The document summarizes pelvic floor anatomy and functions. It describes the levator ani muscles as the most important muscles that support pelvic organs. It outlines the boundaries and contents of the pelvis, perineum, and anterior and posterior triangles. Key structures like the anal sphincter complex, perineal body, and pelvic floor innervation are defined. The document also discusses pelvic floor dysfunction, classifications of perineal tears, and exercises to strengthen the pelvic floor muscles.
2. For obstetrical
purposes, the pelvis
is divided by the
pelvic brim into two
parts:
– The False Pelvis
– The True Pelvis
3.
4. Levator Ani Muscles
Most important muscle in the pelvic floor
Represents a critical component of pelvic organ support
Physiologically, normal levator ani muscles maintain a constant
state of contraction
Provide a solid floor that supports the weight of the
abdominopelvic contents against intra-abdominal forces.
5.
6. Pubococcygeus
Pubovaginalis
No direct attachment to urethra, the muscle fibres that attach
to vagina are responsible to elevate urethra during a pelvic
muscle contraction– contributing to urinary continence
Puboperinealis
Draws the perineal body towards pubic symphysis
Puboanalis
Elevates the anus
All the muscle fibres of levator ani keep the urogenital hiatus
narrowed
7. U-shaped sling
Draws the anorectal junction towards pubis
Contributes to anorectal angle
Part of anal sphincter complex contributing for fecal
continence
Puborectalis
8. Primary support
Arises from arcustendineous and ischial spines
Fibres from either side fuse at anococcygeal
raphe forms a supportive shelf on which
rectum
Upper vagina
Uterus rest
Iliococcygeus
9.
10.
11. Perineum
Diamond-shaped area between
Bounded deeply by the inferior fascia of the pelvic diaphragm
and superficially by the skin
Boundaries of the perineum are the same as those of the bony
pelvic outlet: the pubic symphysis anteriorly, ischiopubic rami
and ischial tuberosities anterolaterally, coccyx posteriorly, and
sacrotuberous ligaments posterolaterally
An arbitrary line joining the ischial tuberosities divides the
perineum into the anterior or urogenital triangle and a posterior
or anal triangle
12. Anterior (Urogenital) Triangle
Content-external genitalia
superficial transverse perineal muscles forms base of triangle
Triangle can be further divided into a superficial and a deep
pouch or space by the perineal membrane
13. Superficial Perineal Space
Closed compartment that lies between Colles fascia and the
perineal membrane
Contents-
Ischiocavernosus –maintain clitoral erection
Bulbocavernosus- contributes to the release of secretions from
bartholin glands
Superficial transverse perineal muscles- contribute to perineal body
Bartholin glands
Vestibular bulbs
Clitoris
Branches of the pudendal vessels and nerve
Urethra and vagina traverse this space
14.
15. Deep Perineal Space
space is continuous superiorly with the pelvic cavity
Contents-
Compressor urethrae
Urethrovaginal sphincter muscles
External urethral sphincter
Parts of urethra and vagina
Branches of the internal pudendal artery
Dorsal nerve and vein of the clitoris.
16.
17. Perineal Membrane
Trilaminar, triangular urogenital diaphragm- main component of
the deep perineal pouch
Contents-deep transverse perineal muscles and sphincter
urethrae muscles
Clinical Correlation
The perineal membrane attaches to the lateral walls of the vagina
approximately at level of the hymen
It provides support to the distal vagina and urethra by attaching
these structures to the bony pelvis
18. Posterior (Anal) Triangle
Contents-
ischioanal fossa
anal canal
anal sphincter complex
branches of the internal pudendal vessels
pudendal nerve
Bounded deeply by the fascia overlying the inferior surface of the
levator ani muscles and laterally by the fascia overlying the
medial surface of the obturator internus muscles
A splitting of the obturator internus fascia in this area- pudendal
or Alcock canal which allows passage of the internal pudendal
vessels and pudendal nerve whoose terminal branches supply the
vulva and perineum
19.
20. Ischiorectal Fossa
Fills the majority of the anal triangle
Contents-
adipose tissue
occasional blood vessels
anal canal
anal sphincter complex lie in the center of this fossa
Bounded
superomedially -inferior fascia of the levator muscles
anterolaterally -fascia covering obturator internus muscles and the ischial
tuberosities
posterolaterally -gluteus maximus muscles and sacrotuberous ligaments. At a
superficial level- bounded anteriorly by the superficial transverse perineal
muscles
deeper level, there is no fascial boundary between the fossa and the tissues deep
to the perineal membrane
Posterior to the anus, the contents of the fossa are continuous across the
midline except for the attachments of the external anal sphincter fibers to the
coccyx. The continuity of the ischioanal fossa across perineal compartments
allows fluid, infection, and malignancy to spread from one side of the anal
canal to the other, as well as into the perineal compartment deep to the
perineal membrane.
