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Senior - OB 3 > 17 - Pelvic Floor > Flashcards

17 - Pelvic Floor Flashcards

1
Q

Pelvic floor is constructed of?

A

Support structures

  • levator ani
  • urogenital diaphragm
  • perineum
  • vagina

Pelvic organs

  • vagina
  • uterus
  • bladder
  • rectum
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2
Q

Anatomy Slides

A

300-301

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3
Q

Chronic pelvic pain definition?

A

Defined by ACOG:

  1. Noncyclic pain that persists for 6+ months
  2. Pain localized to:
    - anatomic pelvis,
    - anterior abdominal wall (at or below umbilicus)
    - lumbosacral back/buttocks
  3. Causes Functional disability or medical intervention
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4
Q

Who gets chronic pelvic pain?

A

Men or women

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5
Q

CPP is often associated with?

A 
IBS
Interstitial cystitis
Vulvodynia 
Fibromyalgia
Psycogenic seizure d/o
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6
Q

CPP is often misdiagnosed as?

A

Endometrosis

- even though the sx are more cyclic

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7
Q

CPP comorbids?

A

Functional somatic syndromes

  • fibromyalgia
  • chronic fatigue syndrome
  • temporomandibular d/o
  • migraine
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8
Q

H and P concerns for CPP?

A

Physical exam can be very painful for pt

  • go slow and allow for relaxation
  • let pt be in charge (stopping)
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9
Q

CPP physical ___ is indicated?

A

Rectal exam

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10
Q

Exam findings for CPP?

A

Allodynia (pain to non-painful stuff)

Hyperalgesia (extreme pain response)

Gait abnormalities

Vulvar varicosities

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11
Q

___ if found in 1/4 of CPP cases on laproscopy?

A

Pelvic adhesions

  • organ to organ
  • organ to wall
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12
Q

What is pelvic congestion syndrome?

A

Retrograde blood flow through incompetent valves -> tortuous congested ovarian or pelvic veins

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13
Q

Pelvic congestions syndrome s/s?

A 
Pelivic ache or heaviness 
- worsens premenstrually
Varicosities 
React to estrogen 
Sx improve w menopause
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14
Q

Tx for pelvic congestion syndrome?

A

Hormonal suppression
Ovarian vein embolization
Hysterectomy w BSO

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15
Q

Meds that may help CPP?

A

Antidepressants

  • TCA
  • SSRI
  • Novel antidepressants

Antiepileptic drugs

  • 1st gen agetns
  • 2nd gen agents

Slide 25 (original) if you want a more in depth list

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16
Q

What is vulvodynia?

A

Vulvar discomfort

- min 3-6 months w/o cause

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17
Q

Sx of vulvodynia?

A

Pain that is:

  • Burning
  • Rawness
  • Itching
  • Cutting

Lacks specific diagnostic physical signs

Dermatosis

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18
Q

ISSVD classification of vulvar pain?

A

Specific D/O

  • infectious
  • inflammatory
  • neoplastic
  • neurologic

Vulvodynia

  • generalized
  • provoked
  • unprovoked
  • mixed

Localized pain (vestibulodynia, clitorodynia, hemivulvodynia)

  • provoked
  • unprovoked
  • mixed
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19
Q

Tx for vulvodynia?

A 
Behavioral health
5% lidocaine
Topical gabapentin
Antidepressants
- TCA 1st line
Anticonvulsants
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20
Q

What should you suspect in new onset insertional dyspareunia (3-4 mo)?

A

localized provoked vulvodynia

Also seen with painful tampon insertion and bathing

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21
Q

Dx for vulvodynia?

A

Light touch cotton applicator in area of tenderness and redness

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22
Q

Tx for vulvodynia?

A

Symptomatic tx
- neuropathic pain meds
—(gabapentin, TCA)
- topical lidocaine

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23
Q

What is dyspareunia?

A 
Painful intercourse
2/2 following D/O
- vulvar
- visceral
- musculoskeletal
- neurogenic
- psychosomatic
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24
Q

what does the great and mighty DSM-5 diagnose dyspareunia as?

A

Merges dyspareunia and vaginismus into

- “genito-pelvic pain/penetration d/o”

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25
Q

Classifications of dyspareunia?

A

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

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26
Q

Sub classifications of dyspareunia?

A

Insertional

Deep

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27
Q

Symptoms of dyspareunia?

A 
Vaginal discharge
Vulvar pain
Dysmenorrhea
CPP
Dysuria
Scant lubrication
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28
Q

Common causes of dyspareunia?

A 
Delivery
Pelvic surgery
Sexual abuse
Mood disorder/depression
Relationship satisfaction
Breast-feeding
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29
Q

Exam for dyspareunia?

