PELVIC FLOOR ANATOMY AND REPAIR.pptx FOR TEACHING

ANATOMY OF CONTINENCE AND
PELVIC SUPPORT.
POP-Q SITE SPECIFIC REPAIR
DR REJI MOHAN,MD,DNB,FELLOW in RM
ASSISTANT PROFESSOR
DEPT. OF REPRODUCTIVE MEDICINE AND SURGERY
SREE AVITTOM THIRUNAAL HOSPITAL
GOVT MEDICAL COLLEGE
THIRUVANANTHAPURAM

My sincere gratitude
Almighty
Teachers
Colleagues
Students
Well wishers
Family
My patients
Organizers-ADVANCES
2019
12/25/2023 drrejimohan@gmail.com 9447044485 2

Surgery is anatomy practically
applied-
Campell

Basic Facts of Anatomy do not Change
But our understanding does…
Evolution is a basic rule
PRIMUM NON CERE
Better understanding of anatomy,sharper diagnosis,targetted surgery ,best
possible surgery with best possible results and less iatrogenic injuries

REMEMBERING THE TITANS
KEGEL
JOHN O DE LANCEY

EVOLUTION
Obstetric Delivery
Pudendal Neuropathy Musculofascial Damage
Decreased levator muscle tone
Decreased urethral and anal muscle tone
Connective tissue stretching
Age, Menopause
Widened levator hiatus Uterovaginal prolapse
Urinary incontinence Anal Incontinence

The Anatomical Components of
Urinary Continence
• Three things are needed for effective urethral closure and
continence at rest and during periods of increased intra-
abdominal pressure :
Properly functioning striated (external)and Smooth
(internal) urethral sphincters
A well-vascularised urethral mucosa submucosa
An intact vaginal support

• Striated external urethral
sphincter (EUS) -Two parts
1.superior, horseshoe- or omega-
shaped part that covers the
urethra and an inferior part that
covers the anterolateral aspect of
the urethra and the lateral aspect
of the vagina.
2.The inferior part is also known
as the urethrovaginal sphincter
Internal urethral sphincter (IUS)
• The smooth muscle is
described completely circular
in females

An intact vaginal support
• Support for the urethra is maintained by the anterior
vagina
These structures provide a hammock-like support system
for the urethra on the anterior wall of the vagina.

Continence mechanism
• The urethral closure by contraction of the EUS and IUS
form the intrinsic continence mechanism.
• The extrinsic continence mechanism is formed by the
pelvic floor muscles, organs, and support structures
surrounding the urethra and urethral sphincter muscles.
• Contraction of the levator ani compresses the urethral
lumen when contraction of the levator ani muscle pulls the
vaginal wall anteriorly against the posterior surface of the
urethra .
So laxity of the vaginal wall
dissipates the effect of contraction of
the LAM and leads to stress urinary
incontinence (SUI)

Anatomy of SUI
• Defects that result in SUI can be repaired surgically with
techniques
Retropubic
colposuspension
Pubovaginal sling
Via minimally invasive RF
bladder neck suspension

Retropubic Colposuspension
• Surgeons use this surgical technique to lift the tissues
near the patient's bladder neck and proximal urethra and
to attach them with sutures to either the ileopectineal line
or the obturator shelf.
• Three variations of this procedure are
 The Burch Approach,
 The Marshall-marchetti-krantz Approach,
 The Paravaginal Defect Repair

Burch procedure
• The Burch procedure has been
the gold standard for surgical
treatment of SUI
• Elevates and fixes the patient's
anterior vaginal wall and
paravesical tissues to the
ileopectineal line of the pelvic
side wall
Vagina and associated structures become a broad sling that supports and
elevates the bladder neck, thus preventing leakage of bladder contents

Pubovaginal Sling
• An artificial support for the
urethra through the use of
a narrow band of either
autologous or synthetic
material, which suspends
the patient's urethra and
helps to prevent leakage of
bladder contents.
• The tension-free vaginal
tape (TVT) procedure
• The transobturator
suburethral tape (TOT)
procedure are the usual
techniques.

RF Bladder Neck Suspension
• Tissue that is targeted with RF thermal energy becomes
denatured and remodeled. This remodeling causes a
decrease in the dynamic compliance of the anatomic
region targeted.
• After RF treatment, elastic fascia is replaced at a
histologic level by stiff fibrotic tissue that improves support
for the bladder neck.

