ANATOMY PELVIC FLOOR

Landmarks Sacro-spinous lig. Sacro-tuberal lig. Arcus tendineus Levator ani muscle Endopelvic fascia Sacro-uterine lig. Pubo-urethral lig. Recto-vaginal septum Vesico-vaginal septum Perineal body

Pelvic Floor Structure Pelvic diaphragm Levator ani Coccygeus Perineal membrane Perineal body

Pelvic Floor structures

Levator Ani Critical component of pelvic support Slow twitch fibers (I) Responsible for normal resting contraction of pelvic floor Keeps UGH closed Fast twitch fibers (II) Reflex contraction of muscle due to  IAP Relaxation During, voiding, defeacation, parturition.

Levator ani muscle M. pubo-coccygeus M. pubo-rectalis - Pubo Vag. - Pubo Peri. - Pubo Analis (Attachement at intersphinc. Groove between int. Ext. Anal sphingter) Levator ani muscle OI M. pubo-rectalis (Forms U – sling behind ano-rectal junction & contributes to ano rectal angle) OI M. ilio-coccygeus (Post. Thinnest arises from ATLA & Is. Spines & join to form the iliococcy. Raphe & Lplate C C

Levator ani muscle M. pubo-rectalis M. pubo-coccygeus M. ilio-coccygeus M. coccygeus

Levator ani muscle M. pubo-rectalis M. ilio-coccygeus

Levator Plate LP formed by union of Iliococcygeus muscle – supportive shelf

Levator Plate

Sagging of Levator Plate Sagging of levator plate due to vertical inclination during valsalva &  UGH

Pelvic Connective tissue Ligament SSL, - STL, - Ant. Long Fascia Parietal (Collagen) allows attachment of muscle to boney pelvis. Visceral (Endo pelvic – Collagen, elastin, adipose) sub peritoneal perivascular CT, loose areolar tissue, allows expansion & contraction of pelvic organ & encases BV, lymphatic, nerves

Sacro-spinous ligament (Coccygeous muscle overlies it)

Sacro-tuberal ligament

GSF – LSF – Sacro-spinous ligament Sacro-tuberal ligament Piriformis, int. pud, inf & sup gluteal vessel, sciatic nerve & sacral. N plexus ( Neuro vasc. Injury during reconst. Surgery & Pud. N. block. LSF – Pudendal neuro vascular bundle & Obt. Int. tendon Sacro-spinous ligament Sacro-tuberal ligament

Pelvic Ligament Sacrospinous Sacrotuberous, & ant. Longitudnal Ligament – suture fixation sites in suspensory procedures. Coopers (IPL) Thickening of periosteum of pubic bone – Burch retropubic bladder neck suspension. Sacrospinous Ligament SSL fixation sutures penetrate the coccy - SSL complex & can lead to injury to L. Ani nerve

Arcus tendineus

Parietal Fascia Arcus tendineus levator. Ani (ATLA) Condensation of fascia overlying medial surface of OBT. INTER NUS muscle, point of origin of L. ANI muscle. Arcus tendineus fasciae pelvis (ATFP) Condensation of fascia over medial aspect of OI muscle & LA muscle, lateral point of attachment of anterior vag. Wall

Delancey – levels of support Lig. Sacro-uterinum

Delancey – levels of support Level – I Suspensory Axis Supports upper 1/3 Vag. by USCL complex, apical support Leads to vault prolapse, Cx descent, cystocoele. Level – II Attachment Axis Middle 1/3 Vag. By L. Ani & ATFP Ant. Vag. Prolapse SUI Level – III Fusion Axis Strongest support Ant. – Urethra Lat.- Pubovag / PM, Post.- P. Body Distal rectocoele, perineal descent, Anal incontinence

Sacro-uterine ligament

Pubo-urethral ligament

Endopelvic fascia komplexes System

Perineal membrane (UGD) Spans opening of ant. Pelvic outlet & supports distal vagina & Urethra Comp. Urethra, Urethro Vag. Sphinc. Muscle, ATFP Distal Vag. IS. PUBIC RAMI Perineal body

Urogenital triangle Anal triangle Symphysis Tuber ossis ischii Os coccygis

Perineal Body Supports distal vag. & rectum – anatomical repair & reapproximation during episiotomy & perineal reconstructive surgery M. Bulbo cav. Sup. Trans Perineal. M Pubo Visc of L. ani RVS Peri. Membrane M. sphincter ani externus

Zones Anterior Middle Posterior EUL / PUL – forms hammock Pubo Cervical Fascia, ATFP, Cx ring Cardinal ligment, USL, RVS, PB Leads to incontinence Leads to paracolpium defect & cystocoele Leads to uterine prolapse Vault Prolapse, enterocoele.

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Lateral defect

Vesico-vaginal septum Recto-vaginal septum

Transobturator Landmarks Adductor longus Urethra Obturator canal SAFE ENTRY ZONE of NEEDLE

Arcus tendineus fasciae pelvis Arcus tendineus M. levator. ani