Urology Today.net

Site updated at Thursday, 12 May 2016

Common Urological Problems

Musculature and Fasciae of the Pelvis

  • - Female Urology & Urogynecology - Anatomy of Pelvic Support
  • Jun 19, 2010
  • Comments
  • Viewed: 11005
  
Tags: | abdominopelvic cavity | coccyx | enterocele | iliococcygeus |

The striated musculature of the pelvic floor provides dynamic support for the visceral contents of the abdominopelvic cavity. The pelvic floor consists of the pelvic diaphragm and the perineal membrane, which are described separately (Fig. 3) (3). The pelvic diaphragm refers to the levator ani group (LAG), the coccygeus muscles, and the associated fascia.

The coccygeus muscle runs between the ischial spine and the lateral aspect of the sacrum and coccyx, overlying the SSL.  The LAG is comprised of the puborectalis, pubococcygeus, and iliococcygeus, named according to their respective points of origin (Fig.  4). 

These muscles form a shelf of support for the pelvic organs.  The pelvic diaphragm is innervated by proximal branches of the pudendal nerve and directly innervated by S3 and S4 sacral nerve roots (4). The pudendal nerve is described in more detail in the section on pelvic circulation.

Laterally, this broad sheet of muscle is attached to the pelvic sidewall by the arcus tendinous fasciae pelvis (ATFP). The ATFP is a curvilinear condensation of the pelvic fascia overlying the obturator internus muscle from the ischial spine to the lower aspect of the pubic symphysis. The obturator internus is located on the pelvic sidewall and passes through the lesser sciatic foramen to insert on the greater trochanter of the femur (2).

Fig. 3. Pelvic floor musculature and perineal body.Pelvic floor musculature and perineal body

The ATFP provides support for the majority of the anterior pelvic diaphragm to the bony pelvis and is often utilized for support during pelvic floor reconstruction.

Fig. 4. Levator ani group (LAG). PR, puborectalis; PC, pubococcygeus; IC, iliococcygeus; O, obturator muscle; TA, tendinous arc of the obturator muscle. Levator ani group. PR, puborectalis; PC, pubococcygeus; IC, iliococcygeus; O, obturator muscle; TA, tendinous arc of the obturator muscle

Midline apertures in the LAG allow passage of the urethra, vagina, and rectum. These apertures are collectively referred to as the levator hiatus. The dimensions of the hiatus can vary depending on parity (Fig. 5).

The LAG and associated fascial attachments provide a dynamic hammock of support for these structures, contributing significantly to urinary and fecal continence. The endopelvic fascia is a viscerofascial layer, superior to the LAG, just beneath the peritoneum and covering adjacent organs (2).

Fig. 5. Levator hiatus. (A) Normal levator floor and vaginal hiatus. (B) Attenuation and separation of the levator fibers and widening of the posterior vaginal hiatus with parity.Levator hiatus

There are several condensations of levator ani fascia that serve discrete functions. For example, the medial edge of the LAG fascia corresponds anteriorly, around the bladder, to the pubocervical fascia and posteriorly, around the cervix, to the cardinal and uterosacral ligaments. The uterosacral and cardinal ligaments are important fascial condensations involved in supporting the uterus and upper vagina and are discussed in the section on genital structures.

The pubocervical fascia, also known as the vesicopelvic ligament, is a continuous band of connective tissue from the pubic symphysis to the cervix (Fig. 6).

Fig. 6. Anterior vaginal fascial support. (From ref. 15.)Anterior vaginal fascial support

The fascia is a fusion of the superior layer of levator ani fascia (endopelvic fascia) and the posterior layer. The fascia fuses anteriorly with the periurethral, perivesical, and anterior vaginal wall fascia and posteriorly to the cardinal ligament complex. Attenuation of this fascial support, either laterally from the ATFP or centrally, results in a cystocele.

The pubourethral ligaments support the urethra to the inferior pubis, just proximal to the striated sphincter. The urethropelvic ligaments are derived from a fusion of the endopelvic and periurethral fascia and are continuous with the pubocervical fascia laterally (Fig.  7).

These ligaments attach laterally to the ATFP on the pelvic sidewall, providing crucial support to the urethra and anterior vaginal wall.

Fig. 7. Schematic of urethral and anterior vaginal wall support. Schematic of urethral and anterior vaginal wall support

An understanding of the supporting structures of the pelvis is essential for successful reconstructive surgery.

