Defining the Female Pelvic Floor

The term "pelvic floor dysfunction" has different meanings for different clinicians. From our viewpoint, the female pelvic floor includes all of the structures within the bony pelvis: from pubic symphysis to coccyx and from lateral pelvic sidewall to lateral pelvic sidewall. It thus includes not only the lower urinary tract, reproductive tract, and lower gastrointestinal tract, but also the neuromuscular components of their support. The neuro-musculo-visceral anatomy of the pelvic floor is described further in Chapter 3-6. The musculature of the pelvic floor includes the levator musculature and the perineal musculature. The levator musculature provides support to all of the pelvic floor organs and is transversed by the urethra, vagina, and anus. Because the levator muscle complex provides support to all three organ systems, its weakness will result in impaired function of any, or all, of the structures that the muscles support. Muscular dysfunction can result from stretch or tear injuries to the pelvic floor muscles. However, the most common etiology for muscular dysfunction is a dener-vation injury from childbirth or lower back trauma. A denervation injury will result in partial paralysis of the supplied muscle groups. As a consequence, any lower back injury can result in weakness of pelvic floor support. This is especially true of the lower components of the pelvic floor. Injury to the pudendal nerve can result in dysfunction of the urethral sphincter, anal sphincter, and motor or sensory dysfunction of the perineum. Significant injury to the pudendal innervation will typically result in multisystem dysfunction, such as urinary and fecal incontinence.

The organ systems of the pelvic floor are enveloped in moderately thick layers of connective neuromuscular tissue. Labeled as endopelvic fascia, this neuromuscular tissue provides circumferential support to the three cavities that transverse the pelvic floor muscles. In addition, they constitute separating structures between the organ systems: the vesicovaginal septum and the rectovaginal septum. Lack of integrity of the fibromuscular layer between two organ systems will lead to herniation of one organ system into another. The resultant cystocele, entero-cele, or rectocele may then result in dysfunction of the underlying visceral organ including disorders of urinary continence and storage, or dysfunction of fecal continence or storage. Frequently, multiple sites of fibromuscular layer damage are found. This is represented by the frequent coexistence of prolapse of the anterior and posterior vaginal walls requiring repair of both.

Figure 1-1.1. a, Traditional vertical view of pelvic floor dysfunction. b, Horizontal integration of pelvic floor dysfunction. (Reprinted with the permission of The Cleveland Clinic Foundation.)
Pregnancy And Childbirth

Pregnancy And Childbirth

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