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At least 19 recordsLinked to original sources
PubMed2004

Female pelvic floor anatomy: the pelvic floor, supporting structures, and pelvic organs.

The development of novel, less invasive therapies for stress urinary incontinence in women requires a thorough knowledge of the relationship between the pathophysiology of incontinence and anatomy. This article provides a review of the anatomy of the pelvic floor and lower urinary tract. Also discussed is the hammock hypothesis, which describes urethral support within the pelvis and provides an explanation of the continence mechanism.

Journal Article↗
PubMed2005

[PET-CT studies of the support system and continence function of pelvic organs. The pivotal importance of Denonvilliers' fascia for surgical procedures].

Like all other organs in the chest or abdominal cavities, pelvic organs are not suspended by specialized ligaments such as those in the skeletomuscular system. In spite of this, the organs of the pelvis remain well suspended within their cavity even during evacuation. This support system for these organs consists of inconspicuous smooth muscle elements scattered throughout pelvic structural fat tissue and fascial structures, in particular Denonvilliers' fascia. We used PET-CT studies to identify spontaneous muscle activity in the pelvis, which is strongest at Denonvilliers' fascia. We were able to correlate continence function, filling, and evacuation of pelvic organs with this spontaneous muscle activity that leads to stiffening and relaxation of the muscular walls of these organs. During the course of different disease processes such as visceral prolapse, these pelvic support structures are prone to fail gradually. Surgical interventions should take the pelvic support system into account to avoid therapeutic errors.

Aged↗
PubMed2003

Do Asian women have less pelvic organ mobility than Caucasians?

Epidemiological studies have postulated racial differences in the incidence and prevalence of pelvic floor disorders. There are anecdotal data from cadaver dissections suggesting that Asian women benefit from stronger pelvic support structures. A prospective observational clinical study was conducted in order to test for differences in pelvic organ support in 200 nulliparous pregnant women. Assessment included translabial ultrasound, documenting the position of the pelvic organs and mobility on Valsalva relative to the inferoposterior symphyseal margin. The largest ethnic groups were Asian ( n=16) and Caucasian women ( n=161). On comparing the groups, both antepartum and postpartum analyses showed significantly less pelvic organ mobility in Asians. This was true for virtually all parameters of organ mobility and both anterior ( P=0.002 antepartum, P=0.009 postpartum) and posterior compartments ( P=0.04 antepartum, P=0.02 postpartum). No significant differences were detected for cervical mobility. It was concluded that Asian women seem to show less mobility of the anterior and posterior vaginal compartments than Caucasians.

Adolescent↗
PubMed1998

Endometriosis. Current issues in diagnosis and medical management.

OBJECTIVE: To explore the hypothesis that endometriosis is a disease not just because it exists but because it is functionally active. STUDY DESIGN: Qualitative research analyzing the morphologic appearances of endometriosis and the clinical effect of medical therapies. RESULTS: Analysis of the appearances of symptomatic endometriosis demonstrates that the ectopic endometriumlike tissue mimics eutopic endometrium but with loss of polarization. Ectopic implants resembling superficial endometrium are hemorrhagic and associated with adhesion and pseudocyst or endometrioma formation. Ectopic implants resembling basal or junction zone endometrium are associated with nodular adenomyotic lesions in the posterior fornix and pelvic supportive structures. They are characterized by smooth muscle hyperplasia and T-lymphocyte aggregates. CONCLUSION: Medical therapy has been shown to be very efficient in reducing pelvic pain as soon as amenorrhea is created and maintained. Regression, but not elimination, of the implant is obtained by medical therapy. Clinical data support the hypothesis that the efficacy of medical therapy is largely achieved by preventing cyclic bleeding in the implants.

Amenorrhea↗
PubMed2001

Visibility of pelvic organ support system structures in magnetic resonance images without an endovaginal coil.

