Oral exam study Flashcards
provide origin insertion innervation function of the ischiocavernosus
O: Ischial tuberosity and ischiopubic ramus
I: crus of clitoris
N: perineal br pudendal N
F: maintains erection of the clitoris
provide origin insertion innervation function of the bulbospongiosis?
any special tests?
O: CTP
I: inferior fascia of the urogenital diaphragm, pubic bone, crus and hood of clitoris
N: perineal br of pudendal N
fucntion: decreases vaginal opening and helps maintain erection of clitoris
special test: bulbospongiosus reflex
provide origin insertion innervation function of the superficial transverse muscle
O: ischial tuberosity
I: CTP
N: perineal br of pudendal N
F: stabilizes CTP
provide origin insertion innervation function of the EAS?
any special tests?
O: ano-coccygeal raphe
I: CTP
N: sacral N root 4 & perineal br pudendal N
function: maintains anal canal and anus closed
special test: tone and contractility of sphincter on external anal palpation
what muscles make up the superficial layer of the pelvic floor?
- ischiocavernosis
- bulbospongiosus
- superficial transverse muscle
- EAS
what is the other name given to the superficial layer of the pelvic floor
the perineum
what muscles make up the urogenitial diaphragm?
what layer is that in the PFM muscle?
intermediate layer is made up of the EUS and deep transverse muscles
provide origin insertion innervation function of the EUS?
any special tests?
O: inferior pubic ramus
I: vaginal wall
N: perineal branch of pudendal
F: helps maintain continence; in men helps expulse last drop of urine
provide origin insertion innervation function of the deep transverse muscle?
any special tests?
O: ischiopubic ramus near ischial tuberosity
I: CTP
N: perineal branch of pudendal N
F: helps expulse the last drops of urine
special test: on anal palpation, can assess for tone and contractility w/ thumb and index
whats muscles make up the pubococcygeus sling?
pubovaginalis
puborectalis
pubococcygeus
provide origin insertion innervation function of the pubovaginalis?
any special tests?
O: medial most portion of the posterior surface of the pubic bone
I: urethra, CTP
N: sacral n root 3 and 4 and perineal branch of pudendal N
F: supports increases in intraabdominal pressure, elevates PFM upon contraction, decreases the diameter of the vaginal hiatus
specific test: vaginal palpation can assess for tone and contractility
treatment via facilitation, pressures, massages and lateral manual resistance
provide origin insertion innervation function of the puborectalis?
any special tests?
O: posterior surface of the pubic bone lateral to pubovaginalis
I: lateral portion of the anorectal junction and on anococcygeal raphe
F: supports and slightly elevates OPF ion contraction, supports increases in intraabdominal pressures, closes anus, approximates anus to pubis
N: sacral N root 3 and 4 and perineal branch of pudendal N
special test: anorectal tone, puborectalis tone and contractility via anal palpation. Rx: posterior manual resistance of ano-rectal angle via vagina
provide origin insertion innervation function of the pubococcygeus?
any special tests?
O: posterior surface of pubic bone, lateral to puborectalis
I: lateral portion of the anorectal junction and on anococcygeal raphe
F: supports and elevates PF. Pull all contents anteriorly. approximates anus to pubis. Closes anus
N: sacral N root 3 and 4 and perineal branch of pudendal N
special tests: tone and contractility via anal palpation
provide origin insertion innervation function of the iliococcygeus?
any special tests?
O: ischial spine and tendinous arch of levator ani muscle
I: coccyx and ano-coccygeal raphe
F: supports and elevated PFM, resists increases in intraabdominal pressure, approximates anus to pubis, pull anus up
N: sacral N root 3 & 4 & perineal branch of pudendal N
F: tone and contractility via anal palpation
Rx: manual resistance to iliococcygeus via vaginal palpation
provide origin insertion innervation function of the ischiococcygeus?
any special tests?
O: ischial spine
I: inferior portion of sacrum and proximal portion of coccyx
N: sacral N root 3 and 4
F: supports and elevates PF, resists increases in intraabdominal pressures, brings coccyx forwards after defecation and delivery
provide origin insertion innervation function of the respiratory diaphragm?
any special tests?
O: xiphoid process, costal cartilage of lower 6 ribs, VB of T12
I: central tendon
N: phrenic nerve C3-C4-C5
F: lowers during inspiration and increases volume of thoracic cavity
special tests: Rx elevation of the respiratory diaphragm, reflex contraction and visceral mobility to assess for cystocele
provide origin insertion innervation function of the TrA?
any special tests?
