Does the Way Hysterectomy Is Performed Make a Difference? How to Prevent Prolapse at the Time of Hysterectomy
Victor Gomel, Bruno van Herendael in Female Genital Prolapse and Urinary Incontinence, 2007
The muscular support comes from the pelvic diaphragm or the levator ani. Of the levator ani muscles, the ilicoccygeus and pubococcygeus provide the majority of support. The iliococcygeus muscle comes from the tendious arch of the levator ani muscle and inserts between the anus and coccyx. The pubococcygeus muscles start on the inner aspect of the pubic bone and traverse to insert onto the sacrum. These two muscles maintain active support. The levator ani muscles are usually damaged from childbirth secondary to pudendal nerve injury. Damage can also occur as a result of chronic constipation, chronic lung problems or anything that increases intra-abdominal pressure. After these muscles are damaged the endopelvic fascia takes over as the primary pelvic support (10).
Fecal incontinence
Miranda A. Farage, Howard I. Maibach in The Vulva, 2017
The levator ani muscles are thought of as the pelvic diaphragm and consist of three individual muscles: the puborectalis, the iliococcygeal, and the pubococcygeal. Combined, the pelvic diaphragm encompasses a thin and broad muscle that attaches to the posterior pubic rami bilaterally and to the inner surface of the ischium posteriorly. The levator ani serves to support the pelvic viscera. The puborectalis is controlled by the somatic nervous system and serves as a major contributor to the anatomic angle that creates a barrier when at rest, and when contracted straightens out the rectum, allowing defecation. It attaches to the posterior pubic rami, then wraps posteriorly around the rectum and reinserts on the pubic rami, creating a sling (8).
The Exercise Prescription
Maria A. Fiatarone Singh, John Sutton Chair in Exercise, Nutrition, and the Older Woman, 2000
Although a complete discussion of urinary incontinence is beyond the scope of this chapter, a few points are worth emphasizing. Loss of urine when standing, coughing, sneezing, or initiating exercise is often due to stress incontinence secondary to the rise in intra-abdominal pressure caused by these activities. The presence of such symptoms should be part of the pre-exercise assessment of the older woman. If there are any other urinary symptoms, such as dysuria, frequency, urge incontinence, hematuria, etc., then referral for medical evaluation is necessary. If not, then the simple measures outlined in Table 17 can be instituted to minimize the occurrence of incontinent episodes. Pelvic floor muscle exercises are essentially isometric resistance training for the levator ani muscles which prevent the urethra from descending in response to increases in intra-abdominal pressure as noted above. A proven effective regimen is as follows: Hold a maximal contraction of levator ani muscles (without Valsalva) for 5 seconds; these muscles can be identified during pelvic exam or as the muscles which are used voluntarily to stop the stream of urine.Rest for 10 seconds.Repeat above steps for a total of 10 minutes.Complete this 10-minute session 4 times per day every day.
Pelvic floor dysfunction in midlife women
Published in Climacteric, 2019
Pelvic floor integrity is maintained by the coordinated actions of muscles (levator ani, urethral and anal sphincters), nerves (sacral plexus and pudendal nerve), and connective tissue (endopelvic ‘fascia’, perineal body, uterosacral and cardinal ‘ligaments’) anchored to the bony pelvis. The levator ani muscles close the urogenital hiatus, providing support by preventing protrusion of organs through that aperture. The fused posterior component of the muscles (the levator plate) offers a hammock-like support for the pelvic organs, preventing stretch and tension on the supportive connective tissue10. Endopelvic connective tissue provides additional visceral support, and is particularly important in maintaining it when the levators are weak. In the context of levator weakness, chronic tension can lead to fascial attenuation and structural failure. The levator ani muscles and endopelvic connective tissue therefore work together to provide normal pelvic support and urinary continence11. The quality of both muscle and collagen is integral to its ability to provide this dynamic support. Blood flow is essential for fibromuscular and neuromuscular tissue health, and vascularity is compromised by estrogen deficiency. It seems logical to conclude that menopause would negatively affect the pelvic floor and lead to dysfunction, especially over time and especially in the context of overall tissue aging.
Keeping the pelvic floor healthy
Published in Climacteric, 2019
C. Dumoulin, L. Pazzoto Cacciari, J. Mercier
The PFMs form a diaphragm that spans the entire pelvic cavity and provide support for the pelvic organs1. They comprise the coccygeus and the levator ani muscles with their five parts: the pubovaginal, puboperineal, and puboanal portions, which form the pubovisceral complex, and the puborectalis and iliococcygeus muscles6. These parts of the levator ani muscle form three different regions of the pelvic floor, from anterior to posterior:The pubovisceral muscle consists of muscle fibers that arise from the pubic bone on either side of the symphysis and attach to the walls of the pelvic organs and the perineal body; these help to close the urogenital hiatus.The puborectal muscle forms a sling around and behind the rectum, just cephalad to the external anal sphincter.The iliococcygeal muscle forms a relatively flat, horizontal shelf spanning the potential gap from one pelvic sidewall to the other near the sacrum6.
Investigation of pelvic floor disorders
Published in Climacteric, 2019
Since the 1980s, the evolution of real-time sonography combined with the wide availability and the low cost of ultrasound systems resulted in a remarkable increase in the field of urogynecology. Sonographic assessment of the LUT and the pelvic floor can be performed via the transperineal (translabial), the transvaginal, and the transabdominal routes. For a basic sonographic evaluation, usual two-dimensional curved array or transvaginal transducers can be used. The resulting image includes the symphysis pubis anteriorly, the urethra and bladder neck, the vagina, cervix, rectum, and anal canal, and the anorectal angle indicating the location of the levator plate24. Three-dimensional ultrasonography has also been evaluated, offering an increased imaging accuracy and allowing the analysis of various planes by different investigators at a comfortable time following the examination. Three-dimensional evaluation of the axial plane allows assessment of the levator ani muscle and its hiatus, the triangular opening between the symphysis pubis anteriorly and the puborectalis part of the levator ani laterally and posteriorly24. Four-dimensional sonography may also be obtained by analyzing the dynamic changes of the pelvic floor between rest and Valsalva maneuver or contraction24.
Related Knowledge Centers
- Coccygeus Muscle
- Ischium
- Muscle
- Pelvic Floor
- Vaginismus
- Pelvic Cavity
- Hip Bone
- Pelvis
- Orgasm
- Tendinous Arch of Pelvic Fascia