Midterm Flashcards
4 types of pelvis
gynecoid
android
anthropoid
platypelloid
best type of pelvis for childbirth
gynecoid
type of pelvis that is triangular
android
type of pelvis that is wider side to side than front to back
anthropoid
where is the “true Pelvis”
below arcuate line
what ligg secures the pubic symphysis
superior arcuate pubic lig
where does pudendal N exit
greater sciatic foramen
why would cutting the sacrospinous lig be bad
the coccygeous muscle attaches to this = poor PF function
uterus in relation to bladder position
uterus rests on bladder (bladder supports it)
ovaries attach to the pelvic wall via what lig
suspensory lig
ovaries attach to uterus via what lig
ovarian lig
rectum is at what sacral segment
3
nerve to bladder
vesicle N plexus of the inferior hypogastric plexus
which system stores which system “pees”
sympathetic N system stores
parasymp system pees
how micturation occurs
PF mm relax and detrussor contracts
lig that gets stretched with preg causing pain
round
this lig attaches from both sides of the uterus to the sacrum
uterosacral
what is one simple tx for hyped up autonaumic system resulting in bowel dysfunction
diaphragmatic breathing
what is sampling
when feces goes into the anal canal
how a bowel movement occurs (muscle involvement)
relaxation of puborectalis and external anal sphincter
this structure houses all external genetalia (including the vulva)
urogenital triange
where round uterus lig ends
labia
what makes up the vulva
mons pubis
labia minor and major
clitoris
vestibule of vagina
what are the 2 vestibular glands
bartholin
skenes
what muscles make up the pelvic floor
3 levator ani and the coccygeous
what are the 3 levator ani muscles
PIP
pubococcygeous
ileococcygeuos
puborectalis
1st layer consists of
ischiocavernosis
bulbospongiosis
superficial transverse perineal
external anal sphincter
function of layer 1
sexual function
second layer consists of
deep transverse perineal
urethral sphincter
compressor urethra
3rd layer consists of
the levator ani muscles
PIP
function of 3 layer
support of internal organs
what muscle is often tight if PF muscles are tight
obturator internus
what serves as an anchor for the vaginal and anal canals
perineal body
helps prevent prolapse
this is a fibromusular mass where PF muscles insert. This is found btwn the 2 trianges. This is the barrier btwn vagina and rectum.
perineal body
what N supplies the perineum
pudendal
what keeps bladder off the floor
S2,3,4
3 branches of pudendal nerve supply what 3 structures
clitoris
vagina
rectum
after pudendal nerve exits the foramen it pierces what muscle
obturatur internus, then it travels to alcocks canal
what time frame is considered chronic pelvic pain
over 6 months
PID is aka
hydrosalpinx
pts with PID have often had what in their medical hx
STD
PID usually has what sx
urinary urgency
what position can flare up PID
prolonged standing
Involuntary loss of urine from a sudden increase in abdominal pressure or a physical stress (cough, sneeze, laugh, run, jump or shout)
this is what type of incontinence
stress
this is what type of incontinence
Involuntary loss of urine from an abrupt/strong desire to void (“gotta go, gotta go right now…)
urge
why is bladder distention an issue
When the bladder is overdistended, urine cannot be eliminated efficiently d/t decreased contractility of the detrusor muscle, overstretched detrusor muscle or urethral obstruction
Frequent dribbling of urine, especially right
after void, d/t overdistension of the bladder
what type of incont.
overflow
effect of estrogen on incontinence
decreased estrogen increases risk for inc.
Symptoms of overflow incontinence
can include dribbling, urge or stress incontinence.
causes of overflow inc.
Medications
Diabetic neuropathy
Neurological conditions
Pelvic organ prolapse
Rectal prolapse vs rectocele:
tissue coming out of anus is rectal prolapse
rectocele is if you feel it vaginally (rectum bulging into vagina)
3 types of pelvic organ prolapse
Ant wall issues: urethra or bladder is falling
cystocele, urethracele or both
Post wall issues: rectal is protruding
Apical – uterus is issue
straining (valsalva) does what to PF muscles
weakens them
stages of prolapse
0-4
Bristol BM scale
Type 1: Hard lumps, like nuts (hard to pass)
Type 2: Sausage-shaped, but lumpy
Type 3: Sausage-like with cracks on its surface
Type 4: Sausage or snake-like, smooth & soft
Type 5: Soft blobs with clear edges that pass easily
Type 6: Fluffy pieces with ragged edges, a mushy stool
Type 7: Watery, no solid pieces. Entirely liquid
this describes what
purpose of this is to evaluate the physiology and pathophysiology of the bladder and urethra
To reproduce the patient’s symptoms in a controlled environment by filling the bladder with saline via a catheter
A transducer records information about bladder filling/emptying
The contraction/relaxation of the detrusor and PFM can be assessed as well.
