Urol. int. 31: 33-37 (1976)
The Suspensory Apparatus of the Female Bladder Neck K nud P. O lesen and Viggo G rau Department of Radiology and Department of Pathology, Gentofte Hospital, Copenhagen
Key Words. Stress incontinence • Bladder base insufficiency • Bladder neck suspension • Upwards backwards fixation • Ligamentous apparatus • Dissections
The simple fact that stress incontinence is rare in the male as long as he has not been prostatectomized but is quite common in the female does naturally focus interest on the support of the female bladder neck in cases of pure stress incontinence. Performing lateral cystourethrograms we have defined a characteristic type of stress incontinence, bladder base insufficiency [6]. The characteristic change from the normal is a downwards-forwards displacement of the bladder neck. Figures la, b show a continent bladder at rest and during a cough. The bladder neck is marked by the urethral catheter. The bladder neck remains closed and no contrast enters into the urethra. That the second exposure is really made during the pressure rise of the cough is controlled on the pressure flow tracings on which the exposures are marked electronically. Figures 2a, b show a stress-incontinent patient suffering from bladder base insufficiency. Comparing the two investigations, it is evident that the bladder neck in the continent person is lifted upwards-backwards by some hypo thetical sling-formed structure. This support withstands the strain ofa
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Abstract. Lateral cystourethrograms have shown a forwards-downwards displacement of the bladder neck in bladder base insufficiency, a type of stress incontinence. In search for the structure which in normal subjects prevents this displacement, a series of 10 dis sections of the female pelvic floor was undertaken. The formerly described structures: The pubo-vesical ligaments and the precervical arc are shown. As a new finding it is demonstrat ed how these structures are dependent on an upwards-backwards suspension by a strong ligament in the fascia over the levator muscle.
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O lesf.n/G rau
cough. The bladder-base-insufficient patient on the other hand has an open and dependent urethrovesical junction. This type of patient is therefore relying on the closing pressure of the posterior urethra for continence. Dur ing the cough the intravesical pressure rises above the urethral closing pressure and leakage occurs. The aim of the present work was to find this hypothetical sling-formed structure. H hiss [2, 3] has performed extensive dissections of the bladder. H utch [4] has continued this work and formed the concept of the flat bladder base. It is part of this concept that the flat part in front of the internal orifice is due to the fundus ring, a muscular sling in the bladder wall proper. In our experience, 30% of the bladder-base-insufficient patients reconstruct
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Fig. 1. Continent bladder at rest (a) and during a cough (b). Fig. 2. Stress-incontinent patient with bladder base insufficiency at rest (a) and during a cough (b.)
The Suspensory Apparatus of the Female Bladder Neck
35
the anterior flat part during micturition. We interpret this to mean that the anterior flat part in the continent bladder base is due to the supporting apparatus. K rantz [5] and Z acharin [7] among others have dissected the suspensory apparatus of the bladder neck and the urethra and describe the pubovesical ligaments. These are two strong fibrous and elastic bands which extend from the lower part of the posterior surface of the symphysis to the bladder neck with which they are intimately connected. A lbers et al. [1] concern them selves with these ligaments and the hole between the symphysis and the bladder neck. They find that this hole increases in size in women who have born children whereas it remains unaltered in men. This is interpreted as an increasing laxity of these ligaments in parous women. K rantz [5] and Z acharin [7] both consider the ligaments of importance in maintaining continence by holding the bladder neck suspended upwards forwards. The Marshall-Marchetti-Krantz operation for incontinence builds directly on this principle. The thing, however, that characterizes bladder base insufficiency is that the bladder neck is located too far anteriorly. In our hypothesis that means that the suspension from behind has become insufficient. The bladder neck then slides downwards-forwards with the secondary result that the anterior ligaments become loose.
10 dissections were carried out on women dead from non urological causes and without known urological complaints in their history. If upon opening the bladder we found macroscopic signs of cystitis the dissection was not carried through. We found identical anatomic conditions in all 10 cases. Figure 3 shows the dissected pelvic floor from the abdominal side. The symphysis pubis (s) is upwards in the picture. The roof of the bladder has been cut away and a suture has been placed in what is left of the anterior wall (v). The pubo vesical ligaments (p) are seen lining laterally the hole between the symphysis and the bladder neck. The ligaments insert broadly in the bladder neck forming anterolaterally on each side a small fibroelastic node (r). These anatomical findings are exactly as described by the authors quoted. Between the two nodes fibres are seen crossing the anterior aspect of the bladder neck (a). H utch [4] calls these the precervical arc. A few fibres are seen to ascend into the superficial layer of the bladder and small connections also
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Material
36
O lesen/G rau
extend laterally to the levator fascia. From the fibro-elastic node a strong ligament is seen to pass backwards laterally and upwards to the greater sciatic notch where it fades away (1). The ligament runs in the fascia over the levator muscle. The direction traverses the muscle fibres at an almost right angle. This ligament was found in all dissections but might consist of two smaller ligaments as in this case on the right side. The direction of the ligament indicates its function: a fixation upwards backwards of the two
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Fig. 3. Dissected pelvic floor from above. For details, see text. Fig. 4. Dissected pelvic floor from above. Oblique view. F or details, sec text.
