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Levator ani
Diaphragmatic
Ileococcygeus Coccygeus
Pubovisceral
Pubococcygeus Puborectalis
Perineal membrane
Triangular sheet of dense fibromuscular tissue Covers the anterior half of the pelvic outlet Urogenital diaphragm Supports the vagina and urethra
Genital hiatus
Space through which the urethra, vagina, and rectum pass
Continence mechanism
Urethra lies on the anterior vaginal wall Anterior vaginal wall supports the urethra and bladder neck Filling phase:
Inhibition of the parasymphathetic mechanism Urine flows down from the kidney, ureter, to bladder No increase in intravesical pressure due to accomodation (elasticity of bladder) There is stimulation of the sympathetic mechanism by alpha-adrenergic receptors of bladder neck and urethra and additional stimulation by the striated muscle of the sphincter urethra
Continence mechanism
Stress Incontinence
Occurs when the intravesical pressure exceeds the closing pressure on the urethra Childbirth is the most common causative factor denervation of the pelvic wall during trauma of delivery Other causes: congenital weakness of the bladder neck, trauma from other causes, estrogen deficiency, s/p pelvic surgery or radiotherapy Signs & symptoms: leakage of urine when patient coughs, sneezes, runs, jumps, carry Incidence higher in multiparous, older patients
Stress Incontinence
Tests:
Midstream urine to exclude infection or glycosuria Uroflowmetry simple non-invasive test that will exclude voiding difficulties. Patient is asked to urinate into a toilet with flow-measuring device in the pan. Normal flow rate = 15ml/second Bladder outflow obstruction is rare in women Cystometry and videocystourethrography used to assess leakage and exclude detrusor instability. Bladder is filled with radioopaque fluid with urethral catheter and pressure is measured by subtracting rectal pressure from bladder pressure
Pad test
Evaluate incontinence intervention Quantifies urine loss Weigh the pad before using, weigh again after use May not be accurate
Treatment of:
Obesity Chronic cough Chronic constipation Urogenital estrogen deficiency
III. Vaginal wall is directly attached to the surrounding structures (distal part)
Cystocele
occurs when the pubocervical fascia between a woman's bladder and her vagina is torn by childbirth, allowing the bladder to herniate into the vagina 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
MRI of Cystocele
Enterocele
protrusion of the small intestines and peritoneum into the vaginal canal
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
MRI of Enterocele
Rectocele
Defect of prerectal and pararectal fascia,and rectovaginal septum Rectal tissue bulges through this tear and into the vagina as a hernia Present in 80% asymptomatic patients Vaginal mass, vaginal pressure, dyspareunia, constipation
MRI 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
Non-surgical treatment
Physiotherapy Pelvic floor exercises Vaginal cones or pessary Hormone replacement therapy Functional electrical stimulation
Medical Treatment
Anticholinergics Smooth muscle relaxants, cholinergics, local anesthetics
Surgical Treatment
Obliterative
Colpocleisis obliterate the vagina
For those not fit for surgery for those with no desire for sexual function,
Restorative
Colporrhaphy anterior/posterior vaginal repair Abdominal sacral colpopexy Sacrospinous ligament fixation
Surgical Treatment
Compensatory
Repair with mesh Paravaginal repair
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