TREATMENT OF SUI

Female Pelvic Floor Anatomy:

The Pelvic Floor, Supporting
Structures, and Pelvic Organs
Sender Herschorn, MD, FRCSC
Division of Urology, Sunnybrook and Women’s College Health Sciences Centre, Toronto, Ontario

The development of novel, less invasive therapies for stress urinary inconti-
nence in women requires a thorough knowledge of the relationship between the
pathophysiology of incontinence and anatomy. This article provides a review
of the anatomy of the pelvic floor and lower urinary tract. Also discussed is
the hammock hypothesis, which describes urethral support within the pelvis
and provides an explanation of the continence mechanism.
[Rev Urol. 2004;6(suppl 5):S2-S10]

© 2004 MedReviews, LLC

Key words: Pelvis • Pelvic diaphragm • Endopelvic fascia • Urogenital diaphragm •

Urethra • Continence

T
he effective management of stress urinary incontinence (SUI) requires
knowledge of the pathophysiologic mechanisms behind the disorder. Key to
identifying these mechanisms and providing proper treatment to women
with SUI is an understanding of the anatomy and function of the female pelvic
floor and its supporting structures.

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 Female Pelvic Floor Anatomy

opposite side, they form the pelvic

diaphragm (Figure 2). The levator ani
is composed of 2 major muscles from
medial to lateral: the pubococcygeus
and iliococcygeus muscles.
The bulkier medial portion of
the levator ani is the pubococcygeus
muscle that arises from the back of
the body of the pubis and anterior
portion of the arcus tendineus. The
arcus tendineus of the levator ani is
Figure 1. (A) The diameters of the female minor pelvis (superior aperture): A, sacroiliac joint; B, iliopubic emi-
a dense connective tissue structure
nence; C and D, middle of pelvic brim; E, sacral promontory; F, pubic symphysis. (B) The female pelvis from above: that runs from the pubic ramus to
The sacrospinous ligament extends from the ischial spines to the lateral margins of the sacrum and coccyx ante- the ischial spine and courses along
riorly to the sacrotuberous ligament, which extends from the ischial tuberosity to the coccyx. The sciatic foramina
are above and below the sacrospinous ligament and anterior to the sacrotuberous ligament. Reprinted, with permission, the surface of the obturator internus
from Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092-1139.36 muscle. The muscle passes back almost
horizontally to behind the rectum. The
Bony Scaffolding tuberous ligament. Its anterior surface inner border forms the margin of the
The maintenance of continence and is muscular and constitutes the coc- levator (urogenital) hiatus, through
prevention of pelvic organ prolapse cygeus; the ligament is often regarded which passes the urethra, vagina,
rely on the support mechanisms of as the degenerate part of the muscle.1 and anorectum.
the pelvic floor. The bony pelvis con- The greater and lesser sciatic forami- Various muscle subdivisions have
sists of the 2 innominate bones, or hip na are above and below the ligament. been assigned to the medial portions
bones, which are fused to the sacrum of the pubococcygeus to reflect the
posteriorly and to each other anteri- Muscular Supports of the attachments of the muscle to the ure-
orly at the pubic symphysis. Each Pelvic Floor thra, vagina, anus, and rectum.2 These
innominate bone is composed of the Pelvic Diaphragm portions are referred to by some
ilium, ischium, and pubis, which are The levator ani and coccygeus mus- investigators as the pubourethralis,
connected by cartilage in youth but cles that are attached to the inner pubovaginalis, puboanalis, and pubo-
fused in the adult.1 The pelvis has surface of the minor pelvis form the rectalis—or collectively as the pubo-
2 basins: the major (or greater) pelvis muscular floor of the pelvis. With visceralis, because of their association
and the minor (or lesser) pelvis. The their corresponding muscles from the and attachment to the midline viscera.3
abdominal viscera occupy the major
pelvis; the minor pelvis is the narrow- Figure 2. Pelvic
er continuation of the major pelvis diaphragm.

inferiorly. The inferior pelvic outlet is

closed by the pelvic floor.
The female pelvis (Figure 1A) has a
wider diameter and a more circular
shape than that of the male. The wider
inlet facilitates head engagement
and parturition. The wider outlet pre-
disposes to subsequent pelvic floor
weakness. Numerous projections and
contours provide attachment sites for
ligaments, muscles, and fascial lay-
ers. Of note is the thin and triangular
sacrospinous ligament (Figure 1B),
which extends from the ischial spines
to the lateral margins of the sacrum
and coccyx anteriorly to the sacro-

