Pelvic Organ Prolapse

I. Pelvic Osteology N. 486 •

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3 bones of the pelvis/hip socket*: o ilium o ischium (ischial spines) o pubic bone important anatomical structures/landmarks* o (iliac crest) o greater & lesser sacrosiatic notch/foramen  sacrospinous ligament and sacrotuberous ligament form the greater sciatic foramen and lesser sciatic foramen o obturator foramen

N. 352 •

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false/greater pelvis o above white line (iliopectineal line) o begins at pelvic inlet which extends from top of pubic bone to the sacrum true/lesser pelvis o below white line (iliopectineal line) o below pelvic inlet to pelvic outlet from inferior part to coccyx at first prenatal visit to determine baby’s position, etc.

N. 353 •

false pelvis borders o anterior abdominal muscles o spine o posterior abdominal muscles

N. 157 N. 354 & handout •

sex differences of pelvis*

Pelvic inlet and outlet Pelvic cavity Public arch

Female Longer transverse & ant./post. diameters Divergent More than 90 degrees –

Male Shorter diameters (heart shape inlet) Convergent 90 degrees or less

pull down and up •

pelvic types o gynecoid o android o anthropoid o platypelloid

1. Gynecoid a. Most common female shape 2. Android a. Most common male shape 3. Anthropoid a. Long A-P diameter and short transverse diameter. b. Higher risk for occiput posterior deliveries (babies face up). 4. Platypelloid a. Very dysfunctional pelvis when it comes to obstetrics b. Gestational age dependent c. Often require C-section for delivery II. Pelvic Musculature ** Netter flashcards** •

extrinsic m.m.* o piriformis & obturator m.m.  where exit N. 356, 357, 358, 359, 379 •

urogenital diaphragm o AKA: deep space/pouch/envelope* o COMPONENTS:*  female ureter to vagina  not rectum! o 2 MUSCLES*  sphincter urethra m. • with urethra and pudenal n., a. and v.  deep transverse perineal m. o FASCIA:  Both sides  Superior fascia*  inferior fascia* • aka perineal membrane

o structures lying on top (outside) of the inferior fascia of the UG diaphragm are in the superficial pouch/space/envelope  extends up along anterior abdominal wall and medial aspects of the inner thigh • continuous with scarsis fascia  components:* • superficial transverse perineal m. • ischiocavernous m. • bublocavernous m. • greater vestibular glands • pudenal a., n., and v. • vestibular bulb (venous plexus)  worry when straddle injuries/assault •

pelvic diaphragm o creates 2 SPACES*  visceral space (aka - intrapelvic space)  ischiorectal fossae o intrinsic muscles make up the pelvic diaphragm o COMPONENTS:*  Levator ani group • Pubococcygeus muscle • Puborectalis muscle (sling) • Iliococcygeus muscle  Coccygeus (aka ischiococcygeus) • (not part of levator ani group but part of pelvis diap) o INNERVATION:  Pelvic nerves S3-5 o FUNCTION:  Support of the pelvic viscera  Resisting inferior thrust with increasing intra-abdominal pressure  Raising the pelvic floor during bodily functions  Causing internal restitution of the fetal head during the first and second stage of labor o **Incomplete anteriorly  Laxity can occur – creating prolapse of the pelvic viscera

III. Vascular Pelvis

N. 402 • • •

Common iliac artery bifurcates – internal iliac and external iliac a.a. A lot of variation!!! Especially the veins! Subdivisions into the anterior and posterior division of the internal iliac a. (aka hypogastric a.) o Anterior division  Umbilical a. ( which becomes medial umbilical ligament)  Vesicular branches  Vaginal branches  Uterine a. • **ureter runs under** • water running under bridge  Inferior gluteal a.  Internal pudenal a.  Middle rectal a.  Obturator a. o Posterior division  Iliolumbar a.  Lateral sacral a.  Superior gluteal a.

N. 400 • • •

Blood vessel orientation in abdomen vs. pelvis Abdomen o medial to lateral Pelvis o Lateral to medial

N. 404 IV. Neural Pelvis N. 413

nerve obturator n.

neural segment L2-4

lumbosacral trunk

L4-5

muscles obturator internus adductors of thigh

sacral plexus

L4-5 & S2-4

sciatic n.