A

Same as cpp

  • look for physical causes, disease etc
  • be careful it may hurt
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30
Q

Tx for dyspareunia

A

Cause dependent but can include:

  • counseling
  • vaginismus-> structured desintization and counseling
  • lubrication/arousal techniques
  • estrogen cream (postmenopausal)
  • surgery (endometrosis, adhesions etc)
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31
Q

What is myofascial pain syndrome?

A

Hyperirritable area w/in a muscle

  • promotes persistent fiber contraction
  • includes trigger points
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32
Q

Primary and secondary myofascial pain syndrome?

A

Primary: muscular

Secondary: endometriosis, interstitial cystitis or IBS
- chronic visceral inflammatory conditions can create pathologic changes in nearby muscles and/or nerves

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33
Q

What is Levator Ani syndrome?

A

Trigger points involving levator ani muscles

spasms of these ->

  • lower abdominal pain
  • low back pain
  • dyspareunia
  • chronic constipation
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34
Q

Tx for levator ani syndrome?

A

Reduced spasm and trigger points

  • pelvic floor PT
  • trigger point massage
  • accupuncture/dry needling
  • biofeedback/relaxation techniques/pyschotherapy
  • meds
35
Q

Meds for levator ani syndrome?

A 
Analgesics
Anti-inflammatory
Muscle relaxants
Neuroleptics
Botulinum toxin
36
Q

What is peripartum pelvic pain syndrome?

A

Pelvic girdle pain

  • begins during pregnancy or immediately post partum
  • prominent around Si joint
37
Q

Onset of peripartum pelvic pain syndrome/?

A

Originate from inj or inflammation of pelvic and/or lower spine ligaments

38
Q

What causes peripartum pelvic pain syndrome?

A

Muscle weakness
Postural adjustments of pregnancy
Hormonal changes
Wt of fetus/gravid uterus

39
Q

Diagnosis of peripartum pelvic pain syndrome?

A

Clinical

- joint manipulation exam to recreate/provoke pain

40
Q

Tx for peripartum pelvic pain syndrome?

A

PT
Exercise
Analgesics

41
Q

What is pedundal neuralgia?

A

A sharp shooting pain in pedundal nerve distribution

Can include

  • clitoris
  • vulva
  • rectum

Rare

42
Q

Pedundal neuralgia what makes it better/worse?

A

Aggravated by sitting
Relieved by nerve blocks
Doesnt awaken from sleep

43
Q

Sensory loss with pedundal neuralgia?

A

Nope

44
Q

Tx for pedundal neuralgia?

A 
PT
Behavior mod
Gabapentin/TCA
Botulinum toxin
Pudendal nerve stimulation
Surgery 
- nerve decompression
45
Q

3rd most common indication for hysterectomy?

A

Pelvic organ prolapse

46
Q

What is pelvic organ prolapse?

A

Protrusion of pelvic organs via vagina

Can include

  • vagina
  • urinary bladder : cystocele
  • recutm : retrocele
  • bowel : enterocele
  • Uterus : procidentia
47
Q

How is pelvic organ prolapse grades?

A

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)

48
Q

Pelvic organ prolapse risk factors?

A

Pregnancy
Vaginal childbirth (1.2x increase per child)
Menopause
Chronically increased intraabdominal pressure
Pelvic floor trauma
Genetic factors
Spina bifida

49
Q

Symptoms of pelvic organ prolapse?

A

Variable

  • bulge symptoms: “fullness, heaviness”
  • urinary: freq, urg, retention, incontinency
  • bowel: constpiation, need to digitize
  • sexual
  • pain

Chart on slide 342-344 (review deck)

50
Q

Pelvic organ prolapse What makes it bettter what makes it worse?

A

Exacerbated by:

  • posture
  • duration of day

Relieved by:
- siting

51
Q

What are splinting and digitation (pelvic organ prolapse)

A

Splinting: manual bolstering of prolapse to improve sx

Digitation: aids stool removal

52
Q

Diagnosis of pelvic organ prolapse?

A

H and P
- pelvic floor impact questionnaires

PE

  • Inspection of vaginal walls w single blade speculum
  • pelvic floor muscle assessment
  • rectovaginal exam
53
Q

Why do pelvic organ prolapse pts need a rectovaginal exam?

A

Distinguishes retrocele from enterocele

54
Q

Management of pelvic organ prolapse?

A

Minimal sx: observe

Symptomatic: Correct underlying issues

  • estrogen (postmenopausal atrophy)
  • kegel’s (mild incontinence)
  • pessaries
  • surgery
55
Q

Patient profile for interstitial cystitis and painful bladder syndrome?

