times a day (morning, afternoon, and night). You can do these exercises at any time and any place. Most people prefer to do the exercises while lying down or sitting in a chair. After 4 - 6 weeks, most people notice some improvement. It may take as long as 3 months to see a major change.
  28. 28. Pelvic floor anatomy
  29. 29. Continuous episiotomy suturing