Surgical Anatomy of the Pelvic Floor
Bony Scaffolding
Muscular Supports
of Pelvic Floor
Endopelvic Fascia
and Connective
Tissue Supports.
Supporting Structures

Bony Scaffolding.
• The bones of the pelvis
provide the scaffold on
which the soft-tissue
supports (muscles,
ligaments, and fascia) are
anchored.
• Paired innominate bones
on both sides of the
sacrum comprise the
pelvic girdle.
• The innominate bones are
further divided into the
ileum, the ischium, and
the pubis.

Ischial spine
• The ischial spine provides attachment
• The arcus tendineus fasciae pelvis
• The sacrospinous ligament (SSL)
• The coccygeus muscle

Muscular Supports of Pelvic Floor
• The pelvic floor is a
three-dimensional
structure that functions
as a unit-muscles
ligaments fascia
• The pelvic diaphragm is
composed of the
levator ani muscles
Pubococcygeus
Iliococcygeus a
Coccygeus

Coccygeus
• The coccygeus is also
termed the
ischiococcygeus
muscle
• It is attached medially
to the lateral margins
of the coccyx and fifth
sacral segment and
laterally to the ischial
spine.

lliococcygeus
• The iliococcygeus is
attached to the ischial
spine and the arcus
tendineus levator ani
laterally and the tip of
the sacrum and coccyx
posteriorly.

The pubococcygeus
• The pubococcygeus is
attached to the back of
the pubis, and it
courses lateral to the
urethra in females and
forms a sling around
the vagina, it is termed
the pubovaginalis.
• Fibers of the
pubococcygeus attach
to the perineal body

Pubococcygeus
• The pubococcygeus
compresses the visceral
canals, which cross the
pelvic floor.
• The puborectalis portion of
the pubococcygeus helps
to create the anorectal
angle.
• Contraction of the
puborectalis causes the
rectoanal junction to move
toward the pubic
symphysis, which is
critical in maintaining
fecal continence.
Although the muscles are referred to separately, like other structures of the
pelvic floor, the boundaries are often difficult to delineate and they perform
similar physiologic functions.
Normal defecography

Levator plate
• The posterior levator ani group
(iliococcygeus, pubococcygeus,
and puborectalis muscles) fuses
in the midline and attaches to
the coccyx. The complex formed
by this fusion is the levator
plate, which serves as a
supporting structure for the
upper vagina and cervix,
• Levator plate stabilizes the
upper vagina in a horizontal
plane
• Provides a protective
mechanism and prevents
downward forces onto the
perineal body

Urogenital diaphragm
• Beneath the pelvic diaphragm is
the diamond-shaped
• The boundaries are the pubic
symphysis anteriorly, the tip of
the coccyx posteriorly and
laterally, and the ischiopubic
rami on either side.
• It can be further divided
anteriorly and posteriorly by
imagining a line between the
ischial tuberosities.
• This results in the urogenital
triangle anteriorly and the
anorectal triangle posteriorly.

Perineal membrane
• The deep transversus perinei muscle
or perineal membrane, is contained by
the urogenital triangle, in which the
urethra and vagina traverse.
• The perineal membrane in females has
a dorsal and ventral region
• The ventral region is contiguous with
the paraurethral and paravaginal
connective tissues. This portion
contains the compressor urethrae and
urethrovaginal sphincter muscles of the
distal urethra
• The dorsal region is attached to the
perineal body and the lateral wall of the
vagina via the ischiopubic rami..

• External to the
urogenital triangle are
bulbospongiosus,
ischiospongiosus, and
superficial transversus
perinei.
• The hymen is located
just inside of the labia
minora

Anorectal triangle
• The anorectal triangle
contains the external
anal sphincter, which
attaches to the
anococcygeal ligament
and fuses to the
superficial transversus
muscle.

The urogenital hiatus
• The urogenital hiatus is the
opening within the levator ani
muscle through which the urethra
and vagina pass. Because the
rectum is attached directly to the
muscles at this level, it is not
within the urogenital hiatus.
• The hiatus is supported anteriorly
by the pubic bones and levator
ani muscles and posteriorly by
the perineal body and external
anal sphincter.
• The urogenital hiatus elongates
and descends with POP.