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Female Pelvic Floor Anatomy continued

demonstrates the urogenital hiatus.7

Direct innervation of the levator
ani muscle on its cranial surface is
primarily from the third and fourth
sacral nerve roots via the pudendal
nerve.8 The puborectalis may derive
some if its innervation from a
pudendal branch on the caudal side.2
Regarding the type of the striated
muscle, it has been reported that the
majority of the muscle fibers in the
levator ani are slow-twitch fibers
that maintain constant tone (type I),9
with an increased density of fast-
Figure 3. Pelvic floor support (midsagittal section of the pelvis): (A) normal tone in the levator ani with acute
anorectal angle and horizontal levator plate; note the normal vaginal axis. (B) With loss of tone in the levator ani,
twitch (type II) fibers distributed in
there is change in the vaginal axis, sagging of the levator plate, and enlargement of the urogenital hiatus. the periurethral and perianal areas.10,11
Reprinted, with permission, from Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092-1139.36 This suggests that the normal levator
ani maintains tone in the upright
The urethral portion forms part of urogenital hiatus and predisposes to position to support the pelvic viscera.
the periurethral musculature, and the pelvic organ prolapse (Figure 3). Furthermore, voluntary squeezing
vaginal and anorectal portions insert Women with prolapse have been of the puborectalis may increase
into the vaginal walls, perineal body, shown to have an enlarged urogeni- the tone to counter increased intra-
and external anal sphincter muscle.4 tal hiatus on clinical examination.6 abdominal pressure.
The puborectalis portion passes behind The coccygeus muscle that extends
the rectum and fuses with its coun- from the ischial spine to the coccyx Urogenital Diaphragm
terpart from the opposite side to form and lower sacrum forms the posterior (Perineal Membrane)
a sling behind the anorectum. Other part of the pelvic diaphragm. It sits Another musculofascial structure, the
more posterior parts of the pubococ- on the anterior surface of the sacro- urogenital diaphragm, is present over
cygeus attach to the coccyx. spinous ligament. Three-dimensional the anterior pelvic outlet below the
The thin lateral part of the levator magnetic resonance imaging (MRI) pelvic diaphragm. However, there is
ani is the iliococcygeus muscle, which of the pelvic diaphragm (Figure 4) controversy over whether this struc-
arises from the arcus tendineus of shows its peripheral attachments and ture contains a transverse sheet of
the levator ani to the ischial spine.
Posteriorly it attaches to the last 2 Figure 4. Three-dimen-
segments of the coccyx. The fibers sional reconstructed mag-
from both sides also fuse to form a netic resonance image of a
28-year-old healthy woman
raphe and contribute to the anococ- showing pelvic floor mus-
cygeal ligament. This median raphe cles and bones. The keyhole
shape indicates normal
between the anus and the coccyx is separation of the vagina
called the levator plate and is the and rectum and intact per-
ineal body. Reprinted from
shelf on which the pelvic organs rest. Fielding JR et al. AJR
It is formed by the fusion of the ilio- Am J Roentgenol. 2000;
coccygeus and the posterior fibers of 174:657-660.7 Reprinted
with permission from
the pubococcygeus muscles. When the American Journal of
the body is in a standing position, Roentgenology.
the levator plate is horizontal and
supports the rectum and upper two
thirds of vagina above it. Weakness
of the levator ani may loosen the sling
behind the anorectum and cause the
levator plate to sag.5 This opens the

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 Female Pelvic Floor Anatomy

