The Pelvic Floor
Bearbeitet von Beate Carrière, Cynthia Markel Feldt
1. Auflage 2006. Buch. 496 S. ISBN 978 3 13 139211 4 Format (B x L): 17 x 24 cm
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Micturition center
Lumbar spinal cord T10–L2
Inferior hypogastric Stretch plexus receptor Pelvic nerve
Bladder
Sacral Pelvic floor spinal cord External Pudendal nerve S2–S4 urethral Stimulating sphincter Inhibitory Fig. 1.17 The nerves of the urogenital complex.
traction of the smooth muscle of the detrusor. The Anorectal Complex Micturition is initiated by opening of the bladder neck, and is continued into dilation of the urethra, The anal hiatus lies in the posterior part of the allowing urine to flow unimpeded. In the male, fibrous arch of the levator. The anal canal, sur- the bladder neck is also subject to adrenergic con- rounded by the external anal sphincter, passes trol, closing the bladder during ejaculation. through it to its external opening. As in the uro- The lower urinary tract is therefore regulated genital hiatus, striated and smooth muscles by a relatively simple reflex arc, which, however, meet in this hiatus, where they are important is under the influence of the central nervous factors in maintaining fecal continence. When system (pontine micturition center, sacral spinal either somatic or autonomic minor motor prob- cord) [Merkle 1997]. lems occur, the plasticity of the CNS should From a physiotherapeutic point of view, it accommodate to maintain function. That adapta- should be noted that the musculature of the pel- tion or plasticity will occur more easily following vic floor takes part in the physiologic control of motor learning principles. (See the section on urinary outflow. The relaxation of the muscles motor learning and motor control, pp. 21–35, of the pelvic floor needed for micturition is facili- for additional information.) tated by certain body postures, such as sitting The striated musculature in this area consists [Wennergren and Oberg 1995]. On the other of parts of the external anal sphincter, which hand, in other postures muscular activity in- receives its somatic innervation through the creases and so supports continence. These two pudendal nerve (S2–S4) (Fig. 1.18). Superiorly, examples are linked to interactions of the pelvic the sling of the puborectalis is continuous with floor muscles with central motor programming the striated external anal sphincter. Its somatic and synergic patterns [Shumway-Cook and innervation is mixed, with afferents from both Woollacott 2001]. the pudendal nerve and the sacral plexus com-
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag 1.1 Anatomy and Physiology of the Pelvic Floor 17
Fig. 1.18 The nerves of the anorectal complex.
Onuf’s nucleus
Inferior mesenteric plexus Inferior hypogastric plexus Pudendal plexus
Superior fascia of pelvic diaphragm
Nerves to levator muscle Inferior rectal nerves
Longitudinal part of levator ani Pudendal nerve Puborectalis muscle
Internal anal sphincter
External anal sphincter
municating sensory information to the CNS system.Whatisacceptedisthatthisregionre- [Roberts et al. 1988]. ceives sympathetic efferents from the inferior The motoneurons for the striated sphincters thoracic cord and the lumbar cord (T6–L2), as originate lateral to the anterior horn cells of well as parasympathetic efferents from S2–S4 the respective segments of the spinal cord (pelvic splanchnic nerves). Yamamoto et al. (Fig. 1.18). This collection of cells is known as [1978] determined the presence of nerve cell col- Onuf’s nucleus [Schr der 1981]. lections in Onuf’s nucleus supplying the smooth The smooth muscles of the internal anal muscle of the internal anal sphincter, while de- sphincter and the outer longitudinal layer are in- monstrating that the nuclei for the striated and nervated by the autonomic nervous system. smooth parts of the sphincter are difficult to se- However, the mechanisms are less well known parate. The autonomic nerves reach the rectum than those of the smooth muscle of the urinary and anal canal by way of the inferior hypogastric
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag 18 1Basics