22. External Anal Sphincter
Surrounds the distal anal canal
Consists of a superficial and a deep portion
The deep fibers blend with the lowest fibers of the puborectalis
muscle
Innervated by branch of the pudendal nerve
Responsible for the squeeze pressure of the anal canal
23. Internal Anal Sphincter
Thickening of the circular smooth muscle layer of the anal wall
Innervated by autonomic nervous system
Responsible for 80 percent of the resting pressure of the anal
canal
24. Perineal Body
mass of fibromuscular tissue
found between the distal part of the posterior vaginal wall and the anus
formed by the attachment of several structures.
Contributions
Bulbocavernosus
superficial transverse perineal
external anal sphincter muscles
At deeper level –
perineal membrane
levator ani muscles and covering fascia
urethrovaginal sphincter muscles
distal part of the posterior vaginal wall
The anterior-to-posterior as well as the superior-to-inferior extents of the
perineal body measure approximately 2 to 4 cm.
25. Clinical Correlation
During episiotomy and other vaginal laceration repairs and with
pelvic reconstructive procedures, particular attention should be
paid to reconstruction of the perineal body in an effort to prevent
pelvic organ prolapse and other pelvic floor dysfunction.
26. Pelvic Floor Innervation
The pelvic diaphragm muscles -second through the fifth
sacral nerve roots (S2-5) (POP)
The perineal or inferior surface is supplied by branches
of the pudendal nerve (incontinence)
28. Classification of Perineal Tears
• First degree: laceration of the vaginal epithelium or perineal skin
only.
• Second degree: first degree with muscles and fascia but not the anal
sphincter.
• Third degree: second degree with involvement of anal sphincter
muscles
3a: Less than 50% of external anal sphincter (EAS) thickness torn
3b: More than 50% of EAS thickness torn
3c: Both EAS and internal anal sphincter (IAS) torn •
Fourth degree: a third degree tear with disruption of the anal
epithelium.
• Rectal mucosal tear (buttonhole) without involvement of the anal
sphincter is very rare and not included in the above classification.
33. PREVENTIVE OF COMPLETE PERINEAL TEAR
Delivery of the head by early extension is to be avoided
Controlled delivery of the flexed head in between uterine
contractions
Timely and judicious mediolateral episiotomy specially on
primigravida, occipito posterior, face , breech or instrumental
delivery
34. Pelvic floor muscle training exercises
• Women with urinary stress incontinence
• People who have fecal incontinence
• A pelvic floor muscle training exercise is like pretending that you have to
urinate, and then holding it
• You relax and tighten the muscles that control urine flow. It's important
to find the right muscles to tighten
• The next time you have to urinate, start to go and then stop. Feel the
muscles in your vagina, bladder, or anus get tight and move up. These
are the pelvic floor muscles. If you feel them tighten, you've done the
exercise right
35. If you are still not sure
Women: Insert a finger into your vagina. Tighten the muscles as if
you are holding in your urine, then let go. You should feel the
muscles tighten and move up and down.
Men: Insert a finger into your rectum. Tighten the muscles as if you
are holding in your urine, then let go. You should feel the muscles
tighten and move up and down. These are the same muscles you
would tighten if you were trying to prevent yourself from passing
gas.
It is very important that you keep the following muscles relaxed
while doing pelvic floor muscle training exercises:
Abdominal
Buttocks (the deeper, anal sphincter muscle should contract)
Thigh
36. PERFORMING PELVIC FLOOR EXERCISES:
1. Begin by emptying your bladder.
2. Tighten the pelvic floor muscles and hold for a count of 10.
3. Relax the muscles completely for a count of 10.
4. Do 10 repititions, 3 to 5 times a day (morning, afternoon, and night).
You can do these exercises at any time and any place. Most people
prefer to do the exercises while lying down or sitting in a chair. After 4
- 6 weeks, most people notice some improvement. It may take as long
as 3 months to see a major change.
![PELVIC FLOOR
DR. SOWJANYA KURAKULA
MBBS, MD [OBS & GYN]](https://image.slidesharecdn.com/pelvicfloor-150426091311-conversion-gate02/85/Pelvic-floor-1-320.jpg)