line between the anus and vagina

with the rectovaginal septum at its
cephalad apex.4 Below this, muscles
and their fascia converge and inter-
lace through the structure. Attached
to the perineal body are the rectum,
vaginal slips from the pubococ-
cygeus, perineal muscles, and the anal
sphincter; it also contains smooth
muscle, elastic fibers, and nerve end-
ings. During childbirth, the perineal
body distends and then recoils.12 It is
an important part of the pelvic floor;
just above it are the vagina and the
uterus. Acquired weakness of the
perineal body gives rise to elongation
and predisposes to defects such as
rectocele and enterocele.14,15 Figure 6
Figure 5. Muscles of the perineum: (A) On the subject’s right side, the membranous layer of the superficial fascia demonstrates the pelvic organs with
has been removed (note the cut edge). On the subject’s left side, the symphysis pubis, pubis, part of the ischiopubic
ramus, superficial perineal muscles, and inferior fascia of the urogenital diaphragm have been removed to show the 2 major levels of muscular sup-
the deep perineal muscles. (B) Deep perineal muscles are continuous with the sphincter urethrae. Reprinted, with port: the upper muscular structure,
permission, from Salmons S. In: Gray’s Anatomy. 1995:737-900.4
with the pelvic diaphragm, and the
lower muscular structure, with the
muscle extending across the pubic or membrane. The ischiorectal fossae perineal membrane anteriorly and
arch (deep transverse perinei muscle) are the spaces lateral to the anus anal sphincter posteriorly.
sandwiched between superior and below the pelvic diaphragm.
inferior fascia12 or 3 contiguous stri- Endopelvic Fascia and
ated muscles (compressor urethrae, Perineal Body Connective Tissue Supports
sphincter urethrae, and urethro- The perineal body is a pyramidal The bladder and urethra and the
vaginalis) and an inferior fascial fibromuscular structure in the mid- vagina and uterus are attached to the
layer called the perineal membrane
(Figure 5).4,13,14 Despite the contro- Figure 6. The 2 major muscular supporting structures: the upper, with the pelvic diaphragm, and the lower, with
versy, MRI scans clearly depict the the perineal membrane (urogenital diaphragm) anteriorly and anal sphincter posteriorly. Reprinted, with permission,
from Herschorn S, Carr LK. In: Campbell’s Urology. 2002:1092-1139.36
structure.2,12
The more superficial ischiocaver-
nosus and bulbocavernosus muscles,
as well as the thin slips of the super-
ficial transverse perinei,14 complete
the inferior aspect of the urogenital
diaphragm. The structure bridges the
gap between the inferior pubic rami
bilaterally and the perineal body. It
closes the urogenital (levator) hiatus;
supports and has a sphincter-like
effect at the distal vagina; and,
because it is attached to periurethral
striated muscles, contributes to conti-
nence. It also provides structural sup-
port for the distal urethra. The poste-
rior triangle around the anus does
not have a corresponding diaphragm

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Female Pelvic Floor Anatomy continued

Figure 7. The hammock The pubourethral ligaments are con-

hypothesis: the anterior vagi-
nal wall with its attachment to nective tissue structures that extend
the arcus tendineus of the from the urethra to the pubic bone.
pelvic fascia forms a ham-
mock under the urethra and
Various authors have described them
bladder neck. Reprinted, with as structures responsible for support-
permission, from DeLancey ing the urethra and keeping the vesi-
JOL. Am J Obstet Gynecol.
1996;175:311-319.37 cal neck closed.20-23 However, other
authors have described connective
tissue between the proximal urethra
(and vesical neck) and the pubis as
containing smooth muscle24 and
cholinergic nerves25 that make the
structures more suited to vesical neck
opening during micturition than to
urethral support. Because there is an
attachment of the lower third of the
urethra to the pubis, it is postulated
that there are 2 separate structures—
one for support at the mid- or distal
pelvic walls by a system of connec- ports of the urethra, bladder, and urethra and one near the bladder
tive tissue that has been called the vagina extend to the arcus tendineus neck that may open it during voiding.
endopelvic fascia. This structure lies of the pelvic fascia on the pelvic The distal support has been described
immediately beneath the peritoneum diaphragm.2,12,17,18 There is also agree- as connective tissue that joins the
and is one continuous unit with var- ment that a “hammock” of anterior vaginal wall and periurethral tissue
ious thickenings or condensations in vaginal wall tissue, bridging the gap to the arcus tendineus of the pelvic
specific areas. The endopelvic fascia medially in the urogenital hiatus, sup- fascia and the levator muscles.24
is continuous with the visceral fascia, ports the vesical neck and urethra.17,19 Since the arcus tendineus inserts into
which provides a capsule containing There is controversy, however, focus- the pubic bone, these are the liga-
the organs and allows displacements ing on the connective tissue structures ments that are palpable during a
and changes in volume. The distinct that are associated with this hammock. retropubic dissection. These ligaments
regions of this structure are given
individual names, specifically liga- Figure 8. Cross section of urethral supports
ments and fascia, with variable inter- below the bladder neck: The urethra is supported
by a hammock of anterior vaginal wall sus-
nal structure. Endopelvic fascia and pended to the levators (pubococcygeus muscles)
ligaments are a mesh-like group of and the fascial attachments (FA) to the tendi-
nous arch of the pelvic fascia. In essence, it is a
collagen fibers interlaced with elastin, “double hammock.” Reprinted, with permission,
smooth muscle cells, fibroblasts, and from Herschorn S, Carr LK. In: Campbell’s
Urology. 2002:1092-1139.36
vascular structures. The structures that
attach the uterus to the pelvic wall,
the cardinal ligaments, derive strength
from the supportive collagen form-
ing the walls of arteries and veins.
Other structures, such as the pelvic
sidewall attachment of the endopelvic
fascia (arcus tendineus of the pelvic
fascia), are predominantly fibrous
collagen.16

