The Anatomy of the Pelvic Floor and Sphincters

  • Jaap Stoker
  • Christian Wallner
Part of the Medical Radiology book series (MEDRAD)

Abstract

The pelvic floor supports the visceral organs, is crucial in maintaining continence, facilitates micturition and evacuation and in women forms part of the birth canal. This multifunctional unit is a complex of muscles, fasciae and ligaments that have numerous interconnections and connections to bony structures, organs and the fibroelastic network within fat-containing spaces. A detailed appreciation of the pelvic floor is essential to understand normal and abnormal function. The embryology of the pelvic floor is included to help explain certain anatomical features.

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Arey LB (1966) Developmental anatomy, 7th edn. Saunders, PhiladelphiaGoogle Scholar
  2. Bannister LH, Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ (1995) Gray’s anatomy, 38th edn. Churchill Livingstone, New YorkGoogle Scholar
  3. Beets-Tan RGH, Morren GL, Beets G et al (2001) Measurement of anal sphincter muscles: endoanal US, endoanal MR imaging, or phased array MR imaging? A study with healthy volunteers. Radiology 220:81–89PubMedGoogle Scholar
  4. Bogduk N (1996) Issues in anatomy: the external anal sphincter revisited. Aust N Z J Surg 66:626–629CrossRefPubMedGoogle Scholar
  5. Cardozo L (ed) (1997) Urogynecology. Churchill Livingstone, EdinburghGoogle Scholar
  6. Chai TC, Steers WD (1997) Neurophysiology of micturition and continence in women. Int Urogynecol J Pelvic Floor Dysfunct 8:85–97CrossRefPubMedGoogle Scholar
  7. Colleselli K, Stenszl A, Eder R, Strasser H, Poisel S, Bartsch G (1998) The female urethral sphincter: a morphological and topographical study. J Urol 160:49–54CrossRefPubMedGoogle Scholar
  8. De Caro R, Aragona F, Herms A, Guidolin D, Brizzi E, Pagano F (1998) Morphometric analysis of the fibroadipose tissue of the female pelvis. J Urol 160:707–713CrossRefPubMedGoogle Scholar
  9. DeLancey JOL (1986) Correlative study of paraurethral anatomy. Obstet Gynecol 68:91–97PubMedGoogle Scholar
  10. DeLancey JOL (1988) Structural aspects of the extrinsic continence mechanism. Obstet Gynecol 72:296–301PubMedGoogle Scholar
  11. DeLancey JOL (1993) Anatomy and biomechanics of genital prolapse. Clin Obstet Gynecol 36:897–909CrossRefPubMedGoogle Scholar
  12. DeLancey JOL (1994a) Functional anatomy of the female pelvis. In: Kursh ED, McGuire EJ (eds) Female urology, 1st edn. Lippincott, PhiladelphiaGoogle Scholar
  13. DeLancey JOL (1994b) Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol 170:1713–1723PubMedGoogle Scholar
  14. DeLancey JOL, Richardson AC (1992) Anatomy of genital support. In: Benson JT (ed) Female pelvic floor disorders: investigation and management, 1st edn. Norton Medical Books, New YorkGoogle Scholar
  15. DeLancey JOL, Starr RA (1990) Histology of the connection between the vagina and levator ani muscles. Implications for urinary tract function. J Reprod Med 35:765–771PubMedGoogle Scholar
  16. Dietz HP, Lanzarone V (2005). Levator trauma after vaginal delivery. Obstet Gynecol 106: 707–712PubMedGoogle Scholar
  17. Dorschner W, Biesold M, Schmidt F, Stolzenburg JU (1999) The dispute about the external sphincter and the urogenital diaphragm. J Urol 162:1942–1945CrossRefPubMedGoogle Scholar
  18. El-Sayed RF, Morsy MM, El-Mashed SM, Abdel-Azim MS (2007) Anatomy of the urethral supporting ligaments defined by dissection, histology, and MRI of female cadavers and MRI of healthy nulliparous women. Am J Roentgenol 189:1145–1157CrossRefGoogle Scholar
  19. Fenger C (1988) Histology of the anal canal. Am J Surg Pathol 12:41–55PubMedCrossRefGoogle Scholar
  20. Fucini C, Elbetti C, Messerini L (1999) Anatomic plane of separation between external anal sphincter and puborectalis muscle. Clinical implications. Dis Colon Rectum 42:374–379CrossRefPubMedGoogle Scholar
  21. Garavoglia M, Borghi F, Levi AC (1993) Arrangement of the anal striated musculature. Dis Colon Rectum 36:10–15CrossRefPubMedGoogle Scholar
  22. Gibbons CP, Trowbridge EA, Bannister JJ, Read NW (1986) Anal cushions. Lancet 8486:886–887CrossRefGoogle Scholar