OBJECTIVE: The aim of this study was to determine which elements of the pelvic organ support system are visible on magnetic resonance imaging performed without an endovaginal coil. STUDY DESIGN: Proton density-weighted pelvic magnetic resonance images were obtained for 20 healthy continent nulliparous women with a mean (+/-SD) age of 30.1 +/- 5.1 years (range, 22-42 years). Standardized analyses of transverse, coronal, and sagittal key images were carried out to describe pelvic organ support system anatomy. RESULTS: Details of both the muscular and fascial supports were clearly seen. The endopelvic fascia was visible on transverse images and could be seen to laterally attach the proximal vagina to the pelvic wall. Its appearance was consistent with its composition of a network of connective tissue, vessels, and nerves. The upward, lateral, and dorsal direction of its most cephalic suspending fibers was visible on both transverse and coronal images. The different nature of the uterosacral ligament relative to the cardinal ligaments was also demonstrated in transverse images. The endopelvic fascia's attachment to the pelvic walls was visible in the midvagina. The 3 parts of the levator ani muscle were likewise visible-the pubococcygeus, puborectalis, and iliococcygeus. Fusion of the levator ani muscle and the vagina at the level of the middle urethra could be recognized on transverse and coronal images. CONCLUSION: Magnetic resonance imaging depicted structures of the pelvic organ supports, including the endopelvic fascia and pelvic floor muscles, without the need for an endovaginal coil.

Adult↗
PubMed2006

Failure of elastic fiber homeostasis leads to pelvic floor disorders.

Pelvic floor disorders, a group of conditions affecting adult women, include pelvic organ prolapse and urinary incontinence. Vaginal childbirth and aging are risk factors, and weakening of the pelvic support structures is a major aspect of the pathology. However, the underlying molecular mechanism remains unknown. Female reproductive organs are rich in elastic fibers that turn over slowly in most adult tissues but undergo massive remodeling in the reproductive organs through pregnancy and birth. Here we show that a failure to maintain elastic fiber homeostasis in mice causes pelvic floor disorders. Lysyl oxidase-like-1 (LOXL1), a protein essential for the postnatal deposition of elastic fibers, was highly expressed and regulated in the reproductive tract of the mouse, and its expression was diminished during aging. LOXL1 deficiency caused an inability of reproductive tissues to replenish elastic fibers after parturition, leading to pelvic organ prolapse, weakening of the vaginal wall, paraurethral pathology, and lower urinary tract dysfunction. These data demonstrate the importance of elastic fibers for maintaining structural and functional integrity of the female pelvic floor. Our findings raise the possibility that a failure of elastic fiber homeostasis, either due to genetic predisposition or advancing age, could underlie the etiology of pelvic floor dysfunction in women.

Amino Acid Oxidoreductases↗
PubMed2006

Striae and pelvic relaxation: two disorders of connective tissue with a strong association.

Pelvic relaxation, a weakening of pelvic support structures, is an under-reported condition that affects a multitude of women. In the United States alone, more than 338,000 procedures for prolapse are performed annually. Decreased collagen content has been noted in the tissues of women affected by this condition. Interestingly, biopsy specimens of women with striae also show a diminution of collagen. Using self-reported anonymous data, we compared the prevalence of striae in women with and without pelvic relaxation to see if an association between these two disorders of connective tissue existed. More than half the women with prolapse (54.7%) (n = 41) reported striae, whereas only 25.0% of women in the non-prolapse group (n = 8) reported striae (P < 0.01). Multivariate logistic regression analysis confirmed striae as a significant risk factor for the development of clinical prolapse (odds ratio 3.12, P < 0.05). There appears to be a strong association between the presence of striae and the development of pelvic relaxation, which is unrelated to conventionally cited risk factors, such as age, weight, number of pregnancies, or postmenopausal status.

Adult↗
PubMed1991

Comparative intrinsic and extrinsic compliance characteristics of S, J, and W ileoanal pouches.