Anterior Supports
There is agreement among investiga-
tors that the connective tissue sup-

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 Female Pelvic Floor Anatomy

are important for urethral support.23 Figure 9. The cardinal and

uterosacral ligaments provide
There is controversy regarding the support to the cervix and indi-
amount of supportive tissue or fascia rectly to the bladder base. The
retropubic, vesicovaginal, and
in the anterior vaginal wall. Although rectovaginal spaces are seen at
the wall is composed of mucosa, the level of the cervix. Reprinted,
muscularis, and adventitia and abuts with permission, from Raz S
et al. In: Campbell’s Urology.
a similar arrangement in both the 1998:1059-1094.30
urethra and bladder, various authors
have attributed to it a vaginal fascial
layer. Weber and Walters18 cited many
articles on both sides of the contro-
versy and reported no specific fascial
layer, whereas DeLancey17 demon-
strated a fascial layer suburethrally
on the anterior vaginal wall. With or
without the suburethral fascial layer,
the anterior vaginal wall supports
the urethra by its lateral attachment
to the levators (pubococcygeus) and
to the endopelvic fascia from the
arcus tendineus of the pelvic fascia
(Figures 7 and 8). In essence, it is
a double hammock. Paradoxically,
the more advanced the prolapse, the
more thickened and hypertrophied is Middle Supports attached to the cervix and upper
the vaginal submucosal layer.18 The paracolpium and parametrium are vaginal fornices posterolaterally.
Urethropelvic ligaments from the the connective tissues surrounding the Posteriorly, they attach to the pre-
suburethral fascia at the bladder neck vagina and the uterus, respectively. sacral fascia in front of the sacroiliac
and proximal urethra to the levators In the midvagina, the paracolpium joint. The connective tissue of the
and arcus tendineus have been fuses with the pelvic wall and fascia uterosacral ligaments is continuous
described and demonstrated on MRI laterally.28 The cardinal ligaments (also with that of the cardinals around the
scans.12 The existence of these liga- called the transverse cervical liga- cervix. The cardinal and uterosacral
ments as separate entities apart from ments of Mackenrodt) extend from ligaments hold the uterus and upper
the hammock of tissue supporting the the lateral margins of the cervix and vagina in their proper place over the
proximal urethra has been disputed.26,27 upper vagina to the lateral pelvic levator plate.29 This supportive struc-
At the level of the bladder base, walls. They originate over a large ture is depicted in Figure 9. According
there is little actual endopelvic fascia area from the region of the greater to Raz and colleagues,30 the cardinals
between the bladder and vaginal sciatic foramen over the piriformis and uterosacrals are not directly
muscularis. Here, the support comes muscles, from the pelvic bones in the important for continence but do play
from the lateral attachment of the region of the sacroiliac joint, and a role in the support of the bladder
vagina to the arcus tendineus of the from the lateral sacrum. They are base in the surgical correction of
pelvic fascia.17 The pubocervical fas- condensations of the lowermost parts large cystoceles.
cia has been described as extending of the broad ligaments. Laterally, the
from the symphysis along the anterior cardinal ligaments are continuous with Posterior Supports
vaginal wall to blend with the fascia the connective tissue surrounding the The posterior vaginal wall, below the
that surrounds the cervix. It is contin- hypogastric vessels. Medially, they cardinals, is supported from the sides
uous laterally with the pubococcygeus are continuous with the paracolpium by the paracolpium, which is attached
and also suspended to the arcus and parametrium as well as the con- to the endopelvic fascia (referred to
tendineus of the pelvic fascia. Its exis- nective tissue in the anterior vaginal as rectovaginal fascia in this area) and
tence as a separate and discernable wall, the so-called pubocervical fascia. pelvic diaphragm. The anterior and
entity is also in dispute.18 The uterosacral ligaments are posterior fascial layers unite along the

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Female Pelvic Floor Anatomy continued

wall (level with the third sacral ver-

tebra) to the rectum and surround
the middle rectal arteries. Additional
prerectal and pararectal fascial ele-
ments are frequently described.30