urodynamic testing
EMG and RTUS (real-time ultrasound)
contraindications of a PF internal exam
Pregnancy (unless physician/midwife ok) Active infection < 6 weeks postpartum A young child Special consideration of those with a hx of abuse (especially sexual)
where you should get clearance from prior to a PF internal exam
OB/GYN
your place of employment
your state practice act
what is first layer of a pelvic floor exam
Examiner’s finger is inserted into vagina to 1st knuckle, assess tone, pt contracts & relaxes PFM
what is second layer of a PF internal exam
Insert finger to 2nd knuckle, assess tone – pt ctx/relaxes PFM
what is 3rd layer of a PF internal exam
Insert finger to MCP, assess tone, pt ctx/relax PFM, assess strength & sensation at each lateral wall. Grade w/ MMT scale…(always move finger slowly)
Laycock’s PERFECT Scale
power endurance reps fast twith every contraction time
how to objectify PF mm contraction
what is q tip test
Gently use the tip of a Q-tip to palpate around the vestibule in a “clockwise direction,” assessing for areas of sensitivity/pain
what is pop q test
For pelvic organ prolapse. With 2 fingers in the vagina, press down as pt bears down, looking for anterior vaginal wall descent, then press up to look for posterior wall bulging. Grade as a Level I-IV
what is a perineometer
a probe is inserted into the vagina, which is attached to a small apparatus that shows the pressure change in millimeters of mercury when the PFMs are contracted
placement of electrodes for pelvic EMG
Surface electrodes are placed on either side of anus or Internal electrode (with lubricant on tip) is placed into the vaginal opening
normal tone on EMG is
Normal Resting Tone: < 2 mV
if too freq voiding is an issue, teach pt to try and wait how long btwn voids
15-30 min
goal for pts who void to freq (how long to hold)
3 hrs
for pts who are working on urnary freq…to avoid voiding too early, pts should contract ____ to supress the urge if too much freq is a prob
To avoid voiding early, pt should ctx her PFM to suppress the urge…
important part of Kegal teaching
manual is needed, more than 1/2 of women do it incorrectly
how to progress PF position
start supine, transition to other positions, functional tasks, coughing and sneezing
is EMG a measurement of strength
no- it tests muscle recruitment
main components of bladder retraining
Contract PFM
Sit
Deep breathing
Mental task/distraction
what is uptraining and downtraining
up-strengthening
down-relaxaion
techniques for urge control problems
Contracting the PFM, will reflexively inhibit the detrusor muscle of the bladder
Distract yourself
Relax by performing diaphragmatic breathing exercises
Walk calmly to the bathroom
You control your bladder
intervaginal estim can help with
PF muscles if they cannot even fire a twitch contraction - can help with UI
will urge inc meds help with stress inc
NO
how meds for urge inc help
relaxes smooth muscle (detrussor) allowing storage, not peeing
list the urge inc meds
Oxybutynin Detrol Ditropan Sanctura Vessicare
study with PFM strengthening with therex vs estim
therex is better
research on inc, behavioral therapy vs drugs (for urge)
behavioral therapy better
what is a pessory
orthotic to support vag wall
dyspareunia
pain with penetration
typical muscle imbalance of pelvic pain pts
Stretched and weakened abdominals
Shortened thoracolumbar fascia
Shortened back extensors
short iliopsoas
coccydynia
Due to fall or childbirth injury
Strains the PFM
Pain often with sitting/sit-stand/ sex/BM
vaginismus
high tone of PF muscles that often causes spasms of PFM, sx of dysparenia
3 types of constipation
Slow transit
Dyssynergic pelvic floor/obstructive defecation (anismus) – starts as child
IBS (constipation predominate)
T or F, all pts with IBS only experience diarrhea
F, can be constipation or diarrhea
when Vestibule is covered with non-keratinized epithelium & is highly sensitive
vestibulodynia
on the labia majora, a thickened patch of dermis with thin scaly epidermal overlay
lichens sclerosus
nursing does what to estrogen
decreases it - can dry out your tissues
decreasing oxalates in diet can help with what
decrease irritation to tissues
these irratate vulva
what is this dx
These pts have very inflamed bladder covered with ulcers, they have to urinate q 10 min, this is VERY painful (40 times a day).