Although compliance of the ileoanal reservoir pouch has been shown to affect function, previous compliance studies may have been influenced by the compliance of the small bowel proximal to the pouch and by supporting pelvic structures. The following study was designed to isolate the pouch and to compare intrinsic and extrinsic factors influencing pouch compliance. Thirty-three mongrel dogs underwent rectal mucosectomy and proctocolectomy with S-pouch (S) in nine, stapled J-pouch (SJ) in nine, handsewn J-pouch (HJ) in nine and handsewn W-pouch (SW) in six. At 2 weeks, each dog underwent laparotomy, the small bowel 2 cm proximal to the pouch was clamped, and in vivo pouch compliance was measured using anal balloon occlusion and continuous saline infusion manometry. The pouch was then removed and ex vivo measurements were repeated. Mean compliance slopes between 0 and 40 cm H2O were compared by ANOVA and paired t-tests. In vivo and ex vivo compliance in ml/cm H2O was 3.1 +/- 1.2 and 3.8 +/- 1.6 (P = 0.25) for the S-pouch, 3.1 +/- 0.6 and 5.2 +/- 1.7 (P less than 0.01) for the SJ-pouch, 2.3 +/- 0.5 and 4.8 +/- 0.7 (P less than 0.001) for the HJ-pouch, 3.6 +/- 0.6 and 6.0 +/- 0.7 (P less than 0.001) for the W-pouch. Pearson's correlation coefficient for in vivo and ex vivo measurements of the S, SJ, HJ, and W pouches were r2 = 0.066, 0.001, 0.039, and 0.379, respectively. It is concluded that: 1) Isolated pouch compliance can be accurately measured in experimental animals with proximal and distal occlusion and inflow manometry. 2) In vivo compliance is significantly less in the HJ compared with S, SJ, and W pouches. 3) Differences between in vivo and ex vivo compliance of SJ, HJ, and SW pouches are significant. 4) In vivo and ex vivo compliance determinations correlate poorly. 5) Extrinsic factors contribute significantly to pouch compliance.

Anal Canal↗
PubMed1981

Vaginal morphology following hysterectomy.

This study was designed to gain more information about morphology of the vagina after hysterectomy. The prospective clinical observations of patients subjected to abdominal or vaginal extrafascial or intrafascial hysterectomy with or without correction of anatomical urinary stress incontinence were included. The length, configuration and axis of the vagina were determined using a vaginal cast technic. Vaginal casts were prepared prior to and 6 months to 4 years after surgery. The gross appearance of the vagina after hysterectomy is affected by understanding normal pelvic anatomy an physiology, careful preoperative evaluation of pelvic defects, proper planning and competent performance of surgery. Proper handling of the endopelvic fascia and its condensations, the cardinal and sacrouterine ligaments, corrects preexisting weakness, provides vaginal suspension and prevents future vaginal disfigurement. Inadequate surgical technics result in magnifying preexisting weakness of pelvic supports. Successful surgery involves correcting the levator complex by reducing and shifting the levator hiatus ventrally. Reconstruction of the perineal body is essential. This study suggests a relationship between successful surgical treatment of urinary stress incontinence and reconstruction of pelvic supportive structures, with restoration of the physiological vaginal axis.

Female↗
PubMed1996

Total Laparoscopic Intrafascial Hysterectomy

Bladder and ureteral injuries are associated with several types of hysterectomies performed laparoscopically. Subtotal hysterectomy is said to cause fewer complications and provide better pelvic support by preserving the uterosacral and cardinal ligaments, but there are also arguments against it. A new technique, total laparoscopic intrafascial hysterectomy (TLIH) has all the benefits of total and subtotal hysterectomies, but fewer complications. Conventionally, uterosacral ligaments are cut at or just below their junction with the cervix, and the remaining vagina and cardinal ligaments are cut at the same level. With TLIH, using a uterine manipulator and colpotomizer, the incision is made at a much higher level. The cervix is circumcised while preserving the entire uterosacral and cardinal ligaments and full length of the vagina, except in cases of malignancy or severe pelvic endometriosis. The ureter is mobilized farther from the cervix. A longer vagina and excellent pelvic support can be achieved with maximum preservation of the vagina and pelvic supporting structures. A modified McCall culdoplasty and reinforcement of the cardinal ligaments are done, and the vaginal cuff is closed with everted mattress sutures either vertically or transversely. Less granulation tissue is formed on the vaginal vault and postoperative leukorrhea or postcoital vaginal bleeding is reduced. Moschcowitz culdoplasty or high McCall culdoplasty can be done at the same time to correct or prevent an enterocele or prolapsed vagina.

