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Funtional Anatomy PDF
Funtional Anatomy PDF
Functional Anatomy of
the Pelvic Floor and
Lower Urinary Tract
JOHN T. WEI, MD* and JOHN O. L. DE LANCEY, MD†
*Department of Urology, Taubman Health Care Center, University
of Michigan Health System, Ann Arbor, Michigan; †Department of
Obstetrics and Gynecology, University of Michigan Medical School,
Ann Arbor, Michigan
3
4 Wei and De Lancey
tissue for support, with control provided downwards in the same way that increases in
through connections to the peripheral and abdominal pressure force the vagina to pro-
central nervous systems. In this chapter, lapse. Figure 2a and Figure 2b provide a
the term “pelvic floor” is used broadly to in- schematic illustration of this prolapse phe-
clude all the structures supporting the pelvic nomenon. In Figure 2c, the lower end of the
cavity rather than the restricted use of this vagina is held closed by the pelvic floor
term to refer to the levator ani group of muscles, preventing prolapse by constric-
muscles. tion. Figure 2d shows suspension of the va-
The pelvic floor consists of several com- gina to the pelvic walls. Figure 2e demon-
ponents lying between the peritoneum and strates that spatial relationships are impor-
the vulvar skin. From above downward, tant. This is a flap-valve closure where the
these are the peritoneum, pelvic viscera and suspending fibers hold the vagina in a posi-
endopelvic fascia, levator ani muscles, peri- tion against the supporting walls of the pel-
neal membrane, and superficial genital vis; increases in pressure force the vagina
muscles. The support for all these structures against the wall, thereby pinning it in place.
comes from connections to the bony pelvis Vaginal support is a combination of con-
and its attached muscles. The viscera are of- striction, suspension, and structural geom-
ten thought of as being supported by the pel- etry.
vic floor, but are actually a part of it. The Because of the way the supportive tissues
viscera play an important role in forming the attach the pelvic organs to the pelvic walls,
pelvic floor through their connections with the female pelvis can naturally be divided
structures, such as the cardinal and uterosac-
ral ligaments.
In 1934, Bonney pointed out that the va-
gina is in the same relationship to the ab-
dominal cavity as the in-turned finger of a
surgical glove is to the rest of the glove (Fig-
ure 1).4 If the pressure in the glove is in-
creased, it forces the finger to protrude
Endopelvic Fascia
On each side of the pelvis, the endopelvic
fascia attaches the cervix and vagina to the
pelvic wall (Figure 4). This fascia forms a
continuous sheet-like mesentery, extending
from the uterine artery at its cephalic margin
to the point at which the vagina fuses with
the levator ani muscles below. The part of
the fascia that attaches to the uterus is called
the parametrium and that which attaches to
the vagina, the paracolpium.5 The vagina is
attached laterally to the pelvic walls forming
a single divider in the middle of the pelvis
that determines the nature of prolapse. An-
terior and posterior prolapse occur from the
front or the back, respectively. There are no
“lateroceles.” The division of clinical prob-
lems into anterior, posterior, and apical pro-
lapse reflects the nature of these lateral con-
FIGURE 3. Compartments of the pelvis. The nections. Therefore, three types of move-
vagina, connected laterally to the pelvic walls, ment can occur in patients with pelvic organ
divides the pelvis into an anterior and posterior prolapse: 1) the cervix or vaginal apex can
compartment (DeLancey 1998, with permission;
based on SEARS 1933).
move downward between the anterior and
posterior supports; 2) the anterior vagina can
protrude through the introitus; and 3) the
into anterior and posterior compartments posterior wall can protrude through the in-
(Figure 3). The levator ani muscles form the troitus. The types of support loss are related
bottom of the pelvis. The organs are attached to the location of the genital tract’s connec-
to the levator ani muscles when they pass tion to the pelvis. The location of connective
tissue damage determines whether a woman separate layer from the vagina, as is often
has anterior, posterior, or vault prolapse. incorrectly depicted, but rather is composed
Understanding the different characteristics of the anterior vaginal wall and its attach-
of support helps us to understand the types ment through the endopelvic fascia to the
of prolapse that can occur. pelvic wall (Figure 6). Similarly, the poste-
rior vaginal wall and endopelvic fascia
(“rectovaginal fascia”) form the restraining
Uterovaginal Support layer that prevents the rectum from protrud-
The cardinal and uterosacral ligaments ing forward, blocking formation of posterior
(parametrium) attach the cervix and uterus prolapse. In the distal vagina (level III), the
to the pelvic walls.6,7 This tissue continues vaginal wall is directly attached to surround-
downward over the upper vagina to attach it ing structures without any intervening para-
to the pelvic walls and is called the paracol- colpium. Anteriorly, the vagina fuses with
pium here.5 These tissues provide support the urethra, posteriorly with the perineal
for the vaginal apex following hysterectomy body, and laterally with the levator ani
(Figure 5). The paracolpium has two por- muscles.
