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GYNECOLOGY
TOPIC CONFERENCE: UROGYNECOLOGY
Dr. Virgilio R. Oblepias
OBJECTIVE: - Identify the functional anatomy of the pelvic floor
muscles and ligament

Group members:Ahmed firoz

Alam sajid
Aman ajit kumar
Aquino, Winnie
Ashish kumar
Atienza, Philip
Avinash
Behera shibasis
Bernardo, noana
Biay, nina lou
Chen, chih-ju
Dhada sumanta kumar

SUBMITTED BY
GROUP 1

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Pelvic Floor
Pelvic Diaphragm
The pelvic diaphragm is a funnel-shaped fibromuscular partition that forms the
Primary supporting structure for the pelvic contents
It is composed of the levator ani and the coccygeus muscles, along with their superior and
inferior fasciae. It forms the ceiling of the ischiorectal fossa.

Levator Ani
The levator ani muscles are composed of the pubococcygeus (including the
pubovaginalis, pubourethralis, puborectalis, and the iliococcygeus)
It is a broad, curved sheet of muscle stretching from the pubis anteriorly and the coccyx
posteriorly, and from one side of the pelvis to the other. It is perforated by the urethra,
vagina, and anal canal. Its origin is from the tendinous arch extending from the body of the
pubis to the ischial spine. It is inserted into the central tendon of the perineum, the wall of
the anal canal, the anococcygeal ligament, the coccyx, and the vaginal wall.
The levator ani assists the anterior abdominal wall muscles in containing the
abdominal and pelvic contents.
It supports the vagina, facilitates defecation, and in maintaining fecal continence. During
parturition, the levator ani supports the fetal head while the cervix dilates. The levator ani is
innervated by S3 to S4, the inferior rectal nerve.

Muscles of the Pelvic Floor (Pelvic Diaphragm):

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Pelvic Floor
Pelvic Diaphragm
Levator Ani
Pubococcygeus
Pubovaginalis
Puborectalis

From the
tendinous arch,
extending from
the body of the
pubis to the
ischial spine

Central tendon
of the
perineum; wall
of the
anal canal;
anococcygeal
ligament;
coccyx;
vaginal wall

Assists the
anterior
abdominal wall
muscles in
containing the
abdominal and
pelvic contents;
supports the
posterior wall of
the vagina;
facilitates
defecation; aids
in fecal
continence;
during
arturition,
supports the
fetal head
during cervical
dilation

S3S4; the
inferior rectal
nerve

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Coccygeus

Ischial spine and

sacrospinous
ligament

Lateral margin
of the fifth
sacral vertebra
and coccyx

Supports the
coccyx and pulls
it anteriorly

S45

Deep transverse
perineal

Medial aspect of
the ischiopubic
rami

Steadies the
central perineal
tendon

S2S4; perineal
nerve

Sphincter
urethrae

Medial aspect of
the ischiopubic
rami

Lower part of
the vaginal wall;
anterior
fibers blend with
those
of the sphincter
urethrae
Urethra and
vagina

Compresses the
urethra

S2S4; perineal
nerve

Origin
Anterior aspect
of S2
S4 and
sacrotuberous
ligament

Insertion
Greater
trochanter of
the femur

Innervation
S1S2; forms a
muscular bed
for the
sacral plexus

Obturator
internus

Superior and
inferior pubic
rami

Greater
trochanter of
the femur

Iliopsoas

Psoas from the

lateral
margin of the
lumbar
vertebrae;
iliacus from
the iliac fossa

Lesser
trochanter of
the femur

Action
Lateral rotation,
abduction of
thigh in flexion;
holds head of
femur in
acetabulum
Lateral rotation
of thigh in
flexion;
assists in
holding head of
femur in
acetabulum
Flexes thigh and
stabilizes trunk
on thigh; flexes
vertebral
column or
bends it
unilaterally

Muscles
Inferior to the
Pelvic Floor
Urogenital
Diaphragm

Lateral Pelvic Wall

Piriformis

(L5, S1)
Obturator
internus nerve

(L1L3)
Psoasventral
rami of lumbar
nerve (L2 L3)
Iliacus-femoral
nerve contains
the
lumbar plexus
within its muscle
body

Urogenital diaphragm
Definition:
Layer of the pelvis that separates the deep perineal sac from the upper pelvis. Lying
between the inferior fascia of the urogenital diaphragm and superior fascia of the urogenital

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diaphragm. Constituents Deep perineal muscles- sphincter urethrae and deep transverse
perinei. Sup. and inf. Fascia of UGD.