  23. Gilpin SA, Gosling JA (1983) Smooth muscle in the wall of the developing human urinary bladder and urethra. J Anat 137:503–512PubMedGoogle Scholar
  24. Goligher J (1967) Surgery of the anus, rectum and colon, 2nd edn. Baillière Tindall, LondonGoogle Scholar
  25. Haas PA, Fox TA (1977) The importance of the perianal connective tissue in the surgical anatomy and function of the anus. Dis Colon Rectum 20:303–313CrossRefPubMedGoogle Scholar
  26. Hamilton WJ, Mossman HW (1972) Hamilton, Boyd and Mossman’s human embryology, 4th edn. Williams and Wilkins, BaltimoreGoogle Scholar
  27. Hobday DI, Aziz Q, Thacker N, Hollander I, Jackson A, Thompson DG (2001) A study of the cortical processing of ano-rectal sensation using functional MRI. Brain 124:361–368CrossRefPubMedGoogle Scholar
  28. Hoyte L, Schierlitz L, Zou K, Flesh G, Fielding JR (2001). Two-and 3-dimensional MRI comparison of levator ani structure, volume, and integrity in women with stress incontinence and prolapse. Am J Obstet Gynecol 185:13–19CrossRefGoogle Scholar
  29. Hussain SM, Stoker J, Laméris JS (1995) Anal sphincter complex: endoanal MR imaging of normal anatomy. Radiology 197:671–677PubMedGoogle Scholar
  30. Kearney R, Miller JM, Ashton-Miller JA, DeLancey JO (2006). Obstetric factors associated with levator ani muscle injury after vaginal birth. Obstet Gynecol 107:144–149PubMedGoogle Scholar
  31. Lansman HH, Robertson EG (1992) Evolution of the pelvic floor. In: Benson JT (ed) Female pelvic floor disorders: investigation and management, 1st edn. Norton Medical Books, New YorkGoogle Scholar
  32. Last RJ (1978) Anatomy. Regional and applied, 6th edn. Churchill Livingstone, EdinburghGoogle Scholar
  33. Li L, Li Z, Huo HS, Wang HZ, Wang LY (1992) Sensory nerve endings in the puborectalis and anal region of the fetus and newborn. Dis Colon Rectum 35:552–559CrossRefPubMedGoogle Scholar
  34. Lien K, Morgan D, Delancey J, Ashton-Miller J (2004) Pudendal nerve stretch during vaginal birth. A 3D computer simulation. Am J Obstet Gynecol 192:1669–1676CrossRefGoogle Scholar
  35. Lierse W, Holschneider AM, Steinfeld J (1993) The relative proportions of type I and type II muscle fibres in the external sphincter ani muscle at different ages and stages of devel opment — observations on the development of continence. Eur J Pediatr Surg 3:28–32CrossRefPubMedGoogle Scholar
  36. Lunniss PJ, Phillips RKS (1992) Anatomy and function of the anal longitudinal muscle. Br J Surg 79:882–884CrossRefPubMedGoogle Scholar
  37. Maas CP, DeRuiter MC, Kenter GG, Trimbos JB (1999) The inferior hypogastric plexus in gynecologic surgery. J Gynecol Tech 5: 55–62Google Scholar
  38. Maas CP (2003) Nerve sparing radical pelvic surgery. PhD Thesis, Leiden University, The NetherlandsGoogle Scholar
  39. Mauroy B, Goullet E, Stefaniak X, Bonnal JL, Amara N (2000) Tendinous arch of the pelvic fascia application to the technique of paravaginal colposuspension. Surg Radiol Anat 22:73–79CrossRefPubMedGoogle Scholar
  40. Milligan ETC, Morgan CN (1934) Surgical anatomy of the anal canal. Lancet 2:1150–1156CrossRefGoogle Scholar
  41. Moore K, Persaud TVN (1998) The developing human: clinically oriented embryology, 6th ed. Saunders, PhiladelphiaGoogle Scholar
  42. Muntean V (1999) The surgical anatomy of the fasciae and the fascial spaces related to the rectum. Surg Radiol Anat 21:319–324CrossRefPubMedGoogle Scholar
  43. Myers RP, Cahill DR, Kay PA et al (2000) Puboperineales: muscular boundaries of the male urogenital hiatus in 3D from magnetic resonance imaging. J Urol 164:1412–1415CrossRefPubMedGoogle Scholar
  44. Nievelstein RAJ, van der Werff JFA, Verbeek FJ et al (1998) Normal and abnormal development of the anorectum in human embryos. Teratology 57:70–78CrossRefPubMedGoogle Scholar
  45. Norton PA (1993) Pelvic floor disorders: the role of fascia and ligaments. Clin Obstet Gynecol 36:926–938CrossRefPubMedGoogle Scholar
  46. Oelrich TM (1983) The striated urogenital muscle in the female. Anat Rec 205:223–232CrossRefPubMedGoogle Scholar
  47. Oh C, Kark AE (1972) Anatomy of the external anal sphincter. Br J Surg 1972:717–723CrossRefGoogle Scholar
  48. Papa Petros PE (1998) The pubourethral ligaments. An anatomical and histological study in the live patient. Int Urogynecol 9:154–157CrossRefGoogle Scholar
