17 - Pelvic Floor Flashcards
Pelvic floor is constructed of?
Support structures
- levator ani
- urogenital diaphragm
- perineum
- vagina
Pelvic organs
- vagina
- uterus
- bladder
- rectum
Anatomy Slides
300-301
Chronic pelvic pain definition?
Defined by ACOG:
- Noncyclic pain that persists for 6+ months
- Pain localized to:
- anatomic pelvis,
- anterior abdominal wall (at or below umbilicus)
- lumbosacral back/buttocks - Causes Functional disability or medical intervention
Who gets chronic pelvic pain?
Men or women
CPP is often associated with?
IBS Interstitial cystitis Vulvodynia Fibromyalgia Psycogenic seizure d/o
CPP is often misdiagnosed as?
Endometrosis
- even though the sx are more cyclic
CPP comorbids?
Functional somatic syndromes
- fibromyalgia
- chronic fatigue syndrome
- temporomandibular d/o
- migraine
H and P concerns for CPP?
Physical exam can be very painful for pt
- go slow and allow for relaxation
- let pt be in charge (stopping)
CPP physical ___ is indicated?
Rectal exam
Exam findings for CPP?
Allodynia (pain to non-painful stuff)
Hyperalgesia (extreme pain response)
Gait abnormalities
Vulvar varicosities
___ if found in 1/4 of CPP cases on laproscopy?
Pelvic adhesions
- organ to organ
- organ to wall
What is pelvic congestion syndrome?
Retrograde blood flow through incompetent valves -> tortuous congested ovarian or pelvic veins
Pelvic congestions syndrome s/s?
Pelivic ache or heaviness - worsens premenstrually Varicosities React to estrogen Sx improve w menopause
Tx for pelvic congestion syndrome?
Hormonal suppression
Ovarian vein embolization
Hysterectomy w BSO
Meds that may help CPP?
Antidepressants
- TCA
- SSRI
- Novel antidepressants
Antiepileptic drugs
- 1st gen agetns
- 2nd gen agents
Slide 25 (original) if you want a more in depth list
What is vulvodynia?
Vulvar discomfort
- min 3-6 months w/o cause
Sx of vulvodynia?
Pain that is:
- Burning
- Rawness
- Itching
- Cutting
Lacks specific diagnostic physical signs
Dermatosis
ISSVD classification of vulvar pain?
Specific D/O
- infectious
- inflammatory
- neoplastic
- neurologic
Vulvodynia
- generalized
- provoked
- unprovoked
- mixed
Localized pain (vestibulodynia, clitorodynia, hemivulvodynia)
- provoked
- unprovoked
- mixed
Tx for vulvodynia?
Behavioral health 5% lidocaine Topical gabapentin Antidepressants - TCA 1st line Anticonvulsants
What should you suspect in new onset insertional dyspareunia (3-4 mo)?
localized provoked vulvodynia
Also seen with painful tampon insertion and bathing
Dx for vulvodynia?
Light touch cotton applicator in area of tenderness and redness
Tx for vulvodynia?
Symptomatic tx
- neuropathic pain meds
—(gabapentin, TCA)
- topical lidocaine
What is dyspareunia?
Painful intercourse 2/2 following D/O - vulvar - visceral - musculoskeletal - neurogenic - psychosomatic
what does the great and mighty DSM-5 diagnose dyspareunia as?
Merges dyspareunia and vaginismus into
- “genito-pelvic pain/penetration d/o”
Classifications of dyspareunia?
Primary
- onset coincident w coitarche (abuse, genital mutilation, congenital)
Secondary
- follows earlier period of pain free sex
Generalized
- occurs in all episodes of intercourse
Situational
- only w specific partners or positions
Sub classifications of dyspareunia?
Insertional
Deep
Symptoms of dyspareunia?
Vaginal discharge Vulvar pain Dysmenorrhea CPP Dysuria Scant lubrication
Common causes of dyspareunia?
Delivery Pelvic surgery Sexual abuse Mood disorder/depression Relationship satisfaction Breast-feeding
Exam for dyspareunia?
Same as cpp
- look for physical causes, disease etc
- be careful it may hurt
Tx for dyspareunia
Cause dependent but can include:
- counseling
- vaginismus-> structured desintization and counseling
- lubrication/arousal techniques
- estrogen cream (postmenopausal)
- surgery (endometrosis, adhesions etc)
What is myofascial pain syndrome?