Boundaries of the Perineum:

Anterior - pubic symphysis (PS) Posterior - coccyx (C) Lateral - ischial tuberosities (IT)
Anterolateral - ischiopubic ramus (IPR) Posterolateral - sacrotuberous ligament.

Cutaneous supply:
Dorsal nerve of penis Ilioinguinal n. and genital br. of genitofemoral n. Perineal branch of
post. Cut. N. of thigh Post.scrotal(labial) n. Perineal br. of pud. N.

Female Urogenital Triangle:

After Colles' fascia is removed; identify the structures in the superficial perineal space
ischiocavernosus muscle overlying the crus of the clitoris bulbospongiosus muscle overlying
the bulb of the vestibule perineal body (central tendon) urethral opening vaginal opening.

Structures piercing perineal membrane:

Urethra Vagina A. and N. to bulb of the vestibule Deep A. of clitoris Dorsal A. of clitoris Post.
labial N.s and vessels Br.s of perineal nerve.

Deep perineal space:

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B/w sup. And inf. Fascia of UGD. CONTENTS: Urethra with sphincter Dorsal nerve of clitoris
Muscular br. Of pudendal n. crus of the clitoris bulb of the vestibule greater vestibular gland
(deep to the bulb)

PERINEAL BODY (central tendon of perineum):

Pyramidal fibromuscular mass in the mid-line of the perineum at the junction between the
urogenital triangle and the anal triangle. In males, it is found between the bulb of penis and
the anus. In females, is found between the vagina and anus.

ATTACHMENTS:
External anal sphincter. Bulbospongiosus. Superficial transverse perineal muscle. Anterior
fibers of the levator ani. Fibers from external urinary sphincter. Deep transverse perineal
muscle.

STRUCTURES CUT WHILE ENTERING PELVIC CAVITY THRU PERINEUM:

Skin fatty superficial fascia (Camper's layer) membranous fascia (Scarpa's layer or Colles'
fascia in perineum) superficial perineal space inferior fascia of urogenital diaphragm deep
transverse perineus muscle superior fascia of urogenital diaphragm anterior extension of
ischiorectal fossa inferior fascia of levator ani levator ani superior fascia of levator ani pelvic
fascia peritoneum pelvic cavity .

Disorders of the pelvic support

Pelvic floor (pelvic support) disorders involve a dropping down (prolapse) of the bladder,
urethra, small intestine, rectum, uterus, or vagina caused by weakness of or injury to the
ligaments, connective tissue, and muscles of the pelvis. Pelvic floor disorders occur only in
women and become more common as women age.
The pelvic floor is a network of muscles, ligaments, and tissues that act like a hammock to
support the organs of the pelvis: the uterus, vagina, bladder, urethra, and rectum. If the
muscles become weak or the ligaments or tissues are stretched or damaged, the pelvic
organs or small intestine may drop down and protrude into the vagina.
Pelvic floor disorders usually result from a combination of factors. Being pregnant and
having a vaginal delivery may weaken or stretch some of the supporting structures in the
pelvis. The risk increases with each delivery. The delivery itself may damage nerves, leading
to muscle weakness. The risk of developing a pelvic floor may be less with a cesarean
delivery than with a vaginal delivery.

Pelvic organ prolapsed

Pelvic organ prolapse is a general term used to describe a group of problems. Prolapse
happens when one or more of the organs in the pelvis (the bladder, uterus, small intestines
or rectum) fall into the vagina. Different terms describing prolapse include cystocele or
dropped bladder; uterine prolapse or dropped uterus; rectocele or enterocele.

