Pelvic Floor and Women's Health Flashcards
Pelvic Floor and Women’s Health
bony boundaries of the pelvic floor
- anterior: pubic symphysis
- anterolateral: inf pubic ramus
- lateral: ischial rami and ischial tubeorsity
- posterolateral: scrotuberous ligamet
- posterior: coccyx
Pelvic Floor and Women’s Health
triangles of the pelvic floor
- urogenital triangle
- anal triangle
Pelvic Floor and Women’s Health
blood supply to the pelvic floor
- 2 pudendal arteries
- internal pudendal artery
- labial veins
Pelvic Floor and Women’s Health
The pelvis is innervated mainly by the sacral and coccygeal spinal nerves and the pelvic part of the
autonomic nervous system.
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the lumbar plexus branches to the pelvis
- genitofemoral
- ilioinguinal
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the sacral plexus branches
- pudendal
- levator ani
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Lumbosacral nerves
- iliohypogastric (T12-L1)
- ilioinguinal nerve (L1)
- genitofemoral nerve (genital branch) (L1-L2)
- lateral femoral cutaneous nerve (perineal branch) (L2-L3)
- pudendal nerve (S2-S4)
- obturator L2-L4
Pelvic Floor and Women’s Health
detrusor muscle
Pelvic Floor and Women’s Health
Sympathetic input to the the pelvis:
- Provides motor innervation to vascular smooth muscle
- Provides constant tone in internal sphincters.
- Detrusor relaxation for filing & storage
Pelvic Floor and Women’s Health
Parasympathetic input to pelvic floor
- Provides motor & sensory to innervation to bladder
- Responsible for relaxation of internal anal sphincter
- Detrusor contraction, promotes bladder emptying
- Blood vessel dilation
- Erection of clitoris or penis
Pelvic Floor and Women’s Health
70% of the muscle fibers in the pelvic floor are type…
type I (slow twitch)
30% are type II (fast twitch)
Pelvic Floor and Women’s Health
Layer 1 (Urogenital Triangle) muscles of the pelvic floor
- perineum or superficial pouch
- bulbocavernosus (bulbospongiosus in men)
- ischiocavernosus
- superficial transverse perineal
- external anal sphincter
Pelvic Floor and Women’s Health
Layer 2 (Urogenital Diaphragm) muscles of the pelvic floor
- urethral sphincter (in men)
- compressor urethra (in men)
- sphincter urethral vaginalis
- deep transverse perineal
- perineal membrane
Pelvic Floor and Women’s Health
Layer 3 (Pelvic Diaphragm) muscles of the pelvic floor
- levator ani muscle (pubococcygeus, puborectalis, iliococcygeus & coccygeus)
- Obturator internus
- Piriformis
Pelvic Floor and Women’s Health
Function of the PFM
- Support of the pelvic viscera
- Sphincteric (bladder & bowel control)
- Sexual functions
Pelvic Floor and Women’s Health
Abdominal Canister by Dianne Lee
- Balance bet. the diaphragm, PFM, transverse abdominus (TrA), other abdominal muscles & multifidus.
- Transmits intra-abdominal pressure during activities
- Keeps alignment of pelvis.
- Keep joints in optimal form closure.
- Keep optimal force closure.
Pelvic Floor and Women’s Health
Pelvic floor dysfunction: Janda’s principles
Muscle contraction properties change in response to inflammatory process or pain → hypertonicity → impaired contraction & relaxation (coordination issues) → trigger points and muscle guarding development
Pelvic Floor and Women’s Health
Musculoskeletal dysfunction of the PFM that may be the 1° cause of pelvic pain in response to pathology in the:
urologic, gynecologic, &/or gastroenterologic
Pelvic Floor and Women’s Health
Pelvic floor dysfunction is often is a response to a 1° pain generator arising from…
bladder, rectal or vaginal pathology.
Pelvic Floor and Women’s Health
Clinical Pearl of Wisdom in Treating PFD
Stretch wht’s tight → strengthen what’s weak → perform neuromuscular reeducation
(Note: “sometimes is weak from reciprocal inhibition.” Dr. Q)
Pelvic Floor and Women’s Health
Postural Muscles Facilitation: Gets Shortened
(NOTE: Get shortened from excessive contraction)
- iliopsoas
- QL
- pectineus
- piriformis
- TFL
- lateral quad
- rectus femoris
- hamstrings
- short adductors
- PELVIC FLOOR
Pelvic Floor and Women’s Health
Dynamic Muscles Inhibition: gets weak
- multifidi
- gluteals
- long adductors
- rectus abdominus
- TrA
Pelvic Floor and Women’s Health
What is muscle tone
Resistance to displacement at rest
Pelvic Floor and Women’s Health
Pelvic floor muscle tone is affected by…
Hormones (pregnancy, menstrual cycle, menopause)
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True or false: pelvic muscle tone helps categorized pelvic floor dysfunction diagnoses
True (hypertonic, hypotonic, etc)
Pelvic Floor and Women’s Health
adequate tension in response to the forces working on the PF at any given moment in time
Normal muscle tone
Pelvic Floor and Women’s Health
too little tone, lax, weak
Hypotonic PFM
Pelvic Floor and Women’s Health
Increase in PFM resting tone (PFM in a constant state of contraction) + impaired relaxation of the PFM leads to muscle fatigue
Hypertonic PFM
Pelvic Floor and Women’s Health
No icrease in PFM resting tone. PFM does NOT feel “springy” during palpation. PFM feels like “firm shelves or violin strings.” + active trigger points. Weakness. Delayed relaxation.
