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Structural Anatomy of the Posterior Pelvic Compartment As It Relates to Rectocele

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Structural Anatomy of the Posterior Pelvic Compartment As It Relates to Rectocele Structural anatomy of the posterior pelvic compartment as it relates to rectocele John O.L. DeLancey, MD Ann Arbor, Michigan OBJECTIVE: This study was undertaken to define posterior compartment structural anatomy relevant to rec- tocele. STUDY DESIGN: Dissection of 42 fresh and 22 fixed cadavers was supplemented by examination of histo- logic (n = 3) and macroscopic (n = 5) serial sections. RESULTS: Distal posterior compartment support involves connection of the halves of the perineal mem- brane (urogenital diaphragm) through the perineal body, preventing downward protrusion of the lower rec- tum. Above this level the posterior vaginal wall is held in place by sheets of bilateral endopelvic fascia that at- tach each side of the posterior vaginal wall to the pelvic diaphragm. Most of these fascial fibers attach to the vaginal wall and a few fibers unite in the midline. Pelvic floor closure by the levator ani muscles relieves pres- sure-induced stress on the midvaginal fascial supports. CONCLUSIONS: Midline perineal membrane union supports the distal posterior compartment and a fascial connection between the pelvic diaphragm and vagina supports the mid vagina. Muscular pelvic floor closure helps to relieve fascial stress. (Am J Obstet Gynecol 1999;180:815-23.) Key words: Endopelvic fascia, levator ani muscles, pelvic organ prolapse, rectocele One in every 9 American women requires surgery for Table I. Anatomic specimens problems related to defective pelvic organ support, and No. examined Age range among these women 1 in every 4 needs a second opera- tion.1 Among women with documented prolapse, 76% Dissections had defects found in support of the posterior compart- Fixed cadavers Embalmed cadavers 17 30–104 y 1 ment. Despite the common occurrence of rectocele, the Immersed cadavers 5 26–56 y structural defects responsible for its formation remain Fresh (unfixed) cadavers 42 7 mo–87 y poorly understood. Serial sections Histologic sections 3 0–29 y The pelvic organ support system has an anterior com- Macroscopic sections 5 14–64 y partment containing the urethra and bladder and a pos- TOTAL 72 0–104 y terior compartment containing the anus and rectum. The vagina, the uterus, and the endopelvic fascia that at- taches them to the pelvic walls separate these 2 compart- specific sites of anatomic defects could be identified to ments and prevent their contents from protruding down- guide more precise scientific and clinical research. ward through the urogenital hiatus in the levator ani muscles. Material and methods The study described here was carried out to define the The anatomic materials used in this study are summa- detailed anatomy of the normal structural supports of the rized in Table I. Among the specimens 14 cadavers were posterior compartment that prevent anterior protrusion nulliparous, 40 were parous, and parity could not reliably of the rectal wall. This research was necessary so that the be established for 18, either from a review of hospital records when these were available or by physical exami- nation. Six cadavers were African American and the re- From the Department of Obstetrics and Gynecology, University of maining 66 were white. Twelve had undergone hysterec- Michigan Medical Center. tomy, 1 had undergone a supracervical hysterectomy, Presented at the Seventeenth Annual Meeting of The American Gynecological and Obstetrical Society, Hot Springs, Virginia, September and 47 had intact uteri. Early in the study, during the first 3-5, 1998. 12 dissections, hysterectomy status was not noted. Reprint requests: John O.L. DeLancey, MD, L4100 Women’s Hospital, Anatomic findings reported are confined to those struc- 1500 E Medical Center Dr, Ann Arbor, MI 48109-0276. Copyright © 1999 by Mosby, Inc. tures and relationships that could be documented on dis- 0002-9378/99 $8.00 + 0 6/6/97081 section of both fresh and embalmed cadavers and verified 815 816 DeLancey April 1999 Am J Obstet Gynecol AB Fig 1. A, Peripheral attachments of perineal membrane to ischiopubic rami and direction of tension on fibers uniting through perineal body (arrows). B, These fibers have been transected, exposing unsupported distal rectum. Note level II fibers are not shown. U-shaped contour of posterior vaginal wall in level III and W-shaped contour in level II are shown. Fig 3. Sagittal histologic section of posterior vaginal wall and anorectum in 29-year-old cadaver showing thickening of con- nective tissue (outlined with dots) between vaginal wall and rec- tum in perineal body. Upper extent of this tissue is approxi- mately 2- to 3-cm area above hymenal ring. RVSp, Rectovaginal space; LMR, longitudinal muscle of rectum; IAS, internal anal Fig 2. Coronal macroscopic section of left side of 33-year-old sphincter. specimen showing connection at level of distal posterior vagina to ischiopubic ramus (IPR) by perineal membrane (PERIN MEMB) between vestibular bulb (VB) and levator ani muscle The overall arrangement of pelvic floor structures was (LAM). Note connection between levator muscle and perineal studied in specimens fixed by injection embalming. membrane. OI, Obturator internus muscle. Because these specimens are known to exhibit distorted spatial relationships,4 additional specimens were spe- with macroscopic and histologic serial cross sections. The cially fixed by an immersion technique that produces term vaginal wall is used to include the vaginal mucosa, specimens with topographic relationships that corre- submucosa, and muscularis. The term endopelvic fascia is spond to data available from living women.5 This used to denote those tissues between the vaginal muscu- process involves floating the specimen in formalin to laris and adjacent organs or the pelvic walls. Description of avoid gravity-induced sagging caused by loss of muscle different levels of support corresponds to those in an ear- tone. lier publication.2 Anatomic terms used conform to the Resistance of posterior vaginal wall support was stud- Nomina Anatomica.3 ied in fresh cadavers in a state not altered by fixation. Volume 180, Number 4 DeLancey 817 Am J Obstet Gynecol A B Fig 4. A, Macroscopic section of 14-year-old nulliparous cadaver. B, Histologic slide of Mallory trichrome–stained sec- tion of left half of 1-year-old infant. Note that most fibers of endopelvic fascia (outlined by dots) attach to lateral sulcus of posterior vaginal wall (VAG WALL) with only a small proportion of fibers connecting with fibers of contralateral side (asterisk). In B note origin of endopelvic fascia from superior fascia of levator ani muscle (LAM). OI, Obturator inter- nus muscle; URETH, urethra. During selected dissections (n = 6) in which rigor mortis and to elucidate the nature of attachments between vari- (as assessed by resistance to forearm extension) main- ous structures. tained levator ani muscle tone, downward force was ap- plied to the pelvic floor. This was done first with a finger Results in the rectum to localize applied force in a specific direc- The distal rectum abuts against the dense connective tion and then with an air-filled transparent bag to apply tissue of the perineal body (level III). The perineal body pressure to the pelvis as a whole. In addition, in 3 of the represents the central connection between the halves of specimens fixed by immersion a string was threaded the perineal membrane (urogenital diaphragm). When from the origin of the puborectalis muscle on the inner the distal rectum is subjected to increased force directed surface of the pubic bones, parallel to the muscle fibers caudally, the fibers of the perineal membrane become passing dorsal to the anorectal junction and returning to tight and resist further displacement. These fibers derive the pubic bone on the opposite side. Tension on the their lateral support from their attachment to the pelvic string was adjusted to achieve normal urogenital hiatus bones at the ischiopubic rami (Fig 1, A, and Fig 2). This size6 and perineal body position.7 This technique served layer’s ability to resist downward displacement depends as a surrogate for puborectalis muscle tone and allowed on the structural continuity between the right and left interactions of connective tissue and muscle to be simu- sides of the perineal membrane. Transection of these lated and observed. fibers in the cadaver leaves the rectum exposed and al- The in situ relationships of the organs and their sup- lows the distal rectum (Fig 1, B) to prolapse downward. portive structures were studied in serial cross sections to The connection between the halves of the perineal supplement the observations mentioned previously be- membrane extends cranially for a distance of approxi- cause dissection by its very nature distorts the specimen. mately 2 to 3 cm above the hymenal ring (Fig 3). It is Macroscopic whole-pelvis cross sections were cut from thickest and densest in the distal perineal body, becom- frozen immersion-fixed specimens at intervals ranging ing progressively thinner toward its cranial margin. This from 5 to 20 mm. region (level III) of the posterior vagina is characterized Serial histologic sections were made available to me by by a U-shaped contour, in contrast to the W-shaped con- Dr Thomas Oelrich; their preparation has previously tour seen in level II (Fig 1, A). The upper extent of the been described elsewhere.8 These were used to confirm perineal body becomes confluent with the supportive the histologic nature of the tissues present, to determine structures of level II, and these 2 levels are structurally in- the specific direction of various fibers within the pelvis, terdependent. 818 DeLancey April 1999 Am J Obstet Gynecol Fig 5. Lateral view of pelvic organs after removal of left ischial bone and ischial tuberosity. Bladder, vagina, and cervix have been cut in sagittal plane to reveal their lumens. Rectum has been left intact. A strip of posterior and lateral vagi- nal wall and its attached endopelvic fascia are shown, indicating their position relative to levator ani muscle and this fascia’s course and attachment.
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