plexus. Apart from this extramural autonomic Following injury that causes loss of function in nerve supply, both of these organs possess an in- sensory, motor, or both neurons, the patient tramural nervous network [Wedel et al. 1999] si- may experience an imbalance in function or re- milar to that of the colon segments above them. sponse in the learned motor programs. Strength- The structure and function of this network have ening weak muscles in isolation from the motor not yet been adequately defined. programs will not guarantee that the established Tonic contraction of both sphincters closes the power will automatically transform into ade- anal canal, with the internal anal sphincter con- quate motor programs. Linking motor learning tributing about 80 % and the external anal sphinc- with motor control and the interactions of sen- ter about 20 % [Stelzner 1998, Sch fer and Enck sory input and motor pattern responses will 1997]. The closure of the anal canal is also sup- lead to the most efficacious interventions. For ex- ported by the puborectalis muscle, which contri- ample, a child initially has no control over emp- butes to a sharp angling of the anorectal angle, tying the rectum. The elimination is automatic/ which in turn prevents passage of the stool reflexive and a response to tension within the from the rectum into the anal canal. Schumann rectum. The child learns through repetition and [1986] was able to show that the physiologic practice to sense afferent stimuli coming from strength of the puborectalis muscle is distinctly the increased tension within the rectum. Simul- greater in the male than in the female, and this taneously, the child learns to inhibit reflexive re- is in agreement with morphologic investigations laxation of the striated sphincter and thus learns of the structure of the sphincter apparatus bowel control. The child learns and thus practices [Fritsch et al. 2002]. According to this work, the releasing fecal matter in a seated position or anal canal in the female is closed voluntarily by squatting, depending on the local culture. In perineal contraction occurring below the level both functional positions gravity and the abdom- of the urethral and vaginal openings. The exter- inal muscles are used to assist in elimination. nal closure of the intestinal tube by muscular Thus, sitting and squatting become the environ- contraction is further enhanced internally by vas- mentally specific functional positions that a pa- cular engorgement of the corpus cavernosum tient must practice prior to being functionally in- recti (arteriovenous plexus). dependent in both retention and elimination. An- Like micturition, defecation is regulated by a other spatial position might initially be incorpo- nervous reflex arc, the details of which, however, rated, such as supine, with the legs over a gym- have not yet been completely clarified. Initially, nastic ball. This position takes away the stretch the wall of the rectal ampulla is distended by to the pelvic muscles and postural stability of an increase in fecal mass. The anatomic location the pelvic floor and back muscles needed for sit- of the corresponding stretch receptors has not ting. The patient can practice pelvic tilts while been defined. It has been established, however, contracting and relaxing the anal region. The that the response to an increase in tension in therapist should be looking for anal contraction the wall of the rectal ampulla is contraction of during both anterior and posterior tilts, as well the sphincters. When the rectum empties, the as relaxation during those movements. As the pa- sphincters are relaxed, although the striated tient is moving the ball toward and away from sphincter can “intervene” at any time and post- the hips, during tilts and squeeze/release move- pone defecation for a time by contracting volun- ments he or she will be practicing a variety of tarily. motor programs. The therapist can then move Normal defecation is aided by contraction of the patient to the sitting position and continue the anterior abdominal muscles, especially the with the same exercises. This upright position re- transversus abdominis. This increases intra- quires integration of postural programs of the abdominal pressure, and this—in contrast to the back and their interaction with abdominal mus- brief rise in intra-abdominal pressure accompa- cles for stabilization of the trunk in vertical. Pro- nying coughing and sneezing—is accompanied gressing first to a hard base, which eliminates the by relaxation of the pelvic floor, including the organ stretch to the pelvic floor, should be easier puborectalis muscle. Practicing this motor con- than a toilet surface that increases the pull of trol as a small child leads to the capacity of the gravity on the organs and the need for sphincter CNS for motor learning and thus rectal control. contraction to retain either feces or urine. Treat- As an individual over time practices the interac- ment has progressed toward using a natural en- tion of muscle groups during defecation and mic- vironment that will lead to control of both elim- turition, these patterns become motor programs. ination and retention. By understanding the in-
