Fascia and Ligaments of the Pelvic Floor

The walls and floor of the pelvis are lined by the parietal endopelvic fascia, which continues on the internal organs as visceral fascia and serves to attach the pelvic organs to the pelvic walls (Figure 4-3.1). Unlike fascia in the abdominal wall, which contains regularly arranged collagen bundles, this fascia has variable amounts of collagen, elastin, and fibrovascular elements. Much of the strength of this endopelvic fascia is derived from the walls of arteries and veins that run within it.

In the female, on each side of the pelvis, the endopelvic fascia connects the cervix and vagina to the pelvic wall.

The attachment forms a broad sheet, laterally extending from the cephalad parametrium, which attaches the uterus to the sidewall, to the inferior paracolpium, which attaches the vagina to the side wall at the level of the levators. The cephalic paracolpium is lengthy and attaches the vagina to the pelvic walls. More caudally the attachment is more direct. It is this attachment that stretches the vagina between the rectum and the bladder. Support of the bladder is dependent on the attachment of the bladder to the vagina posteriorly and the support of the vagina by the more caudal paracolpium. Similarly, the posterior vaginal wall and rectovaginal fascia form a barrier to the anterior bulging of the rectum and thus prevent formation of a rectocele. In the most distal vagina, the vaginal wall is attached directly to surrounding structures without a para-colpium. Anteriorly, it is fused to the urethra, posteriorly with the perineal body and laterally with the levator ani muscles. Damage to the upper supports of the vagina results in vaginal and uterine prolapse whereas damage to the lower supports results in a cystocele and/or rectocele formation.

Posterior to the rectum is the mesorectum, which contains both blood vessels and lymphatics that supply and drain the rectum. This is loosely bound down the front of the sacrum and coccyx by connective tissue known as the fascia propria. The lateral ligaments, which attach the rectum to the pelvic walls, are condensations of the fascia propria and contain loose areolar tissue, nerves, and small blood vessels. Thus, the mesorectum can be mobilized by dissection in the "mesorectal plane" leaving the mesorec-tum invested in this thin layer of fascia. The sacrum and coccyx are also covered in a thicker fascia, which extends downward and forward, just superficial to the anococ-cygeal ligament known as Waldeyer's fascia. Anteriorly the rectum is covered with a layer of visceral fascia that extends from the anterior peritoneal reflection to the urogenital diaphragm. This is Denonvilliers fascia and lies between the rectum and vagina (or prostate in men). Nerves important to bladder control and male sexual function pass through this fascia. The hiatal ligament, originat-

Pelvic Floor Ligament Suspension
Figure 4-3.1. Fascial layers of the female posterior pelvic floor. (Reprinted from Fundamentals of Anorectal Surgery, 2nd ed, DE Beck, SD Wexner, page 3, © 1996, with permission from Elsevier)

ing from the pelvic fascia, surrounds the rectum and vagina and maintains their patency during levator contraction.

In addition to the bony support of the pelvis, there are two true tendons. The arcus tendineus fascia pelvis (ATFP) and arcus tendineus levator ani (ATLA). These are dense aggregations of connective tissue, predominantly collagen, that provide lateral passive pelvic support. These tendons are condensations of the obturator and levator ani fascia. The ATLA inserts anteriorly at the pubic rami and posteriorly at the ischial spine. The ATFP lies medial to the ATLA at the anterior insertion of the pubic rami and inserts posteriorly at the ischial spine. These tendons provide anchoring sites for the levators and the vagina and thus are key to the support of the pelvic floor.

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