  49. Rociu E, Stoker J, Eijkemans MJC, Laméris JS (2000) Normal anal sphincter anatomy and age-and sex-related variations at high spatial resolution endoanal MR imaging. Radiology 217:395–401PubMedGoogle Scholar
  50. Sampselle CM, DeLancey JO (1998) Anatomy of female continence. J Wound Ostomy Continence Nurs 25:63–74PubMedGoogle Scholar
  51. Schraffordt SE, Tjandra JJ, Eizenberg N, Dwyer PL (2004) Anatomy of the pudendal nerve and its terminal branches: a cadaver study. ANZ J Surg 74:23–26CrossRefPubMedGoogle Scholar
  52. Shafik A (1976) A new concept of the anatomy of the anal sphincter mechanism and the physiology of defecation. III. The longitudinal muscle: anatomy and role in anal sphincter mechanism. Invest Urol 13:271–277PubMedGoogle Scholar
  53. Shafik A (1999) Levator ani muscle: new physioanatomical aspects and role in the micturition mechanism. World J Urol 17:266–273CrossRefPubMedGoogle Scholar
  54. Strasser H, Tiefenthaler M, Steinlechner M, Bartsch G, Konwalinka G (1999) Urinary incontinence in the elderly and age-dependent apoptosis of rhabdosphincter cells. Lancet 354:918–919CrossRefPubMedGoogle Scholar
  55. Strohbehn K, Ellis J, Strohbehn JA, DeLancey JOL (1996) Magnetic resonance imaging of the levator ani with anatomic correlation. Obstet Gynecol 87:277–285CrossRefPubMedGoogle Scholar
  56. Strohbehn K (1998) Normal pelvic floor anatomy. Obstet Gynecol Clin North Am 25:683–705CrossRefPubMedGoogle Scholar
  57. Tan IL, Stoker J, Zwamborn AW, Entius KAC, Calame JJ, Laméris JS (1998) Female pelvic floor. Endovaginal MR imaging of normal anatomy. Radiology 206:777–783PubMedGoogle Scholar
  58. Tobias PV, Arnold M (1981) Man’s anatomy, 3rd ed. Witwatersrand University Press, JohannesburgGoogle Scholar
  59. Tunn R, DeLancey JO, Howard D, Thorp JM, Ashton-Miller JA, Quint LE (1999) MR Imaging of levator ani muscle recovery following vaginal delivery. Int Urogynecol J 10:300–307CrossRefGoogle Scholar
  60. Tunn R, DeLancey JOL, Quint EE (2001) Visibility of pelvic organ support system structures in magnetic resonance images without an endovaginal coil. Am J Obstet Gynecol 184:1156–1163CrossRefPubMedGoogle Scholar
  61. Valasek P, Evans DJ, Maina F, Grim M, Patel K (2005) A dual fate of the hindlimb muscle mass: cloacal/perineal musculature develops from leg muscle cells. Development 132:447–458CrossRefPubMedGoogle Scholar
  62. Van der Werff JFA, Nievelstein RAJ, Brands E et al (2000) Normal development of the male anterior urethra. Teratology 61:172–183CrossRefPubMedGoogle Scholar
  63. Van Ophoven A, Roth S (1997) The anatomy and embryological origins of the fascia of Denonvilliers: a medicohistorical debate. J Urol 157:3–9CrossRefPubMedGoogle Scholar
  64. Wallner C, Maas CP, Dabhoiwala NF, Lamers WH, DeRuiter MC (2006a) Innervation of the pelvic floor muscles: a reappraisal for the levator ani nerve. Obstet Gynecol 108:529–534PubMedGoogle Scholar
  65. Wallner C, Maas CP, Dabhoiwala NF, Lamers WH, DeRuiter MC (2006b) Evidence for the innervation of the puborectalis muscle by the levator ani nerve. Neurogastroenterol Motil 18:1121–1122CrossRefPubMedGoogle Scholar
  66. Wallner C, van Wissen J, Maas CP, Dabhoiwala NF, DeRuiter MC, Lamers WH (in print) The contribution of the levator ani nerve and the pudendal nerve to the innervation of the levator ani muscles; a study in human fetuses. Eur Urol. doi:10.1016/j.eururo.2007.11.015 (in print)Google Scholar
  67. Woodburne RT (1983) Essentials of human anatomy, 7th ed. Oxford University Press, New YorkGoogle Scholar
  68. Yucel S, Baskin LS (2004). An anatomical description of the male and female urethral sphincter complex. J Urol 171:1890–1897CrossRefPubMedGoogle Scholar
  69. Yucel S, De Souza A Jr, Baskin LS (2004) Neuroanatomy of the human female lower urogenital tract. J Urol 172:191–195CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2008

Authors and Affiliations

  • Jaap Stoker
    • 1
  • Christian Wallner
    • 2
  1. 1.Department of Radiology Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  2. 2.Department of Anatomy and Embryology Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands

Personalised recommendations