Urethra
The urethra is a complex tubular
structure extending below the bladder
to the external meatus (Figure 11). It
has distinct muscular elements asso-
ciated both within and without to
permit its functioning for storage
(continence) and voiding.
Figure 10. (A) Vagina and supportive structures drawn from dissection of a 56-year-old cadaver after hysterectomy:
The bladder has been removed above the vesical neck. Paracolpium extends along the lateral wall of vagina. (B) In
The smooth muscle of the urethra
level I, paracolpium suspends vagina from the lateral pelvic walls. In level II, the vagina is attached to arcus is contiguous with that of the trigone
tendineus of pelvic fascia and superior fascia of levator ani muscles. Reprinted, with permission, from DeLancey and detrusor.32 It has a prominent
JOL. Am J Obstet Gynecol. 1992;166:1717-1728.28
inner longitudinal and a thin outer
circular layer. The layers lie inside
sides of the vagina (Figure 10). ani muscles and, posteriorly, it fuses the outer striated urogenital sphincter
According to DeLancey,28 the recto- with the perineal body. The recto- muscle and are present throughout
vaginal fascia is found mostly at the vaginal fascia is thickest in this the upper four fifths of the urethra.
sides and is extremely thin in the region,31 and the vagina in this area The configuration of the circular
midline of the vaginal wall. However, has no mobility separate from its muscle implies a role in constricting
a posterior rectovaginal septum, adjacent structures.28 the lumen, and the longitudinal mus-
consisting of fibromuscular elastic The fascial supports for the rectum, cle may aid in shortening the urethra
tissue, extending from the peritoneal the lateral rectal ligaments, extend during voiding.33
reflection to the perineal body has from the posterolateral pelvic side The outer layer of the urethra is
been described.21 During fetal life, the
peritoneal cavity extends to the cra-
nial part of the perineal body, but it Figure 11. Urethral
anatomy: the urethra
becomes obliterated in early life. Its has distinct muscular
fused layers (Denonvillier’s fascia) elements associated
both within and without
probably become part of the recto- to permit its functioning
vaginal septum adherent to the for storage and voiding.
undersurface of the posterior vaginal Reprinted, with permis-
sion, from Strohbehn K,
wall. This fascia forms the anterior DeLancey JOL. Oper
margin of another potential space, Tech Gynecol Surg.
1997;2:5-16.38
the rectovaginal space. The recto-
vaginal septum, if intact and normal,
permits independent mobility of the
rectal and vaginal walls.
In the distal vagina, 2 cm to 3 cm
above the hymeneal ring, the vaginal
wall is directly attached to surround-
ing structures without any intervening
paracolpium. Anteriorly, the vagina
fuses with the urethra and the connec-
tive tissue of the perineal membrane
and muscles (urogenital diaphragm).
Laterally, it blends with the levator

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 Female Pelvic Floor Anatomy

formed by the muscle of the striated Figure 12. Lateral view of the pelvic
floor with the urethra, vagina, and
urogenital sphincter that is found in fascial tissues transected at the level
the middle three fifths of the length. of the vesical neck, drawn from
3-dimensional reconstruction indi-
In its upper two thirds, the sphincter- cating compression of the urethra
like fibers are circular. In the distal by downward force (arrow) against
part, the fibers exit the urethra and the supportive tissues. Reprinted,
with permission, from DeLancey
surround the vaginal wall as the ure- JOL. Am J Obstet Gynecol. 1996;
throvaginal sphincter or extend 175:311-319.37

