Endopelvic fascia

Last revised by Vikas Shah on 6 Sep 2020

The endopelvic fascia is the enveloping connective tissue network for the pelvic viscera, suspending, supporting and fusing the pelvic organs to the arcus tendineus fasciae pelvis, which itself inserts onto the pelvic sidewalls and pubic bones.

The major anterior component is the pubovesical ligaments, attaching between the pubic symphysis, bladder and anterior vaginal wall. Posteriorly, the major component is the rectovaginal fascia between the anterior rectal wall and the posterior wall of the vagina.

Three levels of endopelvic fascial support have been described:

  • level 1 suspends the upper portion of the vagina and the uterine cervix
  • level 2 supports the middle portion of the vagina and the posterior bladder wall
  • level 3 attaches the lower portion of the vagina to the perineal membrane, and also includes the urethral suspensory ligaments 

The fascia cannot be seen on imaging, but damage to the fascia can be inferred by the presence of various signs. The upper third of the vagina usually has a horizontal appearance, but in the event of damage to the level 1 fascia, the lateral support is lost and the vagina may have an inverted V shape, known as the chevron sign. The middle third of the vagina usually has a H or W shape on axial imaging, and loss of the level 2 fascia along with puborectalis dehiscence, may lead to loss of the normal shape on one or both sides. Loss of the paravaginal ligaments leads to loss of support of the posterolateral aspect of the bladder and the saddlebag bladder sign. Damage to the pubovesical ligaments and rectovaginal fascia may also lead to the development of cystoceles and rectoceles, respectively. Finally, damage to the level 3 fascia and the periurethral ligaments leads to posterior drooping of the lateral corners of the retropubic fat, leading to the drooping moustache sign.

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