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag 1.1 Anatomy and Physiology of the Pelvic Floor 19 teractions between the striated and smooth- muscle anatomy with motor learning and con- Aging of Pelvic Floor Muscles trol, the therapist should be able to individualize the intervention while maintaining a highly ef- It is generally accepted that the pelvic floor is fective treatment environment. subject to the physiological process of aging. However, there have been few reliable investiga- Levator Ani–Gluteus tions of this process. Functional changes in the lower urinary tract Maximus Complex occur in the process of aging in both sexes. These The levator ani is without a doubt the key struc- are expressed specifically in a diminished bladder ture in the female pelvic floor. Its function is capacity, weaker urinary flow and increased noc- supported by the fat body of the ischioanal turia—i. e., essentially tied to the smooth-muscle fossa and the gluteus maximus, both of which structures. A tendency to weaker detrusor con- form a functional unit with the levator ani. Ana- tractions has been demonstrated in postmeno- tomically, the two muscles are connected by pausal women (Malone-Lee and Wahedna 1993, strong connective-tissue septa that cross the Sommer et al. 1990]. With weakness within the ischioanal fossa (Fig. 1.19). In a functional mag- detrusor, abdominal contraction could be used netic resonance image, the fat body of the to compensate. Teaching the CNS when to con- ischioanal fossa can be observed to shift cranially tract the abdominal muscles with relaxation of when the gluteus maximus contracts. This shift is the external sphincter for micturition, versus accompanied by a synchronous movement of the when to tighten the abdominal muscles when levator ani [Janssen et al. 2001]. Thus, the levator standing up from a chair or sneezing, while tigh- ani, ischioanal fossa, and gluteus maximus form tening the external sphincter to avoid micturi- an anatomically and functionally interlocking tion, requires two motor programs and thus repe- complex (the LFG complex) that is of great im- titive practice in both patterns. portance for the functional integrity of the pos- The functional changes of aging in the anorec- terior compartment of the pelvic floor and for tal region can be attributed to both the smooth- learned motor programs. muscle internal anal sphincter and the striated external anal sphincter. While resting pressure in the internal anal sphincter decreases with age and the muscle undergoes wasting, voluntary activity of the external anal sphincter diminishes. This has been discussed in connection with altera- tions in the composition of fibers of these muscles [Sch fer and Enck 1997]. The plasticity of the CNS and its adaptive behavior in overcoming these changes and maintaining function can be opti- mized by linking voluntary anal sphincter control with motor programs that increase inter- abdominal pressure in order to practice functional movement control of the external sphincter. In women, old injuries to the pelvic floor sus- tained during labor may impair the function of the organs involved in continence and of the le- vator ani. The connective tissue within the pelvic floor, as well as the muscle fibers themselves, have often been stretched during the latter phases of pregnancy and during delivery. If pelvic floor reconditioning is not made an integral part of the normal functional movement, these fibers Levator ani muscle Fat body of Gluteus maximus can remain stretched. With age, this motor con- the ischioanal fossa trol problem often becomes exacerbated, and the ability of the CNS to adapt is limited. Practicing Fig. 1.19 The levator ani–gluteus maximus com- pelvic patterns that encourage tightening during plex. functional activities has the greatest potential