Journal Article↗
PubMedDate not supplied

[Surgery for urogenital prolapse].

Urogenital prolapse can have a significant impact on quality of life. As the population continues to age, the prevalence of urogenital prolapse is increasing, and the lifetime risk of requiring surgery for urogenital prolapse or incontinence is now approximately 11%. The majority of women presenting with symptomatic prolapse suffer from multiple defects of pelvic support and require comprehensive repair to relieve symptoms. An understanding of normal pelvic support structures provides the basis for the anatomic approach to repair. Many appropriate options exist for surgical correction of urogenital prolapse. Procedures to reestablish apical support include culdoplasty techniques, uterosacral ligament suspension, sacrospinous suspension and colpopexy. Repair of the anterior compartment can be achieved with colporrhaphy and paravaginal repair. Posterior compartment defects are repaired with colporrhaphy, site-specific rectovaginal repair and perineorrhaphy. Most often, surgical correction of urogenital prolapse can be performed vaginally, which avoids the risks associated with laparotomy. Laparoscopic approaches for apical support and paravaginal repair may reduce the risks associated with laparotomy, but long-term follow-up data are not yet available with these techniques. The use of graft reinforcement for anterior and posterior repairs may offer improved success rates, particularly in patients with recurrent prolapse. However, further outcome studies are needed and the risks associated with the use of mesh must be considered.

Female Urogenital Diseases↗
PubMed1995

Transvaginal small-bowel evisceration: a case report.

Transvaginal small-bowel evisceration is rare. Only 47 case reports appear in the literature in English. Review of this literature shows that vaginal evisceration occurs mainly in women who are older, multiparous, and have undergone vaginal surgery. The immediate cause of evisceration is either sudden, increased intraabdominal pressure, trauma, or a spontaneous event. The small bowel and omentum are most commonly involved. Surgical repair is performed vaginally, abdominally, or by both methods. We present a case of transvaginal small bowel evisceration caused by inadvertent self-induced trauma, a heretofore unreported cause of this complication, in a 79-year-old woman with known weakness of her pelvic structural support. She experienced sudden evisceration of small bowel following manual decompression of her cystocele during voiding. We used a combined abdominal and vaginal approach to examine the small and large intestines and mesentery for trauma, attach the vaginal vault to the shortened uterosacral ligament, obliterate the cul-de-sac using the Moschowitz procedure, and repair the defect in the levator plate. To limit risk, patients should be evaluated for predisposing conditions. We recommend a combined abdominal and vaginal surgical approach to adequately evaluate the involved tissues and to effect repair.

Aged↗
PubMed1995

Functional female pelvic anatomy.

This article reviews important aspects of female pelvic anatomy with particular emphasis on the structures important for pelvic organ support and urinary control. The pelvis and supporting structures, the pelvic floor, and the relationships of the pelvic organs are described and illustrated by MR imaging.

Female↗
PubMed2006

Histopathological evaluation of the uterosacral ligament: is this a dependable structure for pelvic reconstruction?

