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ABOG Urogynecology and Reconstructive Pelvic Surgery study materials
ABOG Urogynecology and Reconstructive Pelvic Surgery study resources

ABOG Urogynecology and Reconstructive Pelvic Surgery: Female Pelvic Floor Anatomy and Physiology

ABOG Urogynecology and Reconstructive Pelvic Surgery · Work through your exam, one topic at a time.

All guide sections

Female Pelvic Floor Anatomy and Physiology

Core anatomy

The levator ani (pubococcygeus, puborectalis, iliococcygeus) forms the funnel-shaped pelvic diaphragm, with the arcus tendineus levator ani as its lateral attachment. The puborectalis sling maintains the anorectal angle. The endopelvic fascia (uterosacral-cardinal complex, arcus tendineus fascia pelvis) suspends the cervix and upper vagina; Level I (DeLancey) suspension failure produces apical descent and often anterior wall prolapse. The urethra is supported by the pubourethral ligaments and suburethral hammock (pubocervical fascia), the basis of midurethral sling theory.

Physiology and continence

Continence depends on urethral closure pressure exceeding intravesical pressure at rest and with stress. The urethral sphincter has intrinsic (smooth and striated sphincter) and extrinsic (levator, connective tissue) components. The pudendal nerve (S2–S4) supplies the external sphincter and levator; the detrusor is parasympathetic (S2–S4) with sympathetic beta-3 relaxation during storage and alpha-mediated bladder neck closure.

Question traps

  • Confusing the arcus tendineus levator ani (muscle origin) with the arcus tendineus fascia pelvis (fascial attachment).
  • Assuming the cardinal ligaments are the primary anterior support; anterior support is the pubocervical fascia and ATFP.
  • Attributing stress continence solely to sphincter pressure and forgetting urethral support and coaptation.
  • Mixing nerve roots: pudendal S2–S4; obturator L2–L4 (thigh adduction, not continence).

Rule of thumb

Level I (apical) defects are the keystone: restore apical suspension and anterior/posterior prolapse often improves. When a question describes a large cystocele with a descended apex, think Level I failure first.