O: lateral 1/3 of inguinal ligament, Iliac Crest, Lx fascia and costal cartilage of last 6 ribs
i: Xiphoid process, linea alba and pubis
N: thoracic nerve 8-12, iliohypogastric N (L1) and ilioinguinal N (L1)
F: compression of abdomen
identify on pictures; Iliac spine
see image
identify on picture ASIS
see image
identify on image pubic sympthysis?
what attaches to it
see image
pubococcygeal sling
identify on image the ischial tuberosities?
what attaches onto it?
see image
ischiocavernosus ms, superficial transverse ms
identify on image to ischiopubic ramus?
what attaches to it?
see image
deep transverse muscle,
identify on images ischial spine?
what attaches to it?
iliococcygeus, ischioscoccygeus
see image
identify sacrum on image?
what attaches to it
ischiococcygeus
see image
identify coccyx, what attaches it to?
see image
ischiococcygeus, iliococcygeus,
identify the borders of the pelvic outlet
anterior: pubic bone
medial and lateral: ischial tuberosities
posteriorly: coccyx
identifiy the piriformis on the model?
see image
provide the origin insertion innervation function for the piriformis muscle
o: Anterior aspect of the sacrum at the level of about S2 through S4
Sacrotuberous ligament
Periphery of the greater sciatic notch
I: greater trochanter
N: sacral plexus and S1-S2
F: Lateral Rotation of the hip when it is extended (that is when in standing).
Abduction of the hip when it is flexed.
Aids slightly in tilting pelvis laterally.
Also aids in tilting pelvis posteriorly by pulling the sacrum down towards the thigh
identify the sacrotuberous ligament?
see image
identify sacrospinous ligament
see image
how to properly ask for consent?
explicit informed continuing free volontary
upon external vaginal palpation what can you assess through observation
- trophicity
- color
- puffiness of labia majora
- labia minora
- sulcus
- presence of vaginal gapping
- central tendon of perineum
what do you expect to see exernally w/ PFM contraction?
elevation and inward movement of the CTP, possible mvmt of labias
how to determine if there is full PFM relaxation
if CTP return to pre-contraction position
what are you assessing when the patient coughs and you are assessing the patients PFM?
- presence of bulging of visceral contents indicative of prolapse
- abdominal competence w/ prolapse
how to perform bulbospongiosus reflex?
slight tap on the hood of the clitoris & should notice a PFM contraction to see if good conductibility of your nerve
how to perform anal wink?
PT using pinky strokes from anus neck out laterally as if lighting a match and aims to see PFM contraction
what is the goals of applying flat pressures on the perineum?
can be comforting for the patient
allow to identify the borders of the perineum
allows to determine if there is protective reactions present
before you proceeded to doing vaginal palpation how would you assess for sensation?
assess for light touch on R and L side near the vulva along the inner thigh; look at he common dermatomes; S2-S4
how to assess for the pelvic floor global tone test?
have the fingers face posteriorly and rest on the CTP; provide a slow movement posterior and inferiorly to assess resistance to passive stretch
performed in a diagnonal
how would you grade PFM tone as?
+ 3: hypertonic
0: normal
- 3: hypotonic
how would you assess global pelvic floor muscle contractility?
both fingers are placed laterally, pulp of hand is facing down and fingers are slightly spread appart, ask patient to contract and resist by splaying fingers
how would you grade the global pelvic floor muscle contractility if the patient manages to break your finger?
5
how would you grade the global pelvic floor muscle contractility if the patient manages to break fingers initially, but when the PT splays then back, patient cannot resist
3
how would you assess for the tone of the pubovaginalis muscle?
two digits are together and DIP is bent and pointing twds 9 O’clock
fingers press laterally and inferiorly along the muscle fibers
the same can then be repeated at 3 O’clock on the other side
what would be considered as a hypotonic pubovaginalis muscle
if it is easy to pull the muscle bulk
how to assess for contractility of the pubovaginalis muscle?
with the fingers in the hook like motion ask the patient ton contract the PFM and add resistance against the muscle which is squeezing or attempting to squeeze your finger
how would you perform longitudinal massage on the pubovaginalis muscle as Rx?
locate the pubovaginalis muscle and with the palm of your finger begin at the pubic bone and rapidlu go down
to ensure you are at the proper place, ensure that your finger is adequately hooked onto all of the pubovaginalis muscle and ask patient to contract PFM to confirm adequate location
what is the goal of performing longitudinal massage in patients?
this method can be used as a treatment technique for patients who have hypotonic PFM and can be used to increase proprioception of the muscle
how would you perform transverse friction massage to pubovaginalis muscle as Rx?
initially have the patient contract the PFM and then perpendicular to the muscle fibers orientation apply the transverse frictions
what is the goal of performing transverse friction massages as a RX technique
in the case of hypertonic PFM, it can help release the tension
what is the main objective of proprioceptive pressures and tapping?
mostly used in patients w/ hypotonic PFM, can be used as aid in increasing proprioception
how to assess for visceral mobility in a patient w/ PFM contraction?
what to look out for?
as you splay the labia and compress the CPT as the patient to contract PFM and observe what is occuring inside
generally should see elevation of visceral contents
how to assess for visceral mobility in a patient w/ cough or valsalva maneuver?
what to look out for?