Endopelvic Fascia and Connective Tissue Supports.
• The endopelvic fascia is a
network of fibromuscular
tissue located between
the peritoneum and the
levator muscles.
• The parametrium (broad,
cardinal, and uterosacral
ligaments) attach the
uterus and upper vagina
to the pelvic sidewall.
• The paracolpium (the
arcus tendineus levator
ani and the ATFP) attach
the vagina to the pelvic
sidewalls.

Endopelvic fascia
• Three parts: parietal,visceral and deep
• Parietal : covers muscles namely
obturator,levator,coccygeus(sacrospinous ligament) and
pyriformis
• Visceral covers all the pelvic organs except tubes and
ovaries-no supportive function but distensibility
• Deep : is the most important and in continnum with the
retroperitonial connective tissue.

Deep endopelvic fascia
• 6 ligaments-uterosacrals,cardinals and pubocervicals
• 2 septa-pubocervical provides support to ant.vaginal wall
and bladder
• Rectovaginal septum stabilises and suspends rectum and
perinium
• 1 ring-pericervical-connects all the components of EPF-
stabilies cervix @the level of ischial spines
• Main function is suspends cervix away from UG hiatus
places vagina over levator plate thus acts like a flap valve
closes vagina against the anococcygeal raphae when
there is pressure from above.

Uterosacrals
• S234 to cervix @ 5’ 7’O clock
• Primary proximal suspensory element
Cardinals
• Lateral abd and pelvic wall to cervx@
3&9’O clock
• Lateral stabilisation @the level of
ischial spines
Pubocervicals
• Pubic ramus and AFTP to cervix @ 11
& 1’O clock
• Cervical stabilisation and ant.vaginal
wall support

De Lancey
• The supports of the vagina and conceptually divided them
into three parts according to the region of vaginal support

LEVEL I-Suspensory axis
• The cardinal-uterosacral
ligament complex
• These structures
supports the uterus and
cephalad 2 to 3 cm of
the vagina
• The fibers are primarily
vertical in their
orientation and are the
longest fibers of the
endopelvic fascia.

Level II-Attachment axis
• Level II support is at the midvagina.
• These fibers are shorter than level I
support but longer than those at
level III.
• The orientation of the attaching
fibers is lateral, and they are denser
than the cardinal-uterosacral
complex.
• The endopelvic fascia splits at this
level to encompass the bladder and
urethra such that the abdominal leaf
is still named the endopelvic fascia
and the vaginal leaf is termed the
pubocervical (or perivesical ) and
periurethral fascia.
• Posteriorly, the endopelvic fascia,
which attaches laterally to the
superior fascia of the levator ani
muscles, is the rectovaginal fascia.

Level III-Fusion axis strongest support
• Level III support of the vagina
starts at the introitus and
extends 2 to 3 cm above the
hymenal ring.
• In this most distal location there
is no intervening paracolpium
and the vagina is fused directly
to the urethra and is embedded
in the connective tissue of the
perineal membrane (urogenital
diaphragm.)
• Laterally, it blends into the
medial margins of the levator ani
muscles, and posteriorly it
blends into the perineal body.

Posterior and anterior suspensory axis
Perineal body
Rectovaginal
septum
Pericervical
ring
Uterosacral
ring
Presacral
periosteum

POP-Q
Aa

POP-Q
Aa
Ba
Aa-3cm proximal to hymen
Ba-Most distal portion of upper AW
C-Most distal edge of cervix or vault
D-Posterior fornix
Ap-Post vaginal wall 3cm proximal to hymen
Bp-Most distal portion of upper PW
Gh-From middle of ext urthral meatus to
post.midline hymen
Pb- Posterior margin of GH to middle of anal
opening
Tvl- Depth of vagina when point D or C is
reduced to normal

POP-Q
C
Ba
Aa

POP-Q
D
C
Ba
Aa

POP-Q
Bp
D
C
Ba
Aa

POP-Q
Ap
Bp
D
C
Ba
Aa

POP-Q
Ap
Bp
D
C
Ba
Aa
tvl

POP-Q
gh Ap
Bp
D
C
Ba
Aa
tvl

POP-Q
pb
gh Ap
Bp
D
C
Ba
Aa
tvl

Three by three grid
(Quantitative description of POP)
Anterior wall
Aa
Anterior wall
Ba
Cervix or cuff
C
Genital hiatus
gh
Perineal body
pb
Total vaginal
length
tvl
Posterior wall
Ap
Posterior wall
Bp
Posterior fornix
D