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag 20 1Basics
for pelvic floor control—for example, sitting on a Gasparri F, Brizzi E. Significato anatomo-chirurgico compliant surface (e. g., a ball or a dome rocker). delle formazioni connetivali del piccolo bacino. Preventing or discouraging patterns that would Arch Ital Anat Embryol 1951; 66:151–169. stretch the floor, such as prolonged sitting on a Janssen U, Lienemann A, Fritsch H. Die Bedeutung commode, can be recommended. des M. levator ani-Fossa ischioanalis-Glutaeus maximus (LFG)-Komplexes f r den weiblichen Beckenboden. Ann Anat 2001; 183(Suppl):11. Acknowledgment Juenemann KP, Lue TF, Schmidt RA, Tanagko RA. Clinical significance of sacral and pudendal nerve I would like to express my thanks here to Profes- anatomy. J Urol 1988; 139:74–80. sor Darcy Umphred, who kindly helped review Kandel ER, Schwartz JH, Jessel TM. Principles of the English edition of this section, suggesting neural science, 4th ed. New York: McGraw-Hill, additions and improvements to the text. 2000. Kuo AD. The relative roles of feedforward and feed- back in the control of rhythmic movements. References Motor Control 2002; 6:129–145 Lepor H, Gregerman M, Crosby R, Mostofi FK, Walsh Burnett AL, Wesselmann U. History of the neurobiol- PC. Precise localization of the autonomic nerves ogy of the pelvis. Urology 1999; 53:1082–9. from the pelvic plexus to the corpora cavernosa: a detailed anatomical study of the adult male pel- DeGroat WC, Booth AM. Synaptic transmission in the vis. J Urol 1985; 133:207–12. pelvic ganglia. In: Maggi CA, ed. Nervous control Malone-Lee J, Wahedna I. Characterisation of detru- of the urogenital system. Chur, Switzerland: Har- sor contractile function in relation to old age. Br J wood Academic Publishers, 1993: 291–347. Urol 1993; 72:873–80. Elbadawi A, Schenk EA. A new theory of the innerva- Merkle W. Physiologie und Pathophysiologie der tion of bladder musculature, 2: innervation of the Miktion. In: Jost WH, ed. Neurologie des Becken- vesicourethral junction and external urethral bodens. Weinheim, Germany: Chapman & Hall, sphincter. J Urol 1974; 111:613–5. 1997: 39–45. Federative Committee on Anatomical Terminology, Oelrich TM. The striated urogenital sphincter muscle International Federation of Associations of Anato- in the female. Anat Rec 1983; 205:223–32. mists. Terminologia anatomica: international ana- Pernkopf E. Pernkopf anatomy: atlas of topographic tomical terminology. Stuttgart: Thieme, 1998. and applied human anatomy, ed. Platzer W, Fritsch H. Topography of the pelvic autonomic trans. Monsen H. 3rd ed. Baltimore: Urban and nerves in human fetuses between 21–29 weeks Schwarzenberg, 1989. of gestation. Anat Embryol 1989; 180:57–64. Roberts WH, Harrison CW, Mitchell DA, Fischer HF. Fritsch H. [Development of the rectal fascia; in The levator ani muscle and the nerve supply of German.] Anat Anz 1990; 170:273–80. its puborectalis component. Clin Anat 1988; 1:267–283. Fritsch H. Topography and subdivision of the pelvic Sahrmann SA. Diagnosis and treatment of movement connective tissue in human fetuses and in the impairment syndromes. St. Louis: Mosby, 2002: adult. Surg Radiol Anat 1994; 16:259–65. 19–23. Fritsch H, Fr hlich B. Development of the levator ani Sapolsky RM. Stress and plasticity in the limbic sys- muscle in human fetuses. Early Hum Dev 1994; tem. Neurochem Res 2003; 28:1735–42. 37:15–25. Sch fer R, Enck P. Physiologie und Pathophysiologie Fritsch H, K hnel W, Stelzner F. [Development and der Def kation. In: Jost WH, ed. Neurologie des clinical anatomy of the rectal adventitia: signifi- Beckenbodens. Weinheim, Germany: Chapman & cance for radical operation of rectal carcinoma; Hall, 1997: 15–22. in German.] Langenbecks Arch Chir 1996; Schr der H. Onuf’s nucleus X: a morphological study 381:237–43. of a human spinal nucleus. Anat Embryol (Berl) Fritsch H, Brenner E, Lienemann A, Ludwikowski B. 1981; 162:443–53. Anal sphincter complex: reinterpreted morphol- Schumann J. Physiologische Grundlagen kontinen- ogy and its clinical relevance. Dis Colon Rectum zerhaltender Eingriffe am Rektum und Anus. 2002; 45:188–94. Stuttgart: Thieme, 1986. Fritsch H, Lienemann A, Brenner E, Ludwikowski B. Shumway-Cook A, Woollacott MH. Motor control Clinical anatomy of the pelvic floor. Adv Anat Em- theory and practical application, 2nd ed. Balti- bryol Cell Biol 2004; 175:iii–ix, 1–64. more: Lippincott, Williams & Wilkins, 2001.