Hyperirritable area w/in a muscle
- promotes persistent fiber contraction
- includes trigger points
Primary and secondary myofascial pain syndrome?
Primary: muscular
Secondary: endometriosis, interstitial cystitis or IBS
- chronic visceral inflammatory conditions can create pathologic changes in nearby muscles and/or nerves
What is Levator Ani syndrome?
Trigger points involving levator ani muscles
spasms of these ->
- lower abdominal pain
- low back pain
- dyspareunia
- chronic constipation
Tx for levator ani syndrome?
Reduced spasm and trigger points
- pelvic floor PT
- trigger point massage
- accupuncture/dry needling
- biofeedback/relaxation techniques/pyschotherapy
- meds
Meds for levator ani syndrome?
Analgesics Anti-inflammatory Muscle relaxants Neuroleptics Botulinum toxin
What is peripartum pelvic pain syndrome?
Pelvic girdle pain
- begins during pregnancy or immediately post partum
- prominent around Si joint
Onset of peripartum pelvic pain syndrome/?
Originate from inj or inflammation of pelvic and/or lower spine ligaments
What causes peripartum pelvic pain syndrome?
Muscle weakness
Postural adjustments of pregnancy
Hormonal changes
Wt of fetus/gravid uterus
Diagnosis of peripartum pelvic pain syndrome?
Clinical
- joint manipulation exam to recreate/provoke pain
Tx for peripartum pelvic pain syndrome?
PT
Exercise
Analgesics
What is pedundal neuralgia?
A sharp shooting pain in pedundal nerve distribution
Can include
- clitoris
- vulva
- rectum
Rare
Pedundal neuralgia what makes it better/worse?
Aggravated by sitting
Relieved by nerve blocks
Doesnt awaken from sleep
Sensory loss with pedundal neuralgia?
Nope
Tx for pedundal neuralgia?
PT Behavior mod Gabapentin/TCA Botulinum toxin Pudendal nerve stimulation Surgery - nerve decompression
3rd most common indication for hysterectomy?
Pelvic organ prolapse
What is pelvic organ prolapse?
Protrusion of pelvic organs via vagina
Can include
- vagina
- urinary bladder : cystocele
- recutm : retrocele
- bowel : enterocele
- Uterus : procidentia
How is pelvic organ prolapse grades?
Using the pelvic organ prolapse Q system (of course)
- 6 points on vaginal wall + other measurements
- Stages 1-4
Pic of the points on 338 (review deck)
Pelvic organ prolapse risk factors?
Pregnancy
Vaginal childbirth (1.2x increase per child)
Menopause
Chronically increased intraabdominal pressure
Pelvic floor trauma
Genetic factors
Spina bifida
Symptoms of pelvic organ prolapse?
Variable
- bulge symptoms: “fullness, heaviness”
- urinary: freq, urg, retention, incontinency
- bowel: constpiation, need to digitize
- sexual
- pain
Chart on slide 342-344 (review deck)
Pelvic organ prolapse What makes it bettter what makes it worse?
Exacerbated by:
- posture
- duration of day
Relieved by:
- siting
What are splinting and digitation (pelvic organ prolapse)
Splinting: manual bolstering of prolapse to improve sx
Digitation: aids stool removal
Diagnosis of pelvic organ prolapse?
H and P
- pelvic floor impact questionnaires
PE
- Inspection of vaginal walls w single blade speculum
- pelvic floor muscle assessment
- rectovaginal exam
Why do pelvic organ prolapse pts need a rectovaginal exam?
Distinguishes retrocele from enterocele
Management of pelvic organ prolapse?
Minimal sx: observe
Symptomatic: Correct underlying issues
- estrogen (postmenopausal atrophy)
- kegel’s (mild incontinence)
- pessaries
- surgery
Patient profile for interstitial cystitis and painful bladder syndrome?
Women
Caucasians
Smokers
40 +
W unexplained chronic pelvic pain and voiding symptoms
Symptoms of interstitial cystitis and painful bladder syndrome?
General
- freq
- urgency
- pelvic pain
What causes interstitial cystitis?
Mucosal changes and reduced bladder capacity
Painful bladder syndrome pts wont have?
