| Foreword | 5 |
---|
| Preface | 6 |
---|
| Table of contents | 7 |
---|
| 1 The Anatomy of the Pelvic Floor and Sphincters | 9 |
---|
| 1.1 Introduction | 9 |
| 1.2 Embryology | 10 |
| 1.2.1 Cloaca and Partition of the Cloaca | 10 |
| 1.2.2 Bladder | 11 |
| 1.2.3 Urethra | 11 |
| 1.2.4 Vagina | 11 |
| 1.2.5 Anorectum | 12 |
| 1.2.6 Pelvic Floor Muscles | 12 |
| 1.2.7 Fascia and Ligaments | 12 |
| 1.2.8 Perineum | 12 |
| 1.2.9 Newborn | 12 |
| 1.3 Anatomy | 13 |
| 1.3.1 Pelvic Wall | 13 |
| 1.3.1.1 Tendineus Arcs | 15 |
| 1.3.2 Pelvic Floor | 16 |
| 1.3.2.1 Supportive Connective Tissue (Endopelvic Fascia) | 16 |
| 1.3.2.1.1 Endopelvic Fascia | 16 |
| 1.3.2.2 Pelvic Diaphragm | 16 |
| 1.3.2.2.1 Coccygeus Muscle | 16 |
| 1.3.2.2.2 Levator Ani Muscle | 16 |
| 1.3.2.3 Perineal Membrane (Urogenital Diaphragm) | 17 |
| 1.3.2.4 Superfi cial Layer (External Genital Muscles) | 18 |
| 1.3.2.4.1 Transverse Perineal Muscles | 19 |
| 1.3.3 Bladder | 20 |
| 1.3.3.1 Detrusor | 21 |
| 1.3.3.2 Adventitia | 21 |
| 1.3.3.3 Bladder Support | 21 |
| 1.3.3.4 Neurovascular Supply | 21 |
| 1.3.4 Urethra and Urethral Support | 22 |
| 1.3.4.1 Female Urethra | 22 |
| 1.3.4.1.1 Urethral Mucosa | 22 |
| 1.3.4.1.2 Smooth Muscle Urethral Coat | 22 |
| 1.3.4.1.3 External Urethral Sphincter | 23 |
| 1.3.4.2 Male Urethra | 23 |
| 1.3.4.2.1 Lining of the Male Urethra | 23 |
| 1.3.4.2.2 Preprostatic Urethra | 23 |
| 1.3.4.2.3 Prostatic Urethra | 24 |
| 1.3.4.2.4 Membranous Urethra and Spongiose Urethra | 24 |
| 1.3.4.3 Urethral Support | 24 |
| 1.3.5 Uterus and Vagina | 26 |
| 1.3.5.1 Uterus and Vaginal Support | 26 |
| 1.3.6 Perineum and Ischioanal Fossa | 27 |
| 1.3.6.1 Perineal Body | 27 |
| 1.3.6.2 Ischioanal Fossae | 27 |
| 1.3.6.3 Perianal Connective Tissue | 28 |
| 1.3.7 Rectum | 28 |
| 1.3.7.1 Rectal Wall | 29 |
| 1.3.7.2 Rectal Support | 29 |
| 1.3.7.3 Neurovascular Supply of the Rectum | 29 |
| 1.3.8 Anal Sphincter | 29 |
| 1.3.8.1 Lining of the Anal Canal | 30 |
| 1.3.8.2 Internal Anal Sphincter | 31 |
| 1.3.8.3 Intersphincteric Space | 31 |
| 1.3.8.4 Longitudinal Layer | 31 |
| 1.3.8.5 External Anal Sphincter | 31 |
| 1.3.8.6 Pubovisceral (Puborectal) Muscle | 33 |
| 1.3.8.7 Anal Sphincter Support | 33 |
| 1.3.8.8 Anal Sphincter Anatomy Variance and Ageing | 33 |
| 1.3.8.9 Neurovascular Supply of the Anal Sphincter | 34 |
| 1.3.9 Nerve Supply of the Pelvic Floor | 35 |
| 1.3.9.1 Somatic Nerve Supply | 35 |
| 1.3.9.2 Autonomic Nerve Supply | 35 |
