1. ANATOMY PELVIC FLOOR

2. Landmarks Sacro-spinous lig. Sacro-tuberal lig. Arcus tendineus
Levator ani muscle
Endopelvic fascia
Sacro-uterine lig.
Pubo-urethral lig.
Recto-vaginal septum
Vesico-vaginal septum
Perineal body

3. Pelvic Floor Structure
Pelvic diaphragm
Levator ani
Coccygeus
Perineal membrane
Perineal body

4. Pelvic Floor structures

5. Levator Ani Critical component of pelvic support
Slow twitch fibers (I)
Responsible for normal resting contraction of pelvic floor
Keeps UGH closed
Fast twitch fibers (II)
Reflex contraction of muscle due to  IAP
Relaxation
During, voiding, defeacation, parturition.

6. Levator ani muscle M. pubo-coccygeus M. pubo-rectalis
- Pubo Vag.
- Pubo Peri.
- Pubo Analis
(Attachement at intersphinc. Groove between int. Ext. Anal sphingter)
Levator ani muscle OI
M. pubo-rectalis
(Forms U – sling behind ano-rectal junction & contributes to ano rectal angle) OI
M. ilio-coccygeus
(Post. Thinnest arises from ATLA & Is. Spines & join to form the iliococcy. Raphe & Lplate C C

7. Levator ani muscle M. pubo-rectalis M. pubo-coccygeus
M. ilio-coccygeus
M. coccygeus

8. Levator ani muscle
M. pubo-rectalis
M. ilio-coccygeus

9. Levator Plate
LP formed by union of Iliococcygeus muscle – supportive shelf

10. Levator Plate

11. Sagging of Levator Plate
Sagging of levator plate due to vertical inclination during valsalva &  UGH

12. Pelvic Connective tissue
Ligament
SSL, STL, Ant. Long
Fascia
Parietal (Collagen) allows attachment of muscle to boney pelvis.
Visceral (Endo pelvic – Collagen, elastin, adipose) sub peritoneal perivascular CT, loose areolar tissue, allows expansion & contraction of pelvic organ & encases BV, lymphatic, nerves

13. Sacro-spinous ligament (Coccygeous muscle overlies it)

14. Sacro-tuberal ligament

15. GSF – LSF – Sacro-spinous ligament Sacro-tuberal ligament
Piriformis, int. pud, inf & sup gluteal vessel, sciatic nerve & sacral. N plexus ( Neuro vasc. Injury during reconst. Surgery & Pud. N. block.
LSF –
Pudendal neuro vascular bundle & Obt. Int. tendon
Sacro-spinous ligament Sacro-tuberal ligament

16. Pelvic Ligament
Sacrospinous Sacrotuberous, & ant. Longitudnal Ligament – suture fixation sites in suspensory procedures.
Coopers (IPL)
Thickening of periosteum of pubic bone – Burch retropubic bladder neck suspension.
Sacrospinous Ligament
SSL fixation sutures penetrate the coccy - SSL complex & can lead to injury to L. Ani nerve

17. Arcus tendineus

18. Parietal Fascia Arcus tendineus levator. Ani (ATLA)
Condensation of fascia overlying medial surface of OBT. INTER NUS muscle, point of origin of L. ANI muscle.
Arcus tendineus fasciae pelvis (ATFP)
Condensation of fascia over medial aspect of OI muscle & LA muscle, lateral point of attachment of anterior vag. Wall

19. Delancey – levels of support
Lig. Sacro-uterinum

20. Delancey – levels of support
Level – I
Suspensory Axis
Supports upper 1/3 Vag. by USCL complex, apical support
Leads to vault prolapse, Cx descent, cystocoele.
Level – II
Attachment Axis
Middle 1/3 Vag. By L. Ani & ATFP
Ant. Vag. Prolapse SUI
Level – III
Fusion Axis
Strongest support
Ant. – Urethra
Lat.- Pubovag / PM,
Post.- P. Body
Distal rectocoele, perineal descent, Anal incontinence

21. Sacro-uterine ligament

22. Pubo-urethral ligament

23. Endopelvic fascia
komplexes System

24. Perineal membrane (UGD)
Spans opening of ant. Pelvic outlet & supports distal vagina & Urethra
Comp. Urethra, Urethro Vag.
Sphinc. Muscle, ATFP
Distal Vag.
IS. PUBIC RAMI
Perineal body

25. Urogenital triangle Anal triangle Symphysis Tuber ossis ischii
Os coccygis

26. Perineal Body
Supports distal vag. & rectum – anatomical repair & reapproximation during episiotomy & perineal reconstructive surgery
M. Bulbo cav.
Sup. Trans Perineal. M
Pubo Visc of L. ani
RVS Peri. Membrane
M. sphincter ani externus

28. Zones Anterior Middle Posterior EUL / PUL – forms hammock
Pubo Cervical Fascia, ATFP, Cx ring
Cardinal ligment, USL, RVS, PB
Leads to incontinence
Leads to paracolpium defect & cystocoele
Leads to uterine prolapse Vault Prolapse, enterocoele.

29. Thank you

30. Lateral defect

31. Vesico-vaginal septum Recto-vaginal septum

32. Transobturator Landmarks
Adductor longus
Urethra
Obturator canal
SAFE ENTRY ZONE of NEEDLE

33. Arcus tendineus fasciae pelvis
Arcus tendineus M. levator. ani