Bladder pathology or cystoscope findings
Interstitial cystitis and painful bladder syndrome is associated with?
Endometrosis (strong)
Also
- IBS
- gen pain d/o
- fibromyalgia
- pelvic floor dysfunction
- depression
Interstitial cystitis and painful bladder syndrome complaints?
Voiding complaints
Dyspareunia and postcoital ache
Sx worsen premenstrually
Differentiate interstitial cystitis and painful bladder syndrome?
Both have
- triad of: urgency, freq, pelvic pain
Interstitial cystitis
- characteristic mucosal changes
- reduced bladder capacity
Painful bladder syndrome
- no mucosal changes on cystoscopy
- no other bladder pathology
interstitial cystitis and painful bladder syndrome exam?
Single-digit vaginal exam
- urethral/anterior vag/bladder base tenderness
- trigger points
interstitial cystitis and painful bladder syndrome labs?
UA w culture
Cytoscopy and urodynamic studies
- hunner ulceration
- glomerulations
interstitial cystitis and painful bladder syndrome tx?
1st line
- pt education
- behavior mod
- avoid triggers/irritants
2nd line - pelvic floor PT - meds = amitriptyline = cimetidine = hydroxzyzine = pentosan = polysufate sodium (elmiron)
Incontinence factoids and incidence?
Overall prevalence 25-51% in ambulatory women (higher in nursing home)
20-40 : 7%
40-60 : 17%
60-80 : 23%
>80. : 32%
Physiologic changes in aging women that effect incontinence?
- Involuntary detrusor muscle activity increase (urge)
- bladder shrinks
- cant postpone voiding (freq)
- decreased estrogen
- renal filtration changes (GFR, ADH etc)
Estrogen decrease effect on bladder?
Atrophy of urethral mucosal seal
Loss of compliance
Bladder irritation
Types of incontinence?
Stress - leak w intraabdominal pressure Urge - strong need to void Overflow - incomplete emptying Functional - mixed Overactive bladder (urgency w/o incontinence)
Incontinence etiologies?
- DIAPPERS
D - delirium/dementia I - infection A - atrophic vaginitis/urethritis P - psychiatric d/o P - pharm agents E - endocrine disease R - restricted mobility S - stool impaction
Risk factors for incontinence?
Age Obesity Smoking Pregnancy Childbirth Menopause Urinary symptoms Cognitive impairment Functional impairment Chronic intra abdominal pressure - cough - constipation - lifting
What is supposed to happen when increase valsavla leads to downward pressure on bladder?
What happens w incontinence?
Normal:
- Countered by supportive tissue tone provided by levator ani muscles and vaginal connective tissue
Abnormal:
- loss of supportive “backboard” for urethra and bladder neck to be clamped to leads to wet undies
She lists a bunch of questionnaire questions for pt
Slides 361-364
Meds that contribute to incontininence?
ETOH A-agonist A-blocker Anticholinergics ACEI CCB COX-2 inhibitors Diuretics Narcs Thiazolidinediones
Big fucking chart on 365
Degree of incontinence?
I : only w sever stress (cough, sneeze, jumping)
II: moderate stress (rapid movement, stairs)
III: mild stress (standing)
Urge incontinence is caused by?
Detrusor instability not impaired contractile strength
Overflow incontinence is aka?
Incomplete bladder emptying
Meds to avoid w overflow incontinence?
Ca++ blockers
A agonists
MC type of incontinence?
Mixed incontinence
- urge and stress
PE for incontinence?
General inspection and neuro exam
Pelvic support assessment
- proloapse
- muscle strength
- urethral hyper-mobility during abdominal pressure (q tip test)
Bimanual exam and rectovaginal exam
Diagnostic tests for incontinence?
UA + culture
Post-void residual
Urodynamic studies
Tx for incontinence?
Conservative is MC
- pelvic floor strengthening (kegel)
- biofeedback therapy
- diet changes
- schedule voiding
- estrogen replacement
- incontinence pessary
- surgery
- meds
- nerve modultaion
Meds to treat incontinence?
Anticholinergics (effect detrusor muscle)
Imiparmine
Mirabegron
Botulinum toxin A
Nerve mods for incontinence?
Sacral neuromodulation
- implantable system for refractory
Percutaneous tibial nerve stimulation
- for refractory
Sometimes i laugh so hard
Tears run down my leg
