Urinary Incontinence in Obese females-

Urinary Incontinence and Pelvic Floor Anatomy

Pelvic floor is a dome-shaped muscular sheet segregating the pelvic cavity above from the perineal region bottom. This space surrounds the pelvic viscera – intestines, bladder, and uterus in females. {Ritchie, 2022 #1}Two kinds of muscles forming the pelvis include diaphragmatic and pubovisceral muscle groups. Diaphragmatic group is made up of the muscles which emerge from the coccygeus and the obturator membrane, their oblique attachment extending ahead, besides the arcus tendineus, and extends towards the body of the pubis through the attachment of the obturator fascia. The most anterior fibers curve back and down to form an inverted arch with the muscles of the opposite side.

Urinary incontinence in obese females

The pubovisceral group as a whole arises from a curved origin, convex upwards, from the back of the pubes. Posteriorly the origin overlaps, or is overlapped by, the extension of the arcus tendineus to the pubic bone, in front of the obturator canal. It then curves downwards, medially and forwards to reach the pubic symphysis. The pubovisceral muscles with the differing pelvic viscera of the male and female, the constituent muscles and their attachments vary. In the female the pubovisceral group arises from the curved origin from the back of the body of the pubes.

Pelvic floor and Nerve supply

There is a considerable concentration of nervous tissue in relation to the upper surface of the pelvic floor and the pelvic viscera. Much, forming into plexuses, is derived from the autonomic system. The Levator ani derives its nerve supply from two sources. Firstly, nerves arising from the sacral anterior primary Rami crossing the upper surface. Secondly, the pudendal nerve, also arising from the anterior primary rami (S2, 3, and 4, Gray’s Anatomy, 2nd edition) of the sacral nerves, reaches the ischiorectal fossa by crossing the lateral aspect of the spine of the ischium to supply the muscle by branches below the pelvic floor.

Female urinary continence depends on a complex and integrated system, which comprises the PFM, urethral sphincters (smooth and rhabdosphincter), adequate autonomic and somatic innervation, urethral support, and connective tissues.{Burti, 2015 #2} The pelvic floor muscles are found in the base of the pelvis where deep levator ani muscles and superficial muscles are also present. Changes in their function and strength can contribute to, such as urinary or fecal incontinence, pelvic organ prolapse and pelvic
pain. The main function of the pelvic floor are: To support the abdominal and pelvic viscera, To
maintain the continence of urine and faeces, Allows voiding, defaecation, sexual activity, and
childbirth. {Sarah Barnes, 2022 #3}

Pelvic Floor Physiology and Urinary Incontinence

The pelvic floor is a complex assembly of connective tissues and striated muscle that simultaneously counteract gravitational forces, inertial forces, and intra-abdominal pressures while maintaining the position of the pelvic organs. {Lucente, 2017 #4} Urinary incontinence compromises the quality of life. Observational studies indicates obesity a serious risk factor for urinary incontinence. Obesity is interlinked with high prevalence of pelvic floor problems. {Ramalingam, 2015 #5} The dysfunction of suspensory ligaments of the urethra and/or reduced contractility of the sphincter urethra due to myofascial dysfunction of the pelvic floor are also associated with urinary incontinence in women. Obesity results in increased intra-abdominal pressure and this leads to weakening of the pelvic floor innervation and musculature {Sinn, 2018}

References
  1. Ritchie, L. (2022). “Pelvic Floor Anatomy.” Physiopedia.
  2. Burti, J. S., et al. (2015). “Is there any difference in pelvic floor muscles performance between continent and incontinent women?” Neurourology and urodynamics 34(6): 544-548.
  3. Sarah Barnes, C. V. W., Amy McCarthy (2022). “Pelvic Floor Dysfunction.” Physiopedia.
  4. Lucente, V., et al. (2017). “Biomechanical paradigm and interpretation of female pelvic floor conditions before a treatment.” International journal of women’s health 9: 521.
  5. Ramalingam, K. and A. Monga (2015). “Obesity and pelvic floor dysfunction.” Best practice & research clinical obstetrics & gynaecology 29(4): 541-547.
  6. Sinn, C. N. (2018). “Pelvic Floor Disorders.”