Wu Yi, Dabhoiwala Noshir F, Hagoort Jaco, Tan Li-Wen, Zhang Shao-Xiang, Lamers Wouter H
Tytgat Institute for Liver and Intestinal Research, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
Institute of Computing Medicine, Biomedical Engineering College, Third Military Medical University, Chongqing, China.
J Anat. 2017 May;230(5):651-663. doi: 10.1111/joa.12598. Epub 2017 Mar 16.
The pelvic floor guards the passage of the pelvic organs to the exterior. The near-epidemic prevalence of incontinence in women continues to generate interest in the functional anatomy of the pelvic floor. However, due to its complex architecture and poor accessibility, the classical 'dissectional' approach has been unable to come up with a satisfactory description, so that many aspects of its anatomy continue to raise debate. For this reason, we opted for a 'sectional' approach, using the Chinese Visible Human project (four females, 21-35 years) and the Visible Human Project (USA; one female, 59 years) datasets to investigate age-related changes in the architecture of the anterior and middle compartments of the pelvic floor. The puborectal component of the levator ani muscle defined the levator hiatus boundary. The urethral sphincter complex consisted of a circular proximal portion (urethral sphincter proper), a sling that passed on the vaginal wall laterally to attach to the puborectal muscle (urethral compressor), and a circular portion that surrounded the distal urethra and vagina (urethrovaginal sphincter). The exclusive attachment of the urethral sphincter to soft tissues implies dependence on pelvic-floor integrity for optimal function. The vagina was circular at the introitus and gradually flattened between bladder and rectum. Well-developed fibrous tissue connected the inferior vaginal wall with urethra, rectum and pelvic floor. With eight-muscle insertions, the perineal body was a strong, irregular fibrous node that guarded the levator hiatus. Only loose areolar tissue comprising a remarkably well developed venous plexus connecting the middle and superior parts of the vagina with the lateral pelvic wall. The posterolateral boundary of the putative cardinal and sacrouterine ligaments coincided with the adventitia surrounding the mesorectum. The major difference between the young-adult and postmenopausal pelvic floor was the expansion of fat in between the components of the pelvic floor. We hypothesize that accumulation of pelvic fat compromises pelvic-floor cohesion, because the pre-pubertal pelvis contains very little fibrous and adipose tissue, and fat is an excellent lubricant.
盆底保护盆腔器官通向体外的通道。女性尿失禁近乎流行的发病率持续引发人们对盆底功能解剖学的兴趣。然而，由于其结构复杂且难以接近，经典的“解剖”方法无法给出令人满意的描述，以至于其解剖学的许多方面仍存在争议。因此，我们选择了一种“断层”方法，使用中国可视人项目（4名女性，21 - 35岁）和可视人项目（美国；1名女性，59岁）数据集来研究盆底前、中隔结构的年龄相关变化。肛提肌的耻骨直肠部分界定了提肌裂孔边界。尿道括约肌复合体由近端圆形部分（固有尿道括约肌）、一条在阴道壁外侧走行并附着于耻骨直肠肌的吊带（尿道压肌）以及围绕尿道远端和阴道的圆形部分（尿道阴道括约肌）组成。尿道括约肌仅附着于软组织意味着其最佳功能依赖于盆底的完整性。阴道在阴道口处呈圆形，在膀胱和直肠之间逐渐变平。发育良好的纤维组织将阴道下壁与尿道、直肠和盆底相连。会阴体有八块肌肉附着，是一个强壮的、不规则的纤维结节，保护着提肌裂孔。只有疏松的乳晕组织，其中包括一个连接阴道中上部与骨盆侧壁的非常发达的静脉丛。假定的主韧带和骶子宫韧带的后外侧边界与直肠系膜周围的外膜一致。年轻成年人与绝经后盆底的主要区别在于盆底各组成部分之间脂肪的增多。我们推测盆腔脂肪的堆积会损害盆底的凝聚力，因为青春期前的骨盆中纤维和脂肪组织很少，而脂肪是一种极好的润滑剂。
