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Institutt for medisinske basalfag
Pelvic Floor The Pelvic Floor Per Brodal Institutt for medisinske basalfag Universitetet i Oslo 9th Semester 2008
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Abdominal Press (bukpressen)
Pelvic Floor Abdominal Press (bukpressen) Why need for raising the abdominal pressure? Expulsion of various sorts (coughing, defecation, voiding, vomiting, labor) Support of the vertebral column – using the adominal press, reduces the pressure load on intervetrabral discs (lumbar) by 30-50% Firm support for the arms Pelvic floor muscles Pelvic floor muscles Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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The Pelvic Outlet –How is it best Closed?
Pelvic Floor The Pelvic Outlet –How is it best Closed? Conflicting needs: Firm closure, yet allow passage of large ”objects ” P. Brodal 2008
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Pelvic Floor Three Layers: Diaphragma pelvis: Levator ani muscle and associated fascia Diaphragma urogenitale: musculus transversus perinei (profundus) and fascia Striated sphincter muscles The levator ani stems from the depressor cauda of tailed animals, whereas the muscles of the urogen. Diaph. Originate from the sphincter cloaca (the same concerns the ischocavernosus and bulbospongiosus muscles). P. Brodal 2008
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The Male Perineal Region
Pelvic Floor The Male Perineal Region What is the perineum? Andreassen: Regio perinealis: the region outside the pelvic outlet The pelvic floor = perineum (anatomically) In the clinics perineum usually denotes the area between the vulva and the anus in women Benninghoff: somewhat different description – male between the anus and the root of the scrotum POINT: do not assume that all mean the same by perineum! P. Brodal 2008
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Levator Ani from the Inside
Pelvic Floor Levator Ani from the Inside Tendineous arch of levator ani Iliococceygeus Piriformis Puborectalis Levator hiatus Pubococcygeus Iliococceygeus Empasize that the muscles are less impressive in relality, especially in elderly people – often replaced by connective tissus – e.g. the coccygeus and the ischicavernosus in the female Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Levator Ani from the Outside (Urogential Diaphragm Removed)
Pelvic Floor Levator Ani from the Outside (Urogential Diaphragm Removed) Puborectalis Levator hiatus Pubococcygeus Iliococceygeus p. 157 Emphasize the formation of slings Not necessary to learn the separate names, but rather logical Coccygeus Coccyx Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Levator Ani cont’d Obturator internus muscle with fascia
Pelvic Floor Levator Ani cont’d Obturator internus muscle with fascia Point to the attachment of the levator along the tendineous arch Shows clearly that levator ani is a misnomer – it does not lift the anus Tendineous arch Levator ani Muscles of the urogenital diaphragm P. Brodal 2008
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Levator Ani Muscle, The urogenital Muscles, and the Ischioanal Fossa
Pelvic Floor Levator Ani Muscle, The urogenital Muscles, and the Ischioanal Fossa Internal obturator muscle Gluteus maximus p. 496, 5.7A Illustrates the form of the levator ani, and also the topgraphy of the ischianal fossa, and how it is covered dorsally-inferiorly by the gluteus maximus muscle. The fat pad in the ischioanal fossa can easily be moved during defecation and especially important – during labor Traversed bu the pudendal nerve and vessels (in Alcock’s canal) close to the lateral wall. Levator ani Ischianal fossa Thieme, Atlas of Anatomy 2006 Urogenital muscles P. Brodal 2008
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Urogenital Diaphragm (female)
Pelvic Floor Urogenital Diaphragm (female) External urethral sphincter Perineal body (Centrum tendineum perinei) Deep transverse perineal muscle p. 156 M. Coccygeus – from spina ischiadica to coccyx – often replaced by connective tissue; enforcement of the ligament Ischiocavernosus and piriformis are also shown OBS direction of muscle fibers misleading – only the posterior fibers run transverely – the others are arched along the pubic arches – derived from the sphincter cloacae Abundant connective tissue and smooth muscles (Thieme: controversy regarding the existence of the deep perineal muscle – in older women and mulitpara replaced by or heavily infiltarated by connective tissue. Perineal body – meeting point for fibers from all three layers (sphincter ani ext., m. perinealis prof. And levator Levator ani Coccyx Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Sphincters Bulbospongiosus muscle External anal sphincter
Pelvic Floor Sphincters Bulbospongiosus muscle Kari Bø et al: women; about 10 mm lift during contraction, the coccyx moved ventrally; straining about 19 mm downward movement, coccyx moved dorsally Liten gruppe, ikke siginfikante forskjeller mellom kontinente og inkontinente, men andre har funnet tegn til svakere trykk ved kontraksjon i uretra hos inkontinente – men kanskje en koordinasjonsfaktor også – til og med en proprioseptiv del?? Mention conditions in the male – bulbospongiosus Note the action of the sphincters – they are not round Perhaps mention the lig. anococcygeum External anal sphincter Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Fascia of the Urogenital Diaphragm
Pelvic Floor Fascia of the Urogenital Diaphragm Superficial perineal fascia (Colles’) p. 153 Use to compare, e.g the bulbospongiosus muscle Inferior pelvic diaphragmatic fascia Ischioanal fossa (anterior recess) Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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The Pelvic Floor During Delivery
Probably are the muscles much thinner in relality when stretched maximally Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Pelvic Floor Episiotomy Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Spaces Filled with Fat and Loose Connective Tissue
Pelvic Floor Spaces Filled with Fat and Loose Connective Tissue Peritoneal cavity Subperitoneal space p. 497 Ischianal fossa Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Spaces Filled with Fat and Loose Connective Tissue (Male)
Pelvic Floor Spaces Filled with Fat and Loose Connective Tissue (Male) p. 155 Mention also nerves! Use example of prostatectomy, and spread of prostatic carcinoma Thieme, Atlas of Anatomy 2006 P. Brodal 2008
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Continence and Incontinence
Pelvic Floor Continence and Incontinence Continence depends on The integrity of the pelvic floor muscles, their connective tissue layers and the sphincters The integrity of innervation of the muscles Use some time to discuss this point, try to emphasize a way of reasoning; Especially mention damage to the pelvic floor during labor and instrumental delivery – descent Also: surgery damaging nerves P. Brodal 2008
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Pelvic Floor Rupture of the Urethra Rupture in the bulbous part Prostate loosened and displaced Blood trickling from the meatus Urethral rupture may cause extravasation of urine in, below or above the urogenital diaphragm Perineal hematoma P. Brodal 2008
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