The Suspensory Apparatus of the Female Bladder Neck
37
nodes at the bladder neck. In textbooks on anatomy, the ligament is called: arcus tendineus fasciae pelvis. Figure 4 is an oblique view where the upper pencil points at the ligament while the lower one marks the medial border of the levator muscle. Zacharin points out that the pubovesical ligaments have a rather high amount of elastic fibres. We find the same histological picture also in the node and the suspensory ligament.
Conclusion
We continue the findings on the ligamentous apparatus in front of the bladder neck made by other investigators. As a new finding, we add the dependency of this apparatus on a backwards suspension. In bladder base insufficiency, this suspension is inadequate. The urethrovesical junction therefore slides downwards-forwards with the secondary result that the pubovesical ligaments loosen. The therapeutical aim must be to restore normal conditions. An operative method of tightening the posterior sus pension should be considered.
References
K nud P. O i.esf.n , Kobenhavnsvej 35, DK-3400 HUlerod (Denmark)
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
1 A lbers, D. D. ; F aulkner, K. K. ; C heatham, W. N. ; E llee>c; e, E. F., and C oalson, R. E. : Surgical anatomy of the pubovesical (puboprostatic) ligaments. J. Urol. 109: 388-392 (1973). 2 FIeiss, R.: Beiträge zur Anatomie der ßlascnvcnen. Arch. Anat. Physiol. 5/6: 265-276 (1915). 3 FIeiss, R.: Über den Sphincter vesicae internus. Arch. Anat. Physiol. 5/6: 367-384 (1915). 4 FIütch , J. A.: Anatomy and physiology of the bladder, trigone and urethra (Butterworths, London 1972). 5 K rantz, K. E. : The anatomy of the urethra and anterior vaginal wall. Am. J. Obstet. Gynec. 62: 374-386 (1951). 6 O lesen, K. P. : Bladder base insufficiency. Urol. int. 30: 46-53 (1975). 7 Z acharin, R. F. : Stress incontinence of urine (Harper & Row, London 1972).
The Suspensory Apparatus of the Female Bladder Neck K nud P. O lesen and Viggo G rau Department of Radiology and Department of Pathology, Gentofte Hospital, Copenhagen
Key Words. Stress incontinence • Bladder base insufficiency • Bladder neck suspension • Upwards backwards fixation • Ligamentous apparatus • Dissections
The simple fact that stress incontinence is rare in the male as long as he has not been prostatectomized but is quite common in the female does naturally focus interest on the support of the female bladder neck in cases of pure stress incontinence. Performing lateral cystourethrograms we have defined a characteristic type of stress incontinence, bladder base insufficiency [6]. The characteristic change from the normal is a downwards-forwards displacement of the bladder neck. Figures la, b show a continent bladder at rest and during a cough. The bladder neck is marked by the urethral catheter. The bladder neck remains closed and no contrast enters into the urethra. That the second exposure is really made during the pressure rise of the cough is controlled on the pressure flow tracings on which the exposures are marked electronically. Figures 2a, b show a stress-incontinent patient suffering from bladder base insufficiency. Comparing the two investigations, it is evident that the bladder neck in the continent person is lifted upwards-backwards by some hypo thetical sling-formed structure. This support withstands the strain ofa
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Abstract. Lateral cystourethrograms have shown a forwards-downwards displacement of the bladder neck in bladder base insufficiency, a type of stress incontinence. In search for the structure which in normal subjects prevents this displacement, a series of 10 dis sections of the female pelvic floor was undertaken. The formerly described structures: The pubo-vesical ligaments and the precervical arc are shown. As a new finding it is demonstrat ed how these structures are dependent on an upwards-backwards suspension by a strong ligament in the fascia over the levator muscle.
34
O lesf.n/G rau
cough. The bladder-base-insufficient patient on the other hand has an open and dependent urethrovesical junction. This type of patient is therefore relying on the closing pressure of the posterior urethra for continence. Dur ing the cough the intravesical pressure rises above the urethral closing pressure and leakage occurs. The aim of the present work was to find this hypothetical sling-formed structure. H hiss [2, 3] has performed extensive dissections of the bladder. H utch [4] has continued this work and formed the concept of the flat bladder base. It is part of this concept that the flat part in front of the internal orifice is due to the fundus ring, a muscular sling in the bladder wall proper. In our experience, 30% of the bladder-base-insufficient patients reconstruct
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Fig. 1. Continent bladder at rest (a) and during a cough (b). Fig. 2. Stress-incontinent patient with bladder base insufficiency at rest (a) and during a cough (b.)