OBJECTIVE: To explore, by histological examination, whether the uterosacral ligament complex is an adequate support structure for vaginal vault suspension and other reconstructive procedures of the female pelvis. MATERIALS AND METHODS: We dissected 14 fresh hemipelves from seven adult female cadavers. The uterosacral complexes were excised from the pelvic sidewall immediately beneath the uterosacral pedicle. The specimens were stained with connective tissue-specific Movat stain and evaluated microscopically for the presence of collagen and/or elastin. RESULTS: Uterosacral tissue similar to that identified during pelvic reconstructive surgery was obtained in all cases. Six of the women had had a hysterectomy. A ligamentous structure with clearly aligned collagen and interspersed elastin was identified in only three specimens, two from one cadaver of a young woman who had not had a hysterectomy. The other specimens had an attenuated, poorly organized layer of collagen immediately beneath the peritoneum. CONCLUSION: We could not consistently identify normal ligamentous tissue in the uterosacral complexes. The overwhelming majority of specimens from women who had had a hysterectomy showed disorganized tissue with reduced cellularity. This reinforces doubts about the integrity of these tissues as structural supports in pelvic reconstructive surgery, particularly in elderly women who have had a hysterectomy.

Adult↗
PubMedDate not supplied

MR imaging of the female pelvic floor in the supine and upright positions.

The goal of this study was to determine whether a .5-T open configuration magnet system could be used to evaluate the female pelvic floor support structures and their functional changes in the upright and supine positions. We evaluated five normal volunteers with full bladders in the supine and sitting positions. Multiple measurements were obtained, including distance between symphysis and urethra, bladder neck to fixed pubococcygeal line, and posterior urethrovesical angle. The pelvic floor was evaluated for integrity of the urethra, vagina, and supporting ligaments. High quality, interpretable images were obtained for all five patients in both positions. Most of the pelvic floor structures were stable, with the exception of the posterior urethrovesical angle, which increased in the sitting position. We conclude that the vertically open configuration magnet system shows promise for evaluation of the female pelvic floor, including urinary stress incontinence and prolapse.

Adult↗
PubMed1997

[Examination of the female perineum].

Examination of the female perineum consists of evaluation of the constituent musculo-aponeurotic and sphincteric structures and global assessment of any abnormalities of pelvic and perineal tone. This examination is primarily clinical, starting with guided clinical interview designed to investigate urinary, genital and rectal disorders, based on precise signs followed by detailed examination evaluating trophicity, sensitivity, mobility and tone of support structures and pelvic organs. Complementary investigations (radiological, urodynamic, electrophysiological) are not performed routinely. They should be performed selectively to support or confirm a difficult diagnosis and to objectively assess the results of treatment.

Diagnostic Imaging↗
PubMed2002

Classic bladder exstrophy in a nonhuman primate: a comparative analysis.

OBJECTIVES: To describe the pelvic floor musculature and bony pelvic anatomy in a case of naturally occurring classic bladder exstrophy in a rhesus monkey, the first reported case in the animal population since 1832, and compare the results to exstrophy seen in human newborns. METHODS: A 7-day-old male rhesus monkey with classic bladder exstrophy was examined by a pediatric urologist and primate veterinarian before being killed. A multidetector row computed tomography study with three-dimensional reconstruction was obtained, and a comparison computed tomography study of a 17-day-old male human with exstrophy was also reconstructed three dimensionally. The bony pelvis and pelvic floor muscular anatomy of both subjects were then examined and compared. RESULTS: On gross examination, a similar appearance of classic bladder exstrophy in the rhesus monkey and human newborn were noted, including an open exposed bladder, associated penile epispadias, and widely separated pubic bones. The evaluation of the three-dimensional models showed a similar orientation of the bony pelvis in both the rhesus and the human newborn. The iliac wings were significantly rotated outward, and the sacroiliac joint was 10 degrees wider than that seen in normal children. The exstrophy pelvic floor in both the rhesus and the newborn was markedly flattened, with approximately 33% of the muscle located anterior to the rectum to support the pelvic structures (normal children have 50% of their levator ani anterior to the rectum). CONCLUSIONS: By using advancements in imaging modalities, this study illustrated that naturally occurring classic bladder exstrophy in the human newborn and rhesus monkey were identical in both external appearance and internal anatomy.

Animals↗