splay the labia and compress the CPT postertiorly to enlarge the oriface
in the case of prolapse; may notice the bladder will descend upon coughing
what are we assessing for in visceral mobility w/ cough?
presence of prolpase more particularly cystocoele; assessing for protrusion of the anterior vaginal wall
what are we assessing for in visceral mobility with contraction?
elevation of the visceral contents includinh the vaginal wall, urethra and base of bladder. this would be a reflection of proper visceral mobility
how would you verify visceral mobility w/ elevation of the diaphragm
by repeating the same splaying of the labia and pushing down on the CTP to enlarge the vaginal opening then the reflex contraction can be initiated; asses for movement (superior) of visceral contents
explain the principle of the PFM reflex contraction w/ elevation of the diaphragm
this is a hypopressive technique, by elevating arms and doing and inspiration we are relieving some of the intrabdominal pressure and therefore less pressure onto PFM; however will initiate a reflex contraction of the pelvic floor
how to assess for anal sphincter tone
ask patient to contract and relax the PFM muscle, apply a pressure on the sphincter to determine it’s tone
how do you classify or rate the tone of the external anal sphincter
low, normal or high
how to determine the external anal sphincter contractility?
how to rate it?
ask the patient to contract and relax PFM and determine how well it contracted
weak, moderate or strong
in what direction do you insert index for anal palpation
in a superior-anterior direction (towards the umbilicus)
what clue can the anal sphincter length provide to you?
longer in length generally better for continence
how to determine the anorectal angle and what is it indicative of
when the index is inserted in the anal canal, continue deeper until you feel a bend, at this bend, bend PIP and estimate the angle
the angle can determine if puborectalis muscle is hypertonic, normal or hypotonic
how to assess for tone of the puborectalis muscle
pressure on the ano-rectal angle is applied
how to assess for contractility of the puborectalis muscle?
ask the patient to contract the PFM and apply resistance in the downward motion
in what direction should you feel the puborectalis going when PFM contracting?
will feel movement anteriorly
how to assess for the position and mobility of the coccyx?
From the anorectal angle, the examiner slides the index finger deeper and posteriorly to palpate the anterior surface of the coccyx. The index finger of the opposite hand is placed externally in the gluteal fold on the posterior surface of the coccyx.The examiner gently mobilizes the coccyx to assess movement in flexion and in the direction of extension at the sacrococcygeal joint
how to assess for pubococcygeus tone and contractility
index is moved from the anterior surface of the coccyx, and moved slightly laterally, tone is assessed with passive stretch and then the patient is asked to contract PFM to assess for contracility
how to evaluate for tone and contractility of the iliococcygeus
index finger is in the rectum at 9 oclock in a hooked position
the finger is displaced laterally and slightluy superiorly to palpate for ischial spine, remove finger from ischial spine and bring it slightly towards you
ask patient to contract PFM and feel muscle bulk push laterally into your finger then apply passive stretch as patient is resting
repeat at 3 oclock for the other side
upon contraction how does the iliococcygeus move in
will move from lateral side in medially
how to evaluate for tone and contractility of the ischiococcygeus muscle
bring index back to the ischial spine and this time slide finger posteriorly towards the bed, ask patient to contract, and should feel muscle pulling in posteriorly onto finger
tone is assessed by pushing posteriorly onto the muscle bulk
how to assess the integrity of the posterior vaginal wall and what are we assessing for by doing this?
goal is to assess for presence of rectocele
splay the labia
take the pulp of the infex and push into the posterior vaginal wall
indicate the size and relative location of the prolapse
how to assess for deep transversus muscle and what to assess for
one finger inside and thumb on the outde of the perineum
Ax for muscle bulk, tone and contractility
assess bilaterally
how to apply lateral resistance of the pubococcygeal sling?
what is the goal?
- ask the patient to contract PFM
- can apply resistance at any point throughout range or at EOR
- ensure to have finger in a hooked position to be over top of the miscle
goal: strengthen and increase tone in hypotonic muscle
how to conduct manual resistance on iliococcygeus?
Should orient fingers up and posteriorly around 9-10 o’clock, avoid getting too close to obturator internus, may check to compare contraction, should not be feeling anything on the finger with resisted hip ER/ABD
once on the right muscle, ask for PFM contraction and applu resistance against the muscle bulk
how would you conduct stretch reflex as a Rx technique and why?
tug in an inferior-lateral direction 7-8 o’clock and maintain slight stretch and then upon release have the patient contract the PFM
this serves as a facilitatory technique
how would you apply posterior manual resistance at the ano-rectal angle
once you find the little bend as you palpate the vaginal canal, apply a downwards pressure at 6 or 7 oclock based on patient’s comfort
how to palpate for the cervix
finger(s) in deep,should feel cervix above fingers, using the heel of the other hand press down ~2cm above pubic bone and should feel movement of cervic on fingers
why are vaginal closure techniques used? provide examples of some closure techniques
- in patients w/ vaginal gapping to close the oriface
- lift the CPT up and compress it ask the patient to hold it
