1. The Secret about “Down There”: Pelvic Floor and Bladder Edition
Harriette M. Scarpero, MD

2. Why is “Down There”a Secret?
We don’t learn much about our bodies in school
Not much attention paid to pelvic health in health related media:
Name one American female celebrity who
conquered urinary incontinence….
Now name one who has conquered obesity….

3. Are We Really in the Dark about the Pelvis?
How many of you know the meaning of ED? (thank you Viagra)
How many of you know the meaning of PFD ?

4. PFD = pelvic floor disorders

5. What is the Pelvic Floor?
It is composed of bony structures:
pubic bone- front
sacrum- back
ischial spines- sides

6. What is the Pelvic Floor?
Muscles:
Puborectalis
Pubococcygeus
Iliococcygeus
(Levator Ani)

7. What is the Pelvic Floor?
Connective Tissue:
Attaches muscles to bone and each other
Carries nerves and blood vessels

8. What is the Pelvic Floor?
Pelvic Organs:
Uterus, ovaries, vagina
Bladder, pelvic ureters
Rectum

9. Anatomy: Bladder
The bladder is a small triangular & muscular organ that is suspended between the abdominal wall and the abdominal cavity.
The vagina sits beneath it, the rectum to its left, and the uterus on top of it.
The kidneys drain into the bladder continuously via long muscular tubes (ureters).

10. Anatomy:The Urethra
The urethra is a muscular tube and the channel out of which urine leaves the body.
A circumferential muscle called the external sphincter sits at the middle of the urethra and helps prevent urine from spilling out.

11. Source: Brubaker L: Pelvic Floor Anatomy in “The Female Pelvic Floor.
Urethral Support
Connective tissue surrounds, divides and supports the urethra on its top, bottom and sides
In the interest of time, I will breifly review some of the interesting aspects of these defects by 1st examining the urethra where anatomy meets function. As depicted in this illistration from Brubakers Pelvic Floor text, one can see the endopelvic fascia attaching laterally to the arcus as the urethropelvic ligament containing the pubocervical and pubourethral fascia.
Source: Brubaker L: Pelvic Floor Anatomy in “The Female Pelvic Floor.

12. Function: Bladder has Two Jobs
The job of the bladder is to provide a low pressure reservoir to store urine (storage).
The bladder must also provide a sufficient muscular contraction to empty urine efficiently (emptying).
2 jobs = storage & emptying

13. Continence = Control What gives us control over our bladder is:
The brain
Properties of the urethra (ligament support, seal of its lining, outer vascular layer compression)
Tone of the urethral sphincter muscle (anatomy)

14. Neuro Control of Bladder Function (overly simplified)
The brain continuously inhibits the bladder
The lower spinal cord acts as a hub for impulses travelling from the brain to the bladder.
Bladder sensation begins in nerve endings in the bladder (stretch/pressure) and can trigger urination.

15. What We Take for Granted
Humans cannot see their bladders.
Humans do not feel their bladders until a critical volume.
The bladder is only partially under our control.
A complex nerve pathway is at work to keep us dry and allow us to urinate
Bad brain = bad bladder
Same for SCI or nerve damage
volume of urine stretches the wall and triggers a desire to urinate

16. Who Can’t Take Her Bladder for Granted
Who Can’t Take Her Bladder for Granted? Women with bladder fistula, spinal cord injury, occupations like fighter pilot, and those with impaired mobility to name a few. Can you think of others?

17. PFD = Pelvic Floor Disorders
Urinary incontinence
Pelvic Organ Prolapse
Fecal incontinence
Sexual dysfunction

18. How big is PFD?
number of US women with > 1 pelvic floor disorder will increase from 28.1 million in 2010 to 43.8 million in 2050
number with UI will increase 55% from 18.3 million to 28.4 million
number with POP will increase 46% from 3.3 to 4.9 million
For fecal incontinence, the number will increase 59% from 10.6 to 16.8 million
Wu, Jennifer M. MD et al, Obstetrics & Gynecology Dec 2009
used population projections from the U.S. Census Bureau from 2010 to 2050 and published age-specific prevalence estimates for bothersome, symptomatic pelvic floor disorders (urinary incontinence [UI], fecal incontinence, and pelvic organ prolapse [POP]) from the 2005 National Health and Nutrition Examination Survey.

19. If You Are Experiencing PFD Symptoms…
Educate your self on PFD
If seeking a specialist, look for one with additional training in pelvic floor disorders and a practice focus in the specialty
Ask lots of questions- don’t just ask the what, ask the why

20. Take Home Message
Pelvic floor disorders are common and becoming more so
They are Quality of Life issues and therefore are important, not the opposite
Much more needs to be done to educate women about pelvic health