The Suspensory Apparatus of the Female Bladder Neck
35
the anterior flat part during micturition. We interpret this to mean that the anterior flat part in the continent bladder base is due to the supporting apparatus. K rantz [5] and Z acharin [7] among others have dissected the suspensory apparatus of the bladder neck and the urethra and describe the pubovesical ligaments. These are two strong fibrous and elastic bands which extend from the lower part of the posterior surface of the symphysis to the bladder neck with which they are intimately connected. A lbers et al. [1] concern them selves with these ligaments and the hole between the symphysis and the bladder neck. They find that this hole increases in size in women who have born children whereas it remains unaltered in men. This is interpreted as an increasing laxity of these ligaments in parous women. K rantz [5] and Z acharin [7] both consider the ligaments of importance in maintaining continence by holding the bladder neck suspended upwards forwards. The Marshall-Marchetti-Krantz operation for incontinence builds directly on this principle. The thing, however, that characterizes bladder base insufficiency is that the bladder neck is located too far anteriorly. In our hypothesis that means that the suspension from behind has become insufficient. The bladder neck then slides downwards-forwards with the secondary result that the anterior ligaments become loose.
10 dissections were carried out on women dead from non urological causes and without known urological complaints in their history. If upon opening the bladder we found macroscopic signs of cystitis the dissection was not carried through. We found identical anatomic conditions in all 10 cases. Figure 3 shows the dissected pelvic floor from the abdominal side. The symphysis pubis (s) is upwards in the picture. The roof of the bladder has been cut away and a suture has been placed in what is left of the anterior wall (v). The pubo vesical ligaments (p) are seen lining laterally the hole between the symphysis and the bladder neck. The ligaments insert broadly in the bladder neck forming anterolaterally on each side a small fibroelastic node (r). These anatomical findings are exactly as described by the authors quoted. Between the two nodes fibres are seen crossing the anterior aspect of the bladder neck (a). H utch [4] calls these the precervical arc. A few fibres are seen to ascend into the superficial layer of the bladder and small connections also
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Material
36
O lesen/G rau
extend laterally to the levator fascia. From the fibro-elastic node a strong ligament is seen to pass backwards laterally and upwards to the greater sciatic notch where it fades away (1). The ligament runs in the fascia over the levator muscle. The direction traverses the muscle fibres at an almost right angle. This ligament was found in all dissections but might consist of two smaller ligaments as in this case on the right side. The direction of the ligament indicates its function: a fixation upwards backwards of the two
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
Fig. 3. Dissected pelvic floor from above. For details, see text. Fig. 4. Dissected pelvic floor from above. Oblique view. F or details, sec text.
The Suspensory Apparatus of the Female Bladder Neck
37
nodes at the bladder neck. In textbooks on anatomy, the ligament is called: arcus tendineus fasciae pelvis. Figure 4 is an oblique view where the upper pencil points at the ligament while the lower one marks the medial border of the levator muscle. Zacharin points out that the pubovesical ligaments have a rather high amount of elastic fibres. We find the same histological picture also in the node and the suspensory ligament.
Conclusion
We continue the findings on the ligamentous apparatus in front of the bladder neck made by other investigators. As a new finding, we add the dependency of this apparatus on a backwards suspension. In bladder base insufficiency, this suspension is inadequate. The urethrovesical junction therefore slides downwards-forwards with the secondary result that the pubovesical ligaments loosen. The therapeutical aim must be to restore normal conditions. An operative method of tightening the posterior sus pension should be considered.
References
K nud P. O i.esf.n , Kobenhavnsvej 35, DK-3400 HUlerod (Denmark)
Downloaded by: Karolinska Institutet, University Library 130.237.122.245 - 7/15/2017 3:40:08 PM
1 A lbers, D. D. ; F aulkner, K. K. ; C heatham, W. N. ; E llee>c; e, E. F., and C oalson, R. E. : Surgical anatomy of the pubovesical (puboprostatic) ligaments. J. Urol. 109: 388-392 (1973). 2 FIeiss, R.: Beiträge zur Anatomie der ßlascnvcnen. Arch. Anat. Physiol. 5/6: 265-276 (1915). 3 FIeiss, R.: Über den Sphincter vesicae internus. Arch. Anat. Physiol. 5/6: 367-384 (1915). 4 FIütch , J. A.: Anatomy and physiology of the bladder, trigone and urethra (Butterworths, London 1972). 5 K rantz, K. E. : The anatomy of the urethra and anterior vaginal wall. Am. J. Obstet. Gynec. 62: 374-386 (1951). 6 O lesen, K. P. : Bladder base insufficiency. Urol. int. 30: 46-53 (1975). 7 Z acharin, R. F. : Stress incontinence of urine (Harper & Row, London 1972).