Factors promoting prolapse

1. Erect posture causes increased stress on muscles, nerves and connective tissue
2. Acute and chronic trauma of vaginal delivery
3. Aging

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4. Estrogen deprivation
5. Intrinsic collagen abnormalities
6. Chronic increase in intraabdominal pressure
A. heavy lifting
B. coughing
C. constipation

Anterior compartment defects

A. 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

B. Cystocele
1. Main support of urethra and bladder is the pubo-vesical-cervical fascia
2. Essentially a hernia in the anterior vaginal wall due to weakness or defect in this
fascia
a. Midline weakness allows bladder to descend causing central cystocele
b. Tearing of endopelvic fascial connections from lateral sulci to arcus tendinii
causes lateral or displacement cystocele
c. Detachment of pubocervical fascia from pericervical ring causes a
transverse or apical cystocele
3. Symptoms include pelvic pressure and bulge or mass in the vagina
4. Classified as Grade I, II, or III
5. Grade III is prolapse outside the introitus
a. Surgical repair is treatment of choice
b. Anterior Colporrhaphy
c. Paravaginal repair
d. Colpocleisis
(I)

Vaginal pessary

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C. Cystourethrocele
A cystourethrocele is similar but develops when the upper part of the urethra (bladder neck)
also drops down. Women with either of these disorders may have stress incontinence
(passage of urine during coughing, laughing, or any other maneuver that suddenly increases
pressure within the abdomen) or overflow incontinence (passage of urine when the bladder
becomes too full). After urination, the bladder may not feel completely empty.

Posterior compartment defects

A. Rectocele
1. Chiefly a hernia in the posterior vaginal wall secondary to weakness or defect
in the rectovaginal septum or fascia of Denonvilliers
2. Symptoms include difficulty evacuating stool, a vaginal mass, and fullness
sensation
3. Rectovaginal exam confirms diagnosis
4. Damage generally due to excessive pushing in childbirth or chronic
constipation
5. Surgical treatment if symptomatic
a. Posterior Colporrhaphy
b. Laxatives and stool softeners
(I)

Temporary relief

(II)

Pessary not helpful

Evalua
tion of
a
rectoc
ele

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B. Perineal deficiency
Bulbocavernous and superficial transverse muscle heads retracted
C. Perineal descent
1. Sagging and funneling of the levator ani around the perineum such
that anus becomes most dependent
2. Difficulty with defecation

Apical defects
A. Uterine prolapse
1. Normal cervix located in upper third of vagina
2. Degree of prolapse measured by position of cervix at maximum
intraabdominal pressure, without traction
3. Complete uterovaginal prolapse is called procidentia
4. Weakness of endopelvic fascia and detachment of cardinal and uterosacral
ligaments
5. Complains of severe pelvic or abdominal pressure, bulge or mass, and low
back pain
6. Surgical management includes hysterectomy and vaginal cuff or apex
suspension
a. Estrogen replacement important
B. Prolapse of the Vagina
In prolapse of the vagina, the upper part of the vagina drops down into the lower part, so
that the vagina turns inside out. The upper part may drop part way through the vagina or all
the way through, protruding outside the body and causing total vaginal prolapse. Prolapse of
the vagina occurs only in women who have had a hysterectomy.
C. Enterocele
1. A true hernia of the rectouterine or cul-de-sac pouch (pouch of Douglas) into the
rectovaginal septum

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2. Descent of bowel in a peritoneum-lined sac between posterior vaginal apex and
anterior rectum
Pulsion enterocele is filled with bowel and distended by abdominal
pressure
3. Can occur anteriorly as well
Generally after a surgical change in vaginal axis
4. Symptoms of fullness and vaginal pressure or palpable mass
5. Bowel peristalsis confirms diagnosis
6. Commonly found in association with other defects
7. Surgical approach
a. Vaginal
b. Abdominal
i. Laparoscopic
8. Ligation of hernia sac and obliteration of the pouch of Douglas