The levator ani muscular sling is composed of three muscles: the pubococcygeus, the iliococcygeus, and the ischiococcygeus (see Figure 4-2.4, Chapter 4-2). The ilio-and ischiococcygeus originate from the ischial spine and posterior obturator fascia and insert into the anococcygeal raphe, the coccyx, and the sacrum, forming a shelf on which the pelvic organs may lie.

The pubococcygeus arises from the posterior pubis and anterior obturator and inserts into the anococcygeal raphe, the sacrum, and coccyx. Various muscle subdivisions have been assigned to the medial portion of the pubococcygeus depending on its attachments. These include puborectalis, pubovaginalis, and pubourethralis.

The puborectalis originates from the pubis and inserts into the anococcygeal raphe. It is the medial and inferior portion of the pubococcygeus. The puborectalis is a U-shaped muscle that originates from the pubic bones and passes behind the rectum forming a sling. The puborectalis passes beside the vagina to which it is attached laterally (here named the pubovaginalis) and then passes posterior to the anorectal junction. It provides support for the rectum and indirect support for the vagina, bladder, and urethra by drawing these structures anterior toward the pubic bone. Indirect elevation of the anterior vaginal wall and urethrovesical neck is provided by the bulk of the pub-orectalis muscle as it draws the rectum and posterior vaginal wall forward with contraction. The tonic contraction of the puborectalis closes the urogenital hiatus, contributes to the posterior curve of the vagina, and reduces pressure on the pelvic outlet. When its tone is lax, the urogenital hiatus opens, the anorectal angle becomes obtuse, and the levator plate sags.

The levator muscles maintain constant tone and, provided they are functioning, the supportive ligaments and fascia are under no tension. When the pelvic floor muscles relax or are damaged, the intraabdominal pressures are applied to the pelvic organs and ligaments. The ligaments function well for short periods under this stress but will stretch and weaken over time, eventually leading to organ prolapse and problems with incontinence.

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