Anatomical Basis of Pelvic Floor Defects

Branimir Kelović; Borna Kelović; Vesna Lesko Kelović; Ivana Maurac Pašalić; Mato Pavić

doi:10.26332/kjahae67

Authors

Branimir Kelović Faculty of Medicine, University of Zagreb, Zagreb, Croatia Author
Borna Kelović Faculty of Medicine, University of Zagreb, Zagreb, Croatia Author
Vesna Lesko Kelović University Hospital Centre Zagreb, Zagreb, Croatia Author
Ivana Maurac Pašalić University Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Zagreb, Croatia Author
Mato Pavić University Department of Obstetrics and Gynecology, University Hospital Centre Zagreb, Zagreb, Croatia Author

DOI:

https://doi.org/10.26332/kjahae67

Keywords:

pelvic organ prolapse, pelvic floor, pelvic floor disorders

Abstract

Pelvic Floor Disorders (PFDs) are a common problem affecting women of various ages. Pelvic floor defects are one of the entities that belong to pelvic floor disorders. Each pelvic floor defect is caused by specific damage to the anatomical and functional integrity of the pelvic floor. Understanding the underlying pathological anatomy is crucial for the proper therapeutic approach in treating this condition. Pelvic organ prolapse refers to the descent of pelvic organs into or through the vaginal canal. This includes the bladder, uterus, vaginal vault, small intestine, and large intestine. There are three groups of prolapse: anterior, posterior, and apical. Prolapses occur due to damage to the fibromuscular support system known as the endopelvic fascia, which maintains the pelvic organs in their normal position. To understand the normal statics of pelvic organs, the concept of DeLancey’s levels of support—comprising three levels—is essential. The first level of support consists of the cardinal and uterosacral ligaments. The second level of support consists of the pubocervical and rectovaginal fascia. The third level of support consists of the connection of the vagina to surrounding structures. Each prolapse occurs due to damage to individual levels of support. Thus, defects of the endopelvic fascia have been recognized as key in the pathophysiology of pelvic organ prolapse. Pelvic floor defects often impair the normal mechanisms of maintaining continence, resulting in urinary incontinence as a common symptom of this condition. Only by repairing such damage and restoring the original anatomical relationships can success in surgical therapy be achieved. The aim of this paper is to describe in detail the anatomy of each defect with the purpose of creating a foundation for diagnostic and therapeutic approaches.

References

1. Good MM, Solomon ER. Pelvic Floor Disorders. Obstet Gynecol Clin North Am. 2019 Sep;46(3):527–40.

2. Wei JT, De Lancey JOL. Functional anatomy of the pelvic floor and lower urinary tract. Clin Obstet Gynecol. 2004 Mar;47(1):3–17.

3. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol. 1992 Jun;166(6 Pt 1):1717–24; discussion 1724-1728.

4. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994 Jun;170(6):1713–20; discussion 1720-1723.

5. DeLancey JOL. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol. 1999 Apr;180(4):815–23.

6. Richardson AC. The Rectovaginal Septum Revisited: Its Relationship to Rectocele and Its Importance in Rectocele Repair: Clin Obstet Gynecol. 1993 Dec;36(4):976–83.

7. DeLancey JOL. What’s new in the functional anatomy of pelvic organ prolapse? Curr Opin Obstet Gynecol. 2016 Oct;28(5):420–9.

8. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976 Nov;126(5):568–71.

9. Jelovsek JE, Barber MD. Women seeking treatment for advanced pelvic organ prolapse have decreased body image and quality of life. Am J Obstet Gynecol. 2006 May;194(5):1455–61.

10. DeLancey JO. The anatomy of the pelvic floor. Curr Opin Obstet Gynecol. 1994 Aug;6(4):313–6.

11. Jorge JMN, Bustamante-Lopez LA. Pelvic floor anatomy. Ann Laparosc Endosc Surg. 2022 Apr;7:20–20.

12. Bonney V. The Principles that should Underlie all Operations for Prolapse*. BJOG Int J Obstet Gynaecol. 1934 Oct;41(5):669–83.

13. Orešković S, Kalafatić D. Suvremeni pristup u dijagnostici i liječenju žena s inkontinencijom mokraće i defektima dna zdjelice. Novosti u uroginekologiji.

14. Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williamsova Ginekologija. Treće izdanje. Medicinska naklada.

15. Campbell RM. The anatomy and histology of the sacrouterine ligaments. Am J Obstet Gynecol. 1950 Jan;59(1):1–12.

16. Range RL, Woodburne RT. The gross and microscopic anatomy of the transverse cervical ligament. Am J Obstet Gynecol. 1964 Oct;90(4):460–7.

17. Pelvic Organ Prolapse: Introduction, Nonsurgical Management, and Planning of Surgical Repair | Abdominal Key [Internet]. [cited 2025 Jun 4]. Available from: https://abdominalkey.com/pelvic-organ-prolapse-introduction-nonsurgical-management-and-planning-of-surgical-repair/

18. Cardozo L, Rovner E, Wagg A, Wein A, Abrams P. Incontinence. 7th ed. 2023.

19. DeLancey JO. Anatomy and physiology of urinary continence. Clin Obstet Gynecol. 1990 Jun;33(2):298–307.

20. Enhorning G. Simultaneous recording of intravesical and intra-urethral pressure. A study on urethral closure in normal and stress incontinent women. Acta Chir Scand Suppl. 1961;Suppl 276:1–68.