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag 1.2 The Nervous System and Motor Learning 21
Sommer P, Bauer T, Nielsen KK, Kristensen ES, Her- matter the disease or pathology that has led to mann GG, Steven K, et al. Voiding patterns and the dysfunction, a large component of the move- prevalence of incontinence in women: a question- ment itself is controlled and modified by the cen- naire survey. Br J Urol 1990; 66:12–5. tral nervous system (CNS) and its interaction with Stelzner F. Die anorektale Kontinenz. In: Stelzner F, the way in which the muscles function within the ed. Chirurgie an den viszeralen Abschlusssys- pelvic floor. Conceptual models of the regulation temen. Stuttgart: Thieme, 1998: 121–125. and control of movement by the CNS have chan- Stelzner F, Fritsch H, Fleischhauer K. Die chirurgische ged dramatically over the last few decades. In Anatomie der Genitalnerven des Mannes und ihre the 1960s, therapists were taught that movement Schonung bei der Exzision des Rektums. J Chirurg control within the nervous system was develop- 1989; 60: 228–234. mental and hierarchically based, hard-wired, Umphred DA. The limbic system: influence over and functioned by feedback. Today, students motor control and learning. In: Umphred DA, ed. learn that the motor output from the nervous sys- Neurological rehabilitation, 4th ed. St. Louis: tem is based on a dynamic systems model in Mosby, 2001: 148–177. which there is distributed function, consensus, and a feedforward program that is soft-wired Walsh PC, Donker PJ. Impotence following radical and constantly changing depending on practice, prostatectomy: insight into etiology and preven- tion. J Urol 1982; 128:492–7. environmental demands, and internal restraints within the individual. Concepts and current re- Wedel T, Roblick U, Gleiss J, Schiedeck T, Bruch HP, search relevant to the regulation of movement K hnel W, et al. Organization of the enteric ner- by the central nervous system affect the way vous system in the human colon demonstrated therapists analyze clinical problems, establishing by wholemount immunohistochemistry with spe- the scientific rationale for selecting appropriate cial reference to the submucous plexus. Ann Anat 1999; 181: 327–37. interventions; each physician therefore needs to ensure continuing education. Discussion of the Wennergren J, Oberg B. Pelvic floor exercises for CNS principles of motor learning, motor control, children: a method of treating dysfunctional void- neuroplasticity, and the neural substrates under- ing. Br J Urol 1995; 76:9–15. lying the way in which these concepts and princi- Yamamoto T, Samoti H, Ise H. Sacral spinal innerva- ples apply to pelvic floor dysfunction is just one tions of the rectal and vesical smooth muscle and piece of a much larger puzzle relating to human sphincter striated muscles. Neuroscience 1978; performance and movement. The goal of this 7:47. section is to provide an opportunity to identify these CNS variables and analyze how and why they may affect the outcome of an intervention. 1.2 The Nervous System and Motor Learning Motor Control and Motor Learning Darcy Umphred Before discussing the specific concepts behind Introduction motor control and motor learning, the basis for the general concepts used needs to be clearly Therapists throughout the world are constantly identified. Motor control is the way in which the asked to examine, evaluate, and intervene with CNS controls motor performance, and the study individuals who present large variations in move- of it developed from the sciences of neurophysiol- ment problems that affect their everyday activ- ogy and neuropsychology. Motor control mea- ities and quality of life. These functional move- surementsaremadeinunitsofmilliseconds, ment limitations generally arise from musculo- and these continue to provide basic research skeletal, neuromuscular, cardiopulmonary, and data leading to a better understanding of the integumentary problems, although organ, diges- way in which the CNS controls behavior [Kandel tive, endocrine, and a variety of other systems et al. 2000, Shumway-Cook and Woollacott may also interact and cause motor problems. 2001]. Motor learning is not defined in millise- Each system presents the therapist with different cond responses, but rather as the ability of the challenges, and many problems within each CNS to retain movement programs and then system can lead to pelvic floor dysfunction. No transfer those programs into new environments.
Carri re, The Pelvic Floor (ISBN 3131392118) c 2006 Georg Thieme Verlag