L4-S3

***pudenal n.

S2-4

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pelvic diaphragm & other structures main sensory to the perineum & surrounding

Labor T11-T12 and probably L1 Sympathetic/parasympathetic innervation

V. Visceral Pelvis N. 371, 362, 370, 366, 392, 393, 394, 398, 399, 369 •

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Uterus o 3 parts  cervix, body and fundus o visceral peritoneum is thrown up on the uterus and goes behind the uterus o ligaments  broad ligament • fold of visceral peritoneum • Anterior and posterior leaf  Supsensory ligament of uterus  Round ligament is anterior to the fallopian tube • Be sure tie off tubes and not the ligament • Sampson’s a. is with the round ligament • courses laterally through the inguinal canal to the labia majora  Uterosacral ligament • Aka – sacrouterine/sacrocervical ligament • Extends from cervix to sacral area • Supports the uterus and vagina • Ovary and fallopian tubes o Fallopian tubes are anterior to the ovaries & round ligament is anterior to tubes o Relationship to broad ligament Ovarian cyst o Attachment to:  uvoovarian  infundibular

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blood supply o uterine a. – primary source of blood to the uterus, bifircuates:  superior branch  inferior branch (uterovaginal a.)  uteroovarial a. anastomosis impt in hemorrhaging 3. Blood supply a. Uterine a. – primary source of blood to the uterus 1. Bifurcates at the level of the uterus into: a. Descending branch 1. Anatomoses with vaginal a. b. Ascending branch 1. Joins the ovarian artery to become the uteroovarian a.

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anatomy of the bladder  smooth & rough parts  detrusor m.  trigone of bladder • urethra • 2 uteric orifces  membranous portion passes through urethra in UG diaphragm

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rectum o distal 1/3 not covered by peritoneum o not part of UG diaphragm o smoother in appearance o indentations/invaginations of musculature – pseudo valves  peristalis impt with holding stool in place

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pelvic diaphragm o external anal sphincter – control is voluntary o (vs. internal anal sphincter which is involuntary) o deep, superficial and subcutaneous components

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how to maintain contents inside rectum o intact pelvic diaphragm (deep, superficial and subcutaneous parts)

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blood supply o sigmoid a. – canal inferior hemorrhidal a. o anterior division off of iliac a. where as superior rectal a. off of inf. Epigastric

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support of the pelvis o MAIN – pelvic diaphragm  If support is lost, the urethra can become prolapsed out into the vagina o 2nd- transverse cervical ligament (aka Machendrot’s/cardinal)  contains: • ureter, uterine a., and uterine v. o uterosacral ligament o round ligament provides very little support

VI. Lymphatic Drainage of Pelvis and Perineum N. 407, 406 • • • • •

superficial inguinal lymph nodes go into the deep inguinal then to the femoral nodes pelvic lymph nodes o internal iliac, obturator, external iliac, periaortic, etc. transition is dependent on location and depth of invasion (neoplasm/infection) Bartholw’s gland Nodes are named to where the blood vessels are located

VII. Innervation of Female Reproductive Organs N. 415, 414, 413 •

Pelvic spanchnic n.n.

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1st stage of labor o T11, T12, L1 nd 2 stage of labor o pudenal n. S2, 3, 4  hypogastric plexus/ • inf. Hemorrodial o superior and inferior branches (to deep pouch/UG diaphragm)

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VIII. Clinical Correlates • • • •

apesiodamies/tear if see fat, are in ischiorectal fossa 1st degree

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o skid mark o little abrasion around mucosa nd 2 degree o involves vaginal mucosa and submucosa of perineal body rd 3 degree o rectal sphincter involvement, retracts backward o only see perirectal wall, not inside of rectum o stool incontinence th 4 degree o when posterior wall of rectum is visible o passing gas through vagina

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right/left mediolateral o involving vaginal mucosa, submucosa, and bulbosponginosum o do this to stay out of the anal-rectal region

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male superficial pouch injury o scrotum can be involved

Pelvic Floor prolapse • • •

pelvic floor musculature ligaments not holding well, organs start to protrude – pelvic organ prolapse overactive bladder decreases quality of live significantly