Shortened PFM
Pelvic Floor and Women’s Health
APTA category: supportive
- Urinary incontinence
- fecal incontinence
- pelvic organ prolapse
- pelvic muscle weakness
- disuse, atrophy
- neurologic dysfunction
Pelvic Floor and Women’s Health
APTA category: hypertonus/pain
- Pelvic pain
- dyspareunia (painful sexual intercourse)
- constipation
- dysmenorrhea
- voiding difficulty
- pelvic tension myalgia
Pelvic Floor and Women’s Health
APTA category: incoordination
- Urinary frequency & urgency
- paradoxical pelvic floor
Pelvic Floor and Women’s Health
APTA category: visceral
- Interstitial Cystitis (IC)
- Irritable Bowel Syndrome (IBS)
- fibroids
- endometriosis
- urinary tract infection
Pelvic Floor and Women’s Health
What is the APTA pelvic floor dysfunction category of the following presentation?
Pain lasting 6 mos or longer or pelvic pain not relieved by meds or other measures, altered physical functions, signs of depression (esp sleep disturbance), altered family roles
Chronic Pelvic Pain
Pelvic Floor and Women’s Health
Condition in which involuntary loss of urine is a social or hygienic problem & is objectively demonstrable (definition by International Continence Society).
urinary incontinence
Pelvic Floor and Women’s Health
Stress incontinence
- Symptoms: Leaking with cough, laugh, or sneeze
- Mechanism: Urethral hyper mobility, pelvic floor damage damage, chronic stress to pelvic floor, decreased estrogen
Pelvic Floor and Women’s Health
Urge incontinence:
- Symptoms: leaking when hearing running water, “key in the door” (go all the time), frequent urination
Pelvic Floor and Women’s Health
Mixed incontinence
- Possible mechanism: combined mechanisms of stress & urge
- Symptoms: Combined cues
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Decreased contractility of detrusor muscle, urethral obstruction. Patient presents with chronic dribbling of urine, urinary frequency
Overflow incontinence
Pelvic Floor and Women’s Health
Risk factors for Urinary Incontinence
- PFM weakness
- Pregnancy, vaginal delivery, episiotomy
- Immobility associated with degenerative disease
- Estrogen depletion
- Medications (diuretics)
- Chronic cough/sneezing
- Constipation
- Obesity
- High impact exercise
Pelvic Floor and Women’s Health
PFM grades
- 0 = no contraction
- 1 = flick of muscle detected
- 2 = weak squeeze
- 3 = Fair squeeze with “definite lift” (moving in upward direction)
- 4 = good squeeze with repeatable hold and lift
- 5 = strong, solid, repeatable squeeze and lift
Pelvic Floor and Women’s Health
Weak squeeze
2
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Fair squeeze with “definite lift” (moving in an upward direction)
3
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Good squeeze with repeatable hold & lift
4
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Strong, solid, repeatable squeeze & lift
5
Pelvic Floor and Women’s Health
The normal resting tone as measured by biofeedback (surface electrodes) less than _____ microvolts
2
Pelvic Floor and Women’s Health
with presence of shortened PFM, the biofeedback electrodes will appear weak.
Should you patient perform PFM exercise?
no exercise
Pelvic Floor and Women’s Health
Bladder re-training usually take ____ weeks
6-12
Pelvic Floor and Women’s Health
limiting factor in bladder re-training
pt’s compliance
Pelvic Floor and Women’s Health
normal between voiding time:
3.5 - 4 hours (GOAL)
start with an interval patient is comfortable & do this for few days then increase time bet voids by 15-30 minutes until goal is met
Pelvic Floor and Women’s Health
If urge comes before the scheduled time, pt taught Urge Suppression Techniques:
- stop what you are doing & stance very still
- sit down if you can
- 5 quick PFM contraction
- perform diaphragmatic breathing
- when the urge goes away, walk normally to the bathroom
Pelvic Floor and Women’s Health
advanced kegel exercise is to have pt perform it with…
TrA without holding their breath
Pelvic Floor and Women’s Health
PFM exercises (Kegel exercises). **Verbal cues:**
“pull your pelvic floor up & in”, squeeze as if you are trying to prevent yourself from passing gas”
have the pt do this in the clinic with biofeedback to make sure they are doing it correctly (i.e. not creating increased intra-abdominal pressure while performing the kegels)
Pelvic Floor and Women’s Health
PT Treatment of Urinary Dysfunction.
Pt education on:
- bladder irritants (coffee, vinegar, alcohol)
- hydration (6-8 glasses of water)
- avoid constipation
- effective voiding
- skin protection
Pelvic Floor and Women’s Health
a strong and well-timed contraction of the pelvic floor muscles. It involves the pelvic floor muscles contracting immediately before and during any increase in downward pressure on the pelvic floor.
‘The Knack”
Pelvic Floor and Women’s Health
‘The Knack’ can be used with events or activities that increase downward pressure upon your pelvic floor such as:
- Coughing
- Sneezing
- Lifting
- Blowing your nose
- Rising into standing from sitting
- Stepping down heavily.
Pelvic Floor and Women’s Health
Prolapse or a protrusion of 1 or more pelvic organs into the vaginal canal.
Pelvic Organ Prolapse
Pelvic Floor and Women’s Health
PT Treatment for Pudendal Nerve Entrapment
- Connective tissue mob (skin rolling)
- Biofeedback for down training & work on coordination
- Modalities (TENS to S2-S4, e-stim internal or external, ice)
- Perineal protection (avoid hip ext and abd)
- Neural flossing of pudendal nerve
Pelvic Floor and Women’s Health
Vise-like pressure & heaviness in & around pelvis; pain, burning/aching in perineum, scrotum, penis, urethra, anus, coccyx, labia. Penile/vaginal numbness or hypersensitivity. Muscle weakