Pelvic Floor Disorders

Pelvic Floor Anatomy & Physiology - Pelvic Powerhouse

• Core Structures:
  • Pelvic Diaphragm: Main support layer.
    • Levator ani muscles (📌 PRI: Puborectalis, Pubococcygeus, Iliococcygeus).
    • Coccygeus muscle.
  • Urogenital Diaphragm: Contains external urethral sphincter.
  • Fascia: Endopelvic fascia (provides visceral support).
  • Innervation:
    • Pudendal nerve (S2, S3, S4): Key for sphincter control & perineal sensation.
    • Direct sacral branches (S3, S4) to levator ani.
• Key Functions:
  • Supports pelvic organs (bladder, uterus, rectum).
  • Maintains urinary and fecal continence.
  • Aids in defecation, micturition, parturition, sexual function.
• Clinical Landmark: Perineal body - central fibrous anchor point.

⭐ The pudendal nerve (S2, S3, S4) is the primary motor and sensory nerve to the perineum, including the external anal and urethral sphincters.

Types of Pelvic Floor Disorders - Droops, Drips & Blocks

Pelvic floor dysfunction manifests as:

• "Droops": Pelvic Organ Prolapse (POP) - organ descent.
• "Drips": Urinary Incontinence (UI) - involuntary urine leakage.
• "Blocks": Obstructive symptoms (e.g., voiding dysfunction, constipation).

Urinary Incontinence (UI) Types:

⭐ Stress urinary incontinence is the most common type, characterized by involuntary leakage on effort or exertion, such as coughing or sneezing.

Clinical Evaluation & Diagnosis - Decoding the Descent

⭐ The POP-Q (Pelvic Organ Prolapse Quantification) system is the standardized, objective method for describing and staging pelvic organ prolapse.

• History: Focus on symptoms (fecal incontinence (FI), obstructed defecation (ODS), bulge, pain), obstetric/surgical history.
• Physical Exam:
  • Inspection: Perineal descent during Valsalva.
  • Digital Rectal Exam (DRE): Resting/squeeze tone, puborectalis paradox.
  • POP-Q Assessment: For prolapse staging. 📌 Key points: Aa, Ba, C, D, Gh, Pb, TVL, Ap, Bp.
• Key Investigations:
  • Anorectal Manometry: Assesses sphincter pressures (e.g., resting pressure <40 mmHg suggests weakness).
  • Defecography (Barium/MR): Evaluates dynamic anorectal function, rectoceles, intussusception.
  • Endoanal Ultrasound (EAUS): Visualizes sphincter defects.

Management of Pelvic Floor Disorders - Repair & Restore Roundup

• Conservative First:

  • PFMT (Kegels), lifestyle (weight ↓, bladder train).
  • Pessaries: For POP & SUI.

• Medical Options:

  • OAB: Anticholinergics (Oxybutynin 2.5-5mg), Mirabegron (25-50mg).
  • SUI: Duloxetine (limited).

• Surgical Interventions:

  • Table: PFD Management Approaches

    Disorder	Conservative	Surgical Options
    Stress Urinary Incontinence (SUI)	PFMT, pessary	MUS (TVT/TOT), Burch, bulking agents
    Pelvic Organ Prolapse (POP)	PFMT, pessary	Repair (ant/post), Apical (sacrocolpopexy), Colpocleisis
    Fecal Incontinence (FI)	Diet, PFMT, biofeed.	Sphincteroplasty, SNS

  

⭐ Pelvic floor muscle training (Kegel exercises) is the first-line conservative treatment for stress urinary incontinence and early-stage pelvic organ prolapse.

High‑Yield Points - ⚡ Biggest Takeaways

• Rectal prolapse: True full-thickness protrusion. Altemeier for frail, abdominal rectopexy for fit.
• Fecal incontinence: Anal manometry & EMG for diagnosis. Sacral Nerve Stimulation (SNS) for refractory cases.
• Obstructed defecation syndrome (ODS): Biofeedback is first-line. STARR procedure for selected anatomical defects.
• Solitary rectal ulcer syndrome (SRUS): Linked to straining, internal intussusception. Conservative management is primary.
• Anismus: Paradoxical puborectalis contraction; biofeedback is mainstay treatment.
• Rectocele: Symptomatic anterior rectal wall herniation; may require surgical repair.