Tema 4 - suelo pélvico

• The pelvic floor is a set of muscles and connective tissues that line the lower part of the pelvis.
• It is a fundamental part of the body, but often overlooked.

Pelvic Floor Layers

• Superficial layer: primarily involved in sexual function, but also supports pelvic organs.
• Deep or posterior layer: comprised of muscles that support organs, control sphincters, and improve the quality of sexual relations.

Pelvic Floor Functions

• Continence
• Sexual function
• Support
• Reproductive function

Limits of the Pelvic Floor

• Anterior: posterior aspect of the pubic symphysis and ischiopubic ramus.

• Posterior: sacrotuberous ligament and coccyx.

• Lateral: ischial tuberosities.

• An imaginary line divides the perineum into two triangles.

• Anterior or urogenital triangle: differs between sexes.

• Posterior or anal triangle: same in both sexes.

Tendinous Center of the Perineum

• Important structure in the pelvic floor

Musculature of the Pelvic Floor: Deep Layer (Pelvic Diaphragm)

• Levator ani muscle: includes the pubococcygeus, puborectalis, and iliococcygeus muscles.

Levator Ani Muscle Details

• Origin of puborectalis: both sides of the pubic symphysis, upper branch of the pubic bone.
• Origin of pubococcygeus: pubis.
• Origin of iliococcygeus: tendinous arch of the obturator internus muscle fascia.
• Insertion: anococcygeal ligament, coccyx.
• Innervation: direct branches of the sacral plexus (S2-S4).
• Action: secures the position of the pelvic organs.

Musculature of the Pelvic Floor: Middle Layer (Perineum)

• Urethral sphincter.
• Deep transverse perineal muscle.

Urethral Sphincter Details

• Origin in males: surrounds the anterior aspect of the prostate.
• Origin in females: completely surrounds the urethra, fitting over the smooth sphincter.
• Insertion in males: completely surrounds the membranous urethra and smooth sphincter.
• Insertion in females: posterior segment of the urethra.
• Innervation: pudendal nerve (S2-S4).
• Action: closes the urethra.

Deep Transverse Perineal Muscle Details

• Origin: inferior ramus of the pubic bone and ramus of the ischial bone.
• Insertion: vaginal wall or prostate, tendinous center.
• Innervation: pudendal nerve (S2-S4).
• Action: secures the position of pelvic organs and closes the urethra.

Musculature of the Pelvic Floor: Superficial Layer (Perineum)

• External anal sphincter.
• Superficial transverse perineal muscle.
• Ischiocavernosus muscle.
• Bulbospongiosus muscle.

Superficial Transverse Perineal Muscle Details

• Origin: ischial bone ramus.
• Insertion: tendinous center.
• Innervation: pudendal nerve (S2-S4).
• Action: secures the position of pelvic organs and closes the urethra.

External Anal Sphincter Details

• Origin: ring of concentric striated fibers that form a ring around the terminal portion of the anal canal.
• Insertion: extends from the tendinous center dorsally to the anococcygeal ligament (surrounding the anus).
• Innervation: pudendal nerve (S2-S4).
• Action: closes the anus.

Ischiocavernosus Muscle Details

• Origin: ischial bone ramus.
• Insertion: crus of the penis or clitoris.
• Innervation: pudendal nerve (S2-S4).
• Action: pumps blood into the corpus cavernosum of the crus of the clitoris/penis.

Bulbospongiosus Muscle Details

• Origin/insertion in males: extends from the tendinous center of the perineum ventrally to the raphe of the penis.
• Origin/insertion in females: extends from the tendinous center of the perineum ventrally to the raphe of the clitoris.
• Innervation: pudendal nerve (S2-S4).
• Action in males: surrounds the corpus spongiosum of the penis.
• Action in females: narrows the vaginal opening.

Female Pelvic Floor

• Includes: ischiocavernosus, bulbospongiosus, deep and superficial transverse perineal muscles, perineal body, obturator internus, anus, anococcygeal ligament, coccygeus, inferior pubic ramus, clitoris, urethral orifice, ischiopubic ramus, vagina, perineal membrane, ischial tuberosity, sacrotuberous ligament, external anal sphincter, levator ani (pubococcygeus, iliococcygeus), gluteus maximus, and coccyx.

Adjacent Musculature

• Diaphragm.
• Rectus abdominis.
• Obliques (external + internal).
• Transverse abdominis.
• Quadratus lumborum.
• Psoas.
• Gluteus muscles.

Pelvic Fascia

• Extension of the extraperitoneal pelvic connective tissue of the abdomen.
• Covers the walls, pelvic viscera, and forms sheaths around the vessels and nerves.
• There are differences between men and women.

Assessment

• Posture.
• Diaphragm and abdomen assessment.
• Pelvic floor assessment.
• Specific pelvic floor assessment including:superficial, vaginal, neurological, and rectal examination.