To marcus: this is case 3 on a new page -- [do not include tes
Case 3: Pelvic Floor Dysfunction
Essential Question:
Why is prolapse more a problem for women than men?
Guiding questions:
 What is the boundary between the abdomen and pelvis?
 What is the boundary between the pelvis and perineum/ischiorectal fossa?
 What are the functions of the levator ani?
 What is the function of the urogenital diaphragm?
 What are structures prevent the pelvic visera from descending into the
peritoneum.
Use the History and physical to answer the following questions:
What is the significance of CB’s urinary, bowel and dietary habits?
Flash Movie hpb_1
Which finding(s) from her physical exam is relevant to her chief complaint?
Flash Movie hpb_2
Her surgery could have injured nerves directly or scar tissue may have entrapped nerves.
Which nerves were placed at risk and how would they lead to prolapse (pelvic organs
pushing out the vagina)?
Flash Movie hpb_3
What other factor in CB’s history predisposes her to prolapse?
Flash Movie hpb_4
If this were neuropathy related, it would be appropriate to ask about sexual function and
probe more deeply about urinary frequency. Why, what other nerves are here?
Flash Movie hpb_5
Is the vaginal bulge located anteriorly or posteriorly? What would it be, if it were found
between the vagina and rectum?
Flash Movie hpb_6
Decision: CB has several options, as this is not a serious risk to her health. There are
several considerations to weigh. Briefly, the prolapse may have interfered with a
previously healthy sexual relationship with her partner. If her husband has erectile
dysfunction secondary to diabetic vasculopathy, she may choose a non-surgical approach
merely to restore her normal anatomy and function. There are a variety of sialastic or
latex vaginal rings, donuts, discs, and cubes designed to support the pelvic floor, but
many women find this approach unacceptable. CB opted for surgical management.
Operative Approach:
1) The patient would normally be placed in the dorsal lithotomy position (on her
back with her hips flexed and her legs in stirrups). However, we will place our
donor face down with blocks under her abdomen.
2) In surgery clamps would be used to spread the labia to and an incision would be
made on the posterior wall of the vagina at the junction of the mucosocutaneous
junction (where the mucous lining of the vagina meets the skin). What tendon
will be divided by this procedure and what is its signficance?
Flash movie oab_2
3) Insert a finger in the anus and the vagina and note the close apposition and
parallel course of these structures. Insert your finger into your incision, between
the vagina and rectum and use blunt dissection to separate them up to the
posterior Fornix of the vagina. Be careful not to puncture the rectum. This plane
is large avascular and free of nerves.
4) The surgeon would limit the length of the incision in step 2, but for our purpose
we will use a nonsurgical incision to explore some relationships. Continue the
incision superficially and laterally to the ischial tuberosities. This procedure will
cut the labium majus. Observe the structures within the labium majus. What are
they?
Flash movie oab_4
5) Make two superficial incisions from the labium majus to the coccyx that pass on
either side of the rectum. Fold back the skin to reveal the fat of the ischiorectal
fossa and the inferior border of the gluteus maximus. Use retractors to pull the
gluteus maximus laterally (do not cut them) and gentile blunt dissection to
excavate the fat, being careful not to damage branches of the pudendal nerve.
What is the path of the internal pudendal nerve?
Flash movie oab_5
6) Your excavation of fat has revealed a muscle layer. What is this collection of
muscles called and what is its function?
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7) Trace this muscle layer anteriorly. To do so, you will have to remove more fat
from between two muscle layer. What is the inferior muscle layer called and
what is its function? What structure lies parallel and anterior to the vagina?
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8) Normally, the surgeon works with in the vagina to make an incision the length of
the vagina along the midline of its posterior wall. The surgeon thereby gains
access to the space you just excavated. Make the same incision, but work from
the outside the vagina. This will give you a good view of the interior of the
vagina and the cervix.
9) Reinsert your finger into the incision you made in step 3. Is your finger superior
or inferior to the pelvic diaphagm? What space is it in?
Flash movie oab_9
Replace your finger with a probe along the midline of the posterior wall of the vagina and
push the vagina away from the rectum. Use a scissor to divide the posterior wall along its
length up to the posterior fornix.
10) Turn your donor onto her back. Reflect the uterus anteriorly to observe the
rectouterine space (of Douglas). Place your finger here. Is the tip of your finger
in the abdomen or the pelvis?
Flash movie oab_10
11) It is important not to interfere with the next lab. Be careful to limit the next
incision to the width of the neck of the uterus. Incise the peritoneum to confirm
that you have entered the space that you created between the vagina and the
rectum.
Many of the following structures will be better appreciated after you
perform a hysterectomy in the next lab. Please be patient and do not
dissect further, lest you ruin next lab’s dissection. Without disturbing the
peritoneum any further, make the following observations using your donor and a skeleton
or bony pelvis.
 The line of attachment of the pelvic diaphragm extends from the pubic symphysis
across the middle of the obturator foramen to the ischial spine. Palpate the spine,
but do not disturb the pelvic viscera.
 From the spine, the line of attachment continues to the coccyx. Palpate the
coccyx. Additional support for the uterus is provided by “ligaments” that are
unnamed in the official anatomical nomenclature. Nonetheless, they are
important clinically, because they anchor the cervix. These ligaments are
condensations of fascia the lie on the superior surface of the levator ani (covered
by the peritoneum that you are taking care not to disturb).
o The cardinal (lateral cervical) ligaments course from the cervix to the
lateral walls of the pelvis.
o The pubocervical ligaments course from the pubic symphysis to cervix.
o The uterosacral ligaments course from the cervix to the coccyx.
 To repair the prolapse, the surgeon will which ligaments should be reinforced.
Sutures will be placed to stitch the coroners of the vaginal wall proximal to the
cervix to the sacrospinous ligament and/or the tough fascia proximal to the
coccyx.
 These solutions will be better appreciated after the uterus and ovaries have been
removed next lab.
She was taken to the operating room. She received 1 gram of Kefzol for prophylaxis.
Under general anesthesia, she was placed in the dorsal lithotomy position. The cervix
was circumscribed with a scalpel. The vaginal mucosa was dissected free of the
cervix with a combination of sharp and blunt dissection. The uterosacral ligaments
were identified, doubly clamped/cut and ligated with zero Vicryl. The uterine arteries
were skeletonized, doubly clamped/cut and ligated with zero Vicryl. The cardinal
ligaments were clamped, cut and ligated in portions with zero Vicryl. The uteroovarian ligaments were identified, and doubly clamped/cut and ligated with zero
Vicryl. The uterus was delivered free of the operative field. A culdoplasty was
performed with 2 interuppted 2-0 Vicryl sutures. The cystocoele was reduced by
dissecting the pre-vesical fascia free of the vaginal mucosa, then imbricating it with
2-0 Vicryl sutures. The rectocoele was similarly reduced by dissecting the pre-rectal
fascia free of the posterior vaginal mucosa and imbricating it with 2-0 vicryl sutures.
The levator ani muscles were identified and brought together in the midline with
interrupted zero Vicryl sutures. The vaginal was packed with iodine packing, and the
patient was taken to the recovery room with foley catheter in place.