1034
U N I T 1 1
Genitourinary and Reproductive Function
In the female anatomy, nature is faced with the prob-
lems of supporting the pelvic viscera against the force
of gravity and the increases in intra-abdominal pressure
associated with coughing, sneezing, defecation, and
laughing, while at the same time allowing for urination,
defecation, and normal reproductive tract function,
especially the delivery of an infant.
Relaxation of the pelvic outlet usually comes about
because of overstretching of the perineal supporting tis-
sues during pregnancy and childbirth or years of pro-
longed straining with hard stools. Although the tissues
are stretched only during these times, there may be no
difficulty until later in life, such as in the fifth or sixth
decade, when further loss of elasticity and muscle tone
occurs. Even in a woman who has not borne children,
the combination of aging and postmenopausal changes
may give rise to problems related to relaxation of the
pelvic support structures. The three most common con-
ditions associated with this relaxation are cystocele,
rectocele, and uterine prolapse.
36
These may occur sepa-
rately or together.
Cystocele
is a herniation of the bladder into the
vagina. It occurs when the normal muscle support for
the bladder is weakened, and the bladder sags below
the uterus. This causes the anterior vaginal wall to
stretch and bulge downward, allowing the bladder
to herniate into the vagina due to the force of grav-
ity and pressures from coughing, lifting, or straining
at stool (see Fig. 40-13B). The symptoms of cystocele
include an annoying bearing-down sensation, difficulty
Small bowel
Rectovaginal septum
and uterosacral ligaments
Uterus
Bladder
Urethra
Vagina
Rectum
Intact perineum
A
C
D
B
Cervix
Vaginal rectal fascia
FIGURE 40-13.
(A)
Normal support of the uterus and vagina,
(B)
cystocele,
(C)
rectocele, and
(D)
uterine prolapse.
Bulbocavernosus Ischiocavernosus
Ischial
tuberosity
Levator ani
Anus External anal sphincter
Femur
Gluteus
maximus
Transverse
perineal
Pubis
FIGURE 40-14.
Muscles of the pelvic floor (female perineum).