21. Fantl JA, Hurt WG, Bump RC, Dunn LJ, Choi SC. Urethral axis and sphincteric function. Am J Obstet Gynecol. 1986 Sep;155(3):554–8.

22. Kujansuu E, Kauppila A, Lähde S. Correlation between Urethrovesical Anatomy and Urethral Closure Function in Female Stress Urinary Incontinence before and after Operation: Urethrocystographic and Urethrocystometric Evaluation. Urol Int. 1983;38(1):19–24.

23. Critchley HOD, Dixon JS, Gosling JA. Comparative Study of the Periurethral and Perianal Parts of the Human Levator ani Muscle. Urol Int. 1980;35(3):226–32.

24. Parks AG, Porter NH, Melzak J. Experimental study of the reflex mechanism controlling the muscles of the pelvic floor. Dis Colon Rectum. 1962 Nov;5(6):407–14.

25. McGuire E. Urethral Sphincter Mechanisms. Urol Clin North Am. 1979 Feb;6(1):39–49.

26. Olesen KP, Walter S, Hald T. Anterior Bladder Suspension Defects in the Female: Radiological Classification with Urodynamic Evaluation. Anatomically Corrective Operations. Acta Obstet Gynecol Scand. 1980 Jan;59(6):535–42.

27. Constantinou CE, Govan DE. Spatial Distribution and Timing of Transmitted and Reflexly Generated Urethral Pressures in Healthy Women. J Urol. 1982 May;127(5):964–9.

28. DeLancey JO. Structural aspects of the extrinsic continence mechanism. Obstet Gynecol. 1988 Sep;72(3 Pt 1):296–301.

29. DeLancey JO. Correlative study of paraurethral anatomy. Obstet Gynecol. 1986 Jul;68(1):91–7.

30. Oelrich TM. The striated urogenital sphincter muscle in the female. Anat Rec. 1983 Feb;205(2):223–32.

31. Huisman AB. Aspects on the anatomy of the female urethra with special relation to urinary continence. Contrib Gynecol Obstet. 1983;10:1–31.

32. Reid GC, DeLancey JO, Hopkins MP, Roberts JA, Morley GW. Urinary incontinence following radical vulvectomy. Obstet Gynecol. 1990 May;75(5):852–8.

33. Rud T, Andersson KE, Asmussen M, Hunting A, Ulmsten U. Factors maintaining the intraurethral pressure in women. Invest Urol. 1980 Jan;17(4):343–7.

34. Iglesia CB, Smithling KR. Pelvic Organ Prolapse. Am Fam Physician. 2017 Aug 1;96(3):179–85.

35. Jelovsek JE, Maher C, Barber MD. Pelvic organ prolapse. The Lancet. 2007 Mar;369(9566):1027–38.

36. Kobashi KC, Leach GE. Pelvic prolapse. J Urol. 2000 Dec;164(6):1879–90.

37. Bartscht KD, DeLancey JO. A technique to study the passive supports of the uterus. Obstet Gynecol. 1988 Dec;72(6):940–3.

38. Baah-Dwomoh A, McGuire J, Tan T, De Vita R. Mechanical Properties of Female Reproductive Organs and Supporting Connective Tissues: A Review of the Current State of Knowledge. Appl Mech Rev. 2016 Nov 1;68(6):060801.

39. Badiou W, Granier G, Bousquet PJ, Monrozies X, Mares P, de Tayrac R. Comparative histological analysis of anterior vaginal wall in women with pelvic organ prolapse or control subjects. A pilot study. Int Urogynecol J Pelvic Floor Dysfunct. 2008 May;19(5):723–9.

40. Jaszczak SE, Evans TN. Intrafascial abdominal and vaginal hysterectomy: a reappraisal. Obstet Gynecol. 1982 Apr;59(4):435–44.

41. Conde‐Agudelo A. Intrafascial abdominal hysterectomy: outcomes and complications of 867 operations. Int J Gynecol Obstet. 2000 Mar;68(3):233–9.

42. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the women’s health initiative: Gravity and gravidity. Am J Obstet Gynecol. 2002 Jun;186(6):1160–6.

43. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol. 1981 Mar;57(3):357–62.

44. Muro S, Akita K. Pelvic floor and perineal muscles: a dynamic coordination between skeletal and smooth muscles on pelvic floor stabilization. Anat Sci Int. 2023 Jul;98(3):407–25.

45. Shafik A, Asaad S, Doss S. The histomorphologic structure of the levator ani muscle and its functional significance. Int Urogynecol J Pelvic Floor Dysfunct. 2002;13(2):116–24; discussion 124.

46. Beck DE, Allen NL. Rectocele. Clin Colon Rectal Surg. 2010 Jun;23(2):90–8.

47. Olsen AL, Smith VJ, Bergstrom JO, Colling JC, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol. 1997 Apr;89(4):501–6.

48. Pollak J, Davila GW. Rectocele Repair: The Gynecologic Approach. Clin Colon Rectal Surg. 2003;16(1):061–70.

49. Milley PS, Nichols DH. A correlative investigation of the human rectovaginal septum. Anat Rec. 1969 Mar;163(3):443–51.

50. Luo J, Larson KA, Fenner DE, Ashton-Miller JA, DeLancey JOL. Posterior vaginal prolapse shape and position changes at maximal Valsalva seen in 3-D MRI-based models. Int Urogynecology J. 2012 Sep;23(9):1301–6.

51. Nichols DH, Randall CL. Vaginal surgery. 4. ed. Baltimore London: Williams & Wilkins; 1996. 585 p.