| References | 35 |
| 2 Functional Anatomy of the Pelvic Floor | 38 |
---|
| 2.1 Introduction | 38 |
| 2.2 Support of the Pelvic Organs | 38 |
| 2.2.1 Endopelvic Fascia | 39 |
| 2.2.2 Uterovaginal Support | 40 |
| 2.2.3 Apical Prolapse | Uterus or Vaginal Apex |
| 2.2.4 Anterior Wall Support and Urethra | 42 |
| 2.2.5 Posterior Support | 44 |
| 2.2.6 Levator Ani Muscles | 45 |
| 2.2.7 Pelvic Floor Muscles and Endopelvic Fascia Interactions | 46 |
| 2.2.8 Perineal Membrane and External Genital Muscles | 47 |
| 2.3 Functional Anatomy of the Lower Urinary Tract | 47 |
| 2.3.1 Bladder | 47 |
| 2.3.1.1 Vesical Neck | 49 |
| 2.3.2 Urethra | 49 |
| 2.3.2.1 Striated Urogenital Sphincter | 49 |
| 2.3.2.2 Urethral Smooth Muscle | 49 |
| 2.3.2.3 Submucosal Vasculature | 49 |
| 2.3.2.4 Glands | 49 |
| References | 49 |
| 3 Pelvic Floor Muscles-Innervation, Denervation and Ageing | 51 |
---|
| 3.1 Introduction | 51 |
| 3.2 Innervation and Neural Control | 51 |
| 3.2.1 Somatic Motor System | 52 |
| 3.2.2 Sensory Control | 53 |
| 3.2.3 Sensory-Motor Integration in PFM Control | 54 |
| 3.2.4 Neural Control Manifesting as PFM Activity Patterns | 55 |
| 3.3 Neural Control of Sacral Functions | 57 |
| 3.3.1 Lower Urinary Tract Function and PFM | 58 |
| 3.3.2 Anorectal Function and PFM | 58 |
| 3.3.3 Sexual Behaviour and PFM | 59 |
| 3.4 Ageing and PFM Changes | 59 |
| 3.5 Vaginal Delivery and Neuromuscular Injury | 61 |
| 3.6 Conclusion | 62 |
| References | 63 |
| 4 Imaging Techniques | 66 |
---|
| 4.1 Evacuation Proctography and Dynamic Cystoproctography | 66 |
| 4.1.1 Evacuation Proctography | 66 |
| 4.1.1.1 Introduction | 66 |
| 4.1.1.2 Technique | 66 |
| 4.1.1.3 Normal Findings | 68 |
| 4.1.1.3.1 Pre-Evacuation | 68 |
| 4.1.1.3.2 Evacuation | 69 |
| 4.1.1.3.3 Post-Evacuation | 70 |
| 4.1.1.3.4 Additional Manoeuvres | 70 |
| 4.1.1.3.5 Radiological Report | 70 |
| 4.1.1.4 Alternative Approaches | 70 |
| 4.1.2 Dynamic Cystoproctography | 71 |
| 4.1.2.1 Introduction | 71 |
| 4.1.2.2 Technique | 71 |
| 4.1.2.3 Normal Findings and Defi nition of Prolapse | 72 |
| 4.1.2.3.1 Rectocoele | 73 |
| 4.1.2.3.2 Cystocoele | 73 |
| 4.1.2.3.3 Enterocoele and Sigmoidocoele | 74 |
| 4.1.2.3.4 Peritoneocoele | 76 |
| 4.1.2.3.5 Vaginal Vault Prolapse | 76 |
| 4.1.2.4 Comparison with Physical Examination | 76 |
| 4.1.3 Summary | 77 |
| References | 77 |
| 4.2 Dynamic MR Imaging of the Pelvic Floor | 79 |
| 4.2.1 Abstract Role of MR in Evaluating Pelvic Floor Disorders |