Staging in POP-Q
 Stage 0
 All points 3cm above hymen and
points C &D are above the
hymen equal to or within 2cm of
total vaginal length
 Stage I
 All points >1cm above hymen
(value ≤-1)
 Stage II
 Leading edge of prolapse within
1cm of hymen (value ≥ -1, ≤+1)
 Stage III
 Maximum prolapse protrudes
≥1cm beyond hymen, but< 2cm
of the total vaginal length (value
≥+1 to [tvl-2])
 Stage IV
 Maximal prolapse protrudes to
within 2 cm of total vaginal length
(≥ [tvl -2])
St
0
All points 3cm above hymen
and points C &D are above the
hymen equal to or within 2cm of
total vaginal length
Stage
1
All points >1cm above hymen
(value ≤-1)
Stage
2
Leading edge of prolapse within
1cm of hymen (value ≥ -1, ≤+1)
Stage
3
Maximum prolapse protrudes
≥1cm beyond hymen, but< 2cm
of the total vaginal length (value
≥+1 to [tvl-2])
Stage
4
Maximal prolapse protrudes to
within 2 cm of total vaginal

Site-Specific Defects by Compartment
(Identification)

Support by Compartment-anterior and
repair
The major components
are
• The endopelvic fascia
• The ATFP
• The levator ani
muscles
• At this level, the
endopelvic fascia
surrounds the vagina
and attaches to the
ATFP bilaterally.
• Two types of defects
can lead to cystoceles.
• Central- attenuation or
separation of the
pubocervical fascia
• The lateral cystocele
is as a result of -
Detachment of the
pubocervical fascia
and the pubourethral
ligaments to the ATFP

Correction
• Kelly anterior
colporrhaphy -repairing
the pubocervical fascia
with plication sutures
• Vaginal Paravaginal
Repair-reattaches the
pubocervical fascia to
the ATFP.

Apical Compartment
• Apical compartment
defects involve a
disruption in the
uterosacral-cardinal
ligament complex.
• This defect may lead
to prolapse of the
uterus, the vaginal cuff
after hysterectomy,
and enterocele.
• VH and PFR
• Pexy
• Enterocele correction

Enterocele correction
• Waters described four types of
enteroceles by cause:
• Congenital enteroceles occur
either from the failure of the
peritoneum to fuse with the perineal
body or from reopening of
previously fused structures.
• Pulsion defects occur with
increased intra-abdominal
pressures
• Traction enteroceles occur by a
pulling of the vaginal epithelium
from other prolapsing organs.
• Iatrogenic enteroceles are created
when a surgical procedure is
performed that alters the normal
vaginal axis or when the
pubocervical fascia and the
rectovaginal septum are not
reapproximated after hysterectomy

Culdoplasty

Posterior Compartment
• Defects in the rectovaginal fascia in the
form of either attenuated fascia or site-
specific tears will result in herniation of the
rectum and sometimes the small bowel into
the vagina.
• Richardson 1993
• High rectocele-Defects in the cardinal-
uterosacral ligament complex
• Mid rectocele-Loss of support in the
midvagina from the lateral attachments to
the arcus tendineus fascia rectovaginalis
• Low rectocele- Separation of the perineal
body at the level of the rectovaginal fascia
results in perineal descent or a low
rectocele.
• If perineal body detachment is left
untreated at the time of rectocele repair, a
perineal rectocele can occur in which the
rectum bulges into the perineal body,
termed a perineal rectocele

POSTERIOR COMPARTMENT
REPAIR-KEY POINTS
• Levator plication not advised
• Mesh to be used with caution
• Repair of perineal body by recreating approximation of
rectovaginal connective tissues to the central tendon of
perineum
• Counsel regarding persistence of constipation even after
rectocele correction

WHATS NEW

To conclude
• The pelvic floor is a complex web of muscle
and fascia and is important in maintaining
continence and supporting the pelvic organs
• The pelvic floor plays a major role in many
conditions such as pelvic organ prolapse,
stress urinary incontinence, urgency and
urge incontinence, and pelvic pain.
• AIM for accurate diagnosis and tailored
treatment programs.

SURGERY SHOULD FIT THE PATIENT AND THE
PATIENT SHOULD NOT FIT THE SURGERY
-MICHAEL SMITH
THANK YOU AND GOD BLESS YOU

PELVIC FLOOR ANATOMY AND REPAIR.pptx FOR TEACHING

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