tions from the pelvic inlet toward the pelvic
outlet. The uppermost portion of the para-
colpium consists of a relatively long sheet of Prolapse of the Uterus or
tissue that suspends the superior aspect of Vaginal Apex
the vagina (level I) by attaching it to the pel- Damage to level I support can result in uter-
vic wall. This is true whether or not the cer- ine or vaginal prolapse (Figure 7). The na-
vix is present. In the midportion of the va- ture of uterine support can be understood
gina (level II), the paracolpium attaches the when the cervix is pulled downward with a
vagina laterally and more directly to the pel- tenaculum during dilation and curettage or
vic walls. This attachment stretches the va- pushed downward during laparoscopy. Af-
gina transversely between the bladder and ter a certain amount of descent, the parame-
rectum and has functional significance. The tria become tight and arrest further cervical
structural layer that supports the bladder descent. Similarly, downward descent of the
(“pubocervical fascia”) does not exist as a vaginal apex after hysterectomy is resisted
by the paracolpia. The parametria do not de- of these defects are responsible for the diver-
termine the resting position of the cervix in sity of clinically encountered problems.
normal healthy women, since the cervix can
be drawn to the hymen with little difficulty.8
The same can be said of the vaginal apex af- Anterior Vaginal and
ter hysterectomy. Damage to the upper sus- Urethral Support
pensory fibers of the paracolpium allows The position and mobility of the anterior va-
uterine or vaginal vault prolapse (Figure 8). gina, bladder, and urethra are important to
Damage to the level II and III portions of urinary continence and anterior prolapse.9
vaginal support results in anterior and pos- By fluoroscopy, the urethra and vesical neck
terior prolapse. The varying combinations are normally mobile structures while the dis-
Interactions Between the ani muscles. When the pelvic muscles relax
or are damaged, the urogenital hiatus opens
Pelvic Muscles and and the vagina lies between the high ab-
Endopelvic Fascia dominal pressure and low atmospheric pres-
Interaction between the pelvic muscles and sure. In this situation, the vagina must be
the supportive connective tissue is critical to held in place by the fascia. Although the fas-
pelvic organ support. As long as the levator cia can sustain these loads for short periods
ani muscles function properly, the urogeni- of time, if the pelvic muscles do not close the
tal hiatus is closed and the connective tissue urogenital hiatus, the connective tissue
is under minimal tension, acting to stabilize eventually fails, resulting in prolapse. The
the organs in their position above the levator support of the vagina has been likened to a
ship in its berth, floating on the water and
attached by ropes on either side to a dock.28
The ship is analogous to the vagina, the
ropes to the ligaments, and the water to the
supportive layer formed by the pelvic
muscles. The ropes function to hold the ship
FIGURE 16. Mid-vaginal posterior prolapse FIGURE 17. Levator ani muscles seen from
that protrudes through the introitus despite a nor- below the edge of the perineal membrane (“uro-
mally supported perineal body (DeLancey, with genital diaphragm”) can be seen on the left of the
permission). specimen (DeLancey, with permission).
Functional anatomy of the pelvic floor 13
tomic entity. It denotes that area at the base Striated Urogenital Sphincter
of the bladder where the urethral lumen The striated urogenital sphincter muscle, of-
passes through the thickened detrusor mus- ten referred to as the external urethral
culature of the bladder base that surrounds sphincter, encircles the urethra in its midpor-
the trigone and urethral meatus.34 tion. Distally, under the arch of the pubic
bone, these fibers diverge to insert into the
walls of the vagina and the perineal mem-
Urethra brane (the compressor urethrae and urethro-
The urethra is a complex tubular organ ex- vaginal sphincter muscles) (Figure 18).
tending below the bladder. In its upper third, These muscles are responsible for increas-
it is clearly separable from the adjacent va- ing intraurethral pressure during times of
gina, but its lower portion is fused with the need and contribute about one-third of the
vaginal wall. The urethra is associated with resting tone of the urethra. The muscle fi-
several structures that are relevant for under- bers, which are primarily slow-twitch and
standing lower urinary tract dysfunction.35 fatigue-resistant, are constantly active.
Functional anatomy of the pelvic floor 15
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Functional anatomy of the pelvic floor 17