—-
Melissa Fischer, MD, Priya Padmanabhan, MD, and Nirit Rosenblum, MD
—-


REFERENCES

  1. Brooks JD. Anatomy of the lower urinary tract and male genitalia. In: Campbell's Urology, 8th ed. (Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds.), Saunders, Philadelphia, 2002;41-80.
  2. Klutke CG, Siegel CL. Functional female pelvic anatomy. Urol Clin North Am 1995;22:487-498.
  3. De Lancey JO. Surgical anatomy of the female pelvis. In: Te Linde's Operative Gynecology, 9th ed. (Rock JA, Jones HW, eds.), Lippincott, Williams, and Wilkins, Philadelphia, 2003;63-93.
  4. Strohbehn K. Normal pelvic floor anatomy. Obstet Gynecol Clin North Am 1998;25:683-705.
  5. Whiteside JL, Walters MD. Anatomy of the obturator region: relations to a trans-obturator sling. Int Urogynecol J 2004;15:223-226.
  6. Bartsch G, Strasser H, Poisel S. Surgical anatomy of the genitourinary system. In: Adult and Pediatric Urology, 4th ed. (Gillenwater JY, Grayhack JT, Howards SS, Mitchell ME, eds.), Lippincott, Williams, and Wilkins, Philadelphia, 2002;3-46.
  7. Wahle G, Young G, Raz S. Anatomy and pathophysiology of pelvic support. In: Female Urology, 2nd ed. (Raz S, ed.), Saunders, Philadelphia, 1996;57-72.
  8. Kabalin J. Surgical anatomy of the retroperitoneum, kidneys and ureter. In: Campbell's Urology, 8th ed. (Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds.), Saunders, Philadelphia, 2002;3-40.
  9. Chancellor M, Yoshimura N. Physiology and pharmacology of the bladder and urethra. In: Campbell's Urology, 8th ed. (Walsh PC, Retik AB, Vaughan ED, Wein AJ, eds.), Saunders, Philadelphia, 2002; 831-886.
  10. Stothers L, Chopra A, Raz S. Vesicovaginal fistula. In: Female Urology, 2nd ed. (Raz S, ed.), Saunders, Philadelphia, 1996;490-506.
  11. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance to rectocele repair. Clin Obstet Gynecol 1993;36:976-983.
  12. DeLancey JO. The hidden epidemic of pelvic floor dysfunction: achievable goals for improved prevention and treatment. Am J Obstet Gynecol 2005;192:1488-1495.
  13. Hinman F Jr. Atlas of Urosurgical Anatomy, Saunders, Philadelphia, 1993.
  14. Paraiso MFR, Falcone T. Laparoscopic surgery for genuine stress incontinence and pelvic organ prolapse. In: Urogynecology and Reconstructive Pelvic Surgery (Walters MD, Karram MM, eds.), Mosby-Yearbook, St. Louis, MO, 1999, p. 199:213-226.
  15. Raz S, Little NA, Juma S. Female urology. In: Campbell's Urology, 6th ed. (Walsh PC, Retik AB, Stamey TA, Vaughan ED Jr, eds.), Saunders, Philadelphia, 1992, p. 2783:2782-2828.
  16. Netter FH. Atlas of Human Anatomy. Icon Learning Systems, Teterboro, NJ, 2003.
  17. Benson JT, Walters MD. Neurophysiology of the lower urinary tract. In: Urogynecology and Reconstructive Pelvic Surgery (Walters MD, Karram MM, eds.), Mosby-Yearbook, St. Louis, MO, 1999;31-43.

Bookmark and Share

Post a comment [ + Comment here + ]

There are no comments for this entry yet. [ + Comment here + ]




Comment
Your details

* Required field


Please enter the word you see in the image below:

Comments are moderated by our editors, so there may be a delay between submission and publication of your comment. Offensive or abusive comments will not be published.

risk of second kidney stone1 - aggressive cancer2 - lpn1 - urinary sulfate2 - perineal membrane1 - collagen diseases1 - carcinoid1 - cadmium toxicity1 - renal cell carcinoma5 - fluid retention1 - busm1 - myelomatosis1 - autosomal recessive polycystic kidney disease1 - gift1 - journal of oncology practice1 - cyclophosphamide1 - postpartum depression1 - urine is sterile1 - ecm1 - epidemiology1 - apple shape1 - intravenous pyelography5 - jcem1 - adrenal hyperplasia1 - potassium "wastage" syndrome1 - immunologic mechanisms1 - preemptive kidney transplantation1 - mild hypertension1 - surgery1 - head of the division of urology1 -