along the inferior pubic rami above

the perineal membrane as the com-
pressor urethra.1 The muscle is com-
posed mainly of slow-twitch fibers,
well suited for maintaining constant
tone.10 Voluntary muscle activation
can also increase the constriction of
the urethra when needed.
The urethral mucosa extends from In addition to the muscular and has intact neural control and pro-
the bladder transitional epithelium to vascular tissue of the urethra, there is vides watertight apposition of the
the external meatus and is primarily a considerable quantity of connec- urethral lumen, compression of the
nonkeratinizing squamous epitheli- tive tissue interspersed within the wall around the lumen, and a means
um. It is derived from the urogenital muscle and submucosa. This tissue of compensating for abdominal pres-
sinus along with the lower vagina contains collagen and elastin fibers sure changes.
and vestibule. It is hormonally sensi- and is thought to add to urethral clo-
tive and undergoes changes with stim- sure passively.33 Lastly, a series of Mechanism of Continence
ulation.33 The hormonally sensitive glands are found in the submucosa, The “hammock hypothesis” (Figure 12)
submucosal tissue contains a rich and mainly along the vaginal surface of is a readily understood way to
prominent vascular plexus. Several the urethra.34 They are most predom- explain the continence mechanism.
specialized types of arteriovenous inant in the middle and lower third The requirements for continence
anastomoses have been demonstrated, of the urethra. include a quiescent bladder, func-
and it is thought that they provide a It is the admixture of the smooth tioning musculofascial supports, and
watertight closure of the mucosal and striated muscle, connective tis- a functional urethral sphincter mech-
surface with an increase in blood sue, mucosa, and submucosa that anism. The fascial attachments
flow that may occur with an increase accounts for a functional sphincter.35 connect the periurethral tissue and
in pressure on abdominal vessels.32 A functional urethral sphincter anterior vaginal wall to the arcus

Main Points
• The levator plate, the shelf on which the pelvic organs rest, is horizontal when the body is in a standing position and supports
the rectum and upper two thirds of the vagina above it. Weakness of the levator ani may loosen the sling behind the anorectum
and cause the levator plate to sag, opening the urogenital hiatus and allowing pelvic organ prolapse.
• The urogenital diaphragm closes the levator hiatus, supports and has a sphincter-like effect at the distal vagina, provides struc-
tural support for the distal urethra, and contributes to continence in that it is attached to the periurethral striated muscles.
• There is controversy regarding whether the anterior vaginal wall includes a suburethral fascial layer; regardless, the anterior
vaginal wall provides support to the urethra by its lateral attachment to the levators and to the endopelvic fascia from the arcus
tendineus of the pelvic fascia.
• A combination of smooth and striated muscle, connective tissue, mucosa, and submucosa are necessary for a functional urethral
sphincter, which provides watertight apposition of the urethral lumen, compression of the wall around the lumen, and a means
of compensating for abdominal pressure changes.
• The “hammock hypothesis” describes support of the urethra by a coordinated action of fascia and muscles, which provides a ham-
mock onto which the urethra is compressed during increases in intra-abdominal pressure.

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Female Pelvic Floor Anatomy continued

tendineus at the pelvic sidewall, Obstet Gynecol Clin North Am. 1998;25:683-705. 1969;163:433-451.
3. Lawson JO. Pelvic anatomy I: pelvic floor mus- 22. Zacharin RF. The suspensory mechanism of the
whereas the muscular attachments cles. Ann R Coll Surg Engl. 1974;54:244-252. female urethra. J Anat. 1963;97:423-427.
connect the periurethral tissue to the 4. Salmons S. Muscle. In: Williams PL, Bannister LH, 23. Mostwin JL, Yang A, Sanders R, Genadry R.
Berry MM, et al, eds. Gray’s Anatomy. 38th ed. Radiography, sonography, and magnetic reso-
medial border of the levator ani.24 New York: Churchill Livingstone; 1995:737-900. nance imaging for stress incontinence: contri-
Urethral support is provided by a 5. Berglas B, Rubin IC. Study of the supportive butions, uses, and limitations. Urol Clin North
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Surg Gynecol Obstet. 1953;97:677-692. 24. DeLancey JOL. Pubovesical ligament: a separate
muscles acting as an integrated unit 6. DeLancey JO, Hurd WW. Size of the urogenital structure from the urethral supports (‘pubourethral
under neural control.33 This musculo- hiatus in the levator ani muscles in normal ligaments’). Neurourol Urodyn. 1989;8:53-61.
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fascial support provides a hammock Obstet Gynecol. 1998;91:364-368. Posterior pubo-urethral ligaments in normal
onto which the urethra is compressed 7. Fielding JR, Dumanli H, Schreyer AG, et al. MR- and genuine stress incontinent women. J Urol.
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8. Gosling J, Alm P, Bartch G, et al. Gross anato- nary incontinence. Br J Urol. 1993;72:715-718.
operative and adds to the process. my of the lower urinary tract. In: Abrams P, 27. Aronson MP, Bates SM, Jacoby AF, et al.
Furthermore, failure of one of the Khoury S, Wein A, eds. Incontinence: First Periurethral and paravaginal anatomy: an
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Health Publications Ltd; 1999:21-56.
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S10 VOL. 6 SUPPL. 5 2004 REVIEWS IN UROLOGY