A

Women
Caucasians
Smokers
40 +

W unexplained chronic pelvic pain and voiding symptoms

56
Q

Symptoms of interstitial cystitis and painful bladder syndrome?

A

General

  • freq
  • urgency
  • pelvic pain
57
Q

What causes interstitial cystitis?

A

Mucosal changes and reduced bladder capacity

58
Q

Painful bladder syndrome pts wont have?

A

Bladder pathology or cystoscope findings

59
Q

Interstitial cystitis and painful bladder syndrome is associated with?

A

Endometrosis (strong)

Also

  • IBS
  • gen pain d/o
  • fibromyalgia
  • pelvic floor dysfunction
  • depression
60
Q

Interstitial cystitis and painful bladder syndrome complaints?

A

Voiding complaints
Dyspareunia and postcoital ache
Sx worsen premenstrually

61
Q

Differentiate interstitial cystitis and painful bladder syndrome?

A

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
62
Q

interstitial cystitis and painful bladder syndrome exam?

A

Single-digit vaginal exam

  • urethral/anterior vag/bladder base tenderness
  • trigger points
63
Q

interstitial cystitis and painful bladder syndrome labs?

A

UA w culture
Cytoscopy and urodynamic studies
- hunner ulceration
- glomerulations

64
Q

interstitial cystitis and painful bladder syndrome tx?

A

1st line

  • pt education
  • behavior mod
  • avoid triggers/irritants
2nd line
- pelvic floor PT
- meds
= amitriptyline
= cimetidine
= hydroxzyzine
= pentosan
= polysufate sodium (elmiron)
65
Q

Incontinence factoids and incidence?

A

Overall prevalence 25-51% in ambulatory women (higher in nursing home)

20-40 : 7%
40-60 : 17%
60-80 : 23%
>80. : 32%

66
Q

Physiologic changes in aging women that effect incontinence?

A
  • Involuntary detrusor muscle activity increase (urge)
  • bladder shrinks
  • cant postpone voiding (freq)
  • decreased estrogen
  • renal filtration changes (GFR, ADH etc)
67
Q

Estrogen decrease effect on bladder?

A

Atrophy of urethral mucosal seal
Loss of compliance
Bladder irritation

68
Q

Types of incontinence?

A 
Stress - leak w intraabdominal pressure
Urge - strong need to void
Overflow - incomplete emptying
Functional - mixed
Overactive bladder (urgency w/o incontinence)
69
Q

Incontinence etiologies?

- DIAPPERS

A 
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
70
Q

Risk factors for incontinence?

A 
Age
Obesity
Smoking
Pregnancy
Childbirth
Menopause
Urinary symptoms
Cognitive impairment
Functional impairment
Chronic intra abdominal pressure
- cough
- constipation
- lifting
71
Q

What is supposed to happen when increase valsavla leads to downward pressure on bladder?

What happens w incontinence?

A

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

72
Q

She lists a bunch of questionnaire questions for pt

A

Slides 361-364

73
Q

Meds that contribute to incontininence?

A 
ETOH
A-agonist
A-blocker
Anticholinergics
ACEI
CCB
COX-2 inhibitors
Diuretics 
Narcs
Thiazolidinediones

Big fucking chart on 365

74
Q

Degree of incontinence?

A

I : only w sever stress (cough, sneeze, jumping)

II: moderate stress (rapid movement, stairs)

III: mild stress (standing)

75
Q

Urge incontinence is caused by?

A

Detrusor instability not impaired contractile strength

76
Q

Overflow incontinence is aka?

A

Incomplete bladder emptying

77
Q

Meds to avoid w overflow incontinence?

A

Ca++ blockers

A agonists

78
Q

MC type of incontinence?

A

Mixed incontinence

- urge and stress

79
Q

PE for incontinence?

A

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

80
Q

Diagnostic tests for incontinence?

A

UA + culture
Post-void residual
Urodynamic studies

81
Q

Tx for incontinence?

A

Conservative is MC

  • pelvic floor strengthening (kegel)
  • biofeedback therapy
  • diet changes
  • schedule voiding
  • estrogen replacement
  • incontinence pessary
  • surgery
  • meds
  • nerve modultaion
82
Q

Meds to treat incontinence?

A

Anticholinergics (effect detrusor muscle)
Imiparmine
Mirabegron
Botulinum toxin A

83
Q

Nerve mods for incontinence?

A

Sacral neuromodulation
- implantable system for refractory

Percutaneous tibial nerve stimulation
- for refractory

84
Q

Sometimes i laugh so hard

A

Tears run down my leg

Senior - OB 3 (6 decks)

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