This is different than urge incontinence (the urge isn’t there, just severe pain over the bladder)
Hunners ulcers may be present
interstitial cystitis
Elmiron treats what
it’s the gold standard for interstitial cystitis
it recoats the bladder wall
goal for pts with IC is to
increase time btwn voids
this form of tx should be performed first with almost all conditions
breathing (usually diaphragmatic)
3 most common gyno surgeries
Hysterectomy
Anti-Incontinence Surgery
Prolapse Repair
2 locations of a hysterectomy incision
vertical midline or lower transverse
very common approach to hysterectomy surgery, minimally invasive
Pfannenstiel
explain Pfannesteil approach
an abdominal incision
RA mm are separated from the fascia and not cut
possible post op problems of a Pfannesteil approach
top of vagina is not always sewn back to uterosacral lig
scar pain, nerve issues re: sensation or orgasm and core muscle weakness
explain a vaginal hysterectomy
Steps are performed in reverse
Patient positioned in “dorsal lithotomy”
Much less invasive than abd cut
what problem may arise from being in a dorsal lithotomy position (like with a vaginal hysterectomy)
Nerve compression issues
should discuss pre op with pts about stretching into abduction
TAH
total abd hysterectomy
uterus and cervix removed
subtotal hysterectomy
cervix is left
BSO
bilateral salpingo-oopherectomy
both fallopian tubes & ovaries removed
2 surgical procedures for incontinence
MMK (Marshall-Marchetti-Krantz): Retropubic colposuspension or bladder neck suspension
Pubovaginal Sling: Midurethral sling (high incidence of voiding dysfunction)
are surgical procedures for inc guarateed to work
no, a good percentage of women still have issues
what is POP-Q
ICS (International Continence Society) developed a quotient for measuring the degree of prolapse – using a speculum & 9 measurements of the vagina
grading of prolapse
grade 1 is slight
grade 2 not at opening yet
grade 3 at opening and small protrusion
grade 4 out the door
what prolapse grade has some protrusion out the opening (start of protrusion)
3
what is important to educate pts about after post op for any gyn procedure
no valsalva
use log rolling
laxity occurs
joints and ligg loosen during preg due to
Relaxin & Estrogen
what is important to teach preg pt to do regarding their movement
move with symmetry (log rolling, avoid SLS)
what happens to pelvis and SIJ with pregnancy
more mobile
SIJ “unlocks”
PF strengthening helps support this instability
2 main SIJ liggs
ST
SS
pubic symphsis norms for separation in general
1-5
pubic symphysis norms for separation (preg)
.5-7 mm
max that has happened is 10
precautions for pub symph separation
Use precautions with 7-8 mm separation
Greater than 9.5 mm very painful
what is an easy method you can do in acute setting for pelvic separation pain and instabiilty
use gait belt as SI belt
what happens to ribs during preg
subcostal angle widens (rib cages moves upward and angle expands)
also the costo or chondral joints can get mobile
diaphragm can elevate ___ cm to accomodate for growing uterus
4cm
higher BMI means ____ pelvic rotaiton
less pelvic rotation
what predisposes a person to coccydynia
high BMI
big factor to predispose you for a diastisis
genetics
a diastisis is stretching of the
linea alba
diastisis is tested ___ cm above and below umbilicus
4.5
what lig is this
are made up of wing-like attachments that extend from the lateral margins of the uterus to the pelvic walls. Contains uterus, ovaries, and uterine tubes.
broad
broad lig is an extension of the
peritoneum
this is what lig
extends from the lateral portion of the uterus located in a fold of the peritoneum that is continuous with the broad ligament and extends outward and downward to the inguinal canal
Terminates in the upper portion of the labia majora
round
normal gestation is
37-40 wks
posture changes that occur with preg
- Lumbar lordosis
- Anterior pelvic tilt
- Posterior head position
- External rotation of hips
they often become swayback to compensate
how long does posture/balance changes stick around post preg
6-8 weeks
biggest resp change during preg
Hyperventilation to protect fetus from CO2 exposure
what causes hyperventilation during preg
progesterone
O2 uptate ___ with preg
increases
why does BP decrease with preg
progesterone relaxes smooth tissue (BVs)
heart of mom gets displaced ____ during preg
up, forward, to left
BP of preg mom returns to normal at ___ wks
36
side lying reduces ___in preg mothers
venous pressure
what is supine hypotensive syndrome
Aorta or Vena Cava occluded by enlarging uterus in supine position
starts about 28 weeks
Symptoms: dizziness, shortness of breath, nausea
if a pt has supine hypotensive syndrome episode, what position to put them in
left side lying
other role of progesterone during preg
temp reg
fat reg
pit drip or pitocin is the synthetic form of
oxytocin
this hormone enhances mood, decreasing risk of PPD
oxytocin
relaxin levels peak at ___ wks
12
what can increased progesterone do to GI sx
Progesterone is cause of reflux disease bc esophagus is smooth muscle
Digestion is effected-peristalsis slows – pulling water from gut =constipation
what hormone determines preg test
HCG
also causes morning sickness
premiparous
1 x preg
which stage of labor is connected to high rates of stress inc
Strong correlation between length of second stage of labor (pushing) and development of stress incontinence
bluish discoloration of cervix, labia and vagina caused by congestion of blood vessels
Chadwicks sign
normal preg wt gain
25-35 lbs
what is Meralgia Paresthetica
aka Dunlap disease
Painful cutaneous dyesthesia in 3rd trimester
Due to entrapment of nerve between inguinal ligament and enlarging abdomen
Paresthesia of lateral thigh
Chloasma
mask of preg
what MSK wrist/hand conditions may arise with preg
Dequarvains
median N issues
carpal tunnel
positions to avoid during preg
Abdominal compression
Inversion
Rapid, uncontrolled bouncing or swinging
Sharp twists
with preg pts, always raise head of your mat ___ degrees if they will be supine
45
modifications for MMT for preg women
check for diastisis
have the brace core
2 special tests to avoid for preg
Stork test or
ilio-sacral mobility tests
assymetry
what nerve tension test may be good for preg pts
seated slump
try to avoid spending more than __min in supine (for preg pt)
3
contraindications of treatment choices for preg pts
Electrotherapy (including TENS) – controversial whether to avoid just the trunk or the whole body
Ultrasound over trunk
Mechanical Traction
Diathermy
exercise during preg has been shown to do what to APGAR scores
create higher scores
normal is 8
Appearance, Pulse, Grimace, Activity, Respiration
recommendation for ex during preg
very vague
30 min of mod
rest is common sense
what is placenta previa
when placenta does not implant where it’s supposed to (high) instead it implants low and covers the cervix (if placenta is below baby) these have to be c section delivery
contraindicators for exercise during preg
Significant heart or lung disease Incompetent cervix Multiple gestation w/ risk for premature labor Persistent 2nd or 3rd trimester bleeding Placenta Previa after 26 wk’s pregnant Preterm labor during current pregnancy Ruptured membrane Pre-eclampsia/pregnancy-induced HTN
good range for RPE for preg women exercising
12-14 “mod to somewhat difficult” on RPE Scale
best form of exercise for preg women
water
medical clearance for post partum exercise
usually 6 wks after vaginal birth and 8 weeks after cesarean birth
nursing moms need ____ extra calories per day
500 (luckies!!)
precaution/method for a diastisis pt who wants to exercise
if > 2 fingers in width, the “sheet technique” should be used
position to palpate levator ani and obturator internus
• Sidelying, test side “up,” pillows to support top leg
Founding “mother” of WH PT
Elizabeth Noble
in 1975 she Formed a special interest group (SIG) on obstetrics and gynecology within the APTA (later called SOWH) section of womens health
Elizabeth Noble
Layer 1 and 2 of an internal exam involve assessing tone/contraction/relaxation, what does layer 3 also introduce in addition to those
MMT
clock assessment
Laxity is due to _____ hormone
smooth muscle relaxation is due to ___ hormone
laxity (relaxin and estrogen) smooth muscle (progesterone)
which layer of muscles is the sphincter layer
2nd
Levator Ani Syndrome or Pelvic Floor Tension Myalgia
also called ___
spasms of PF
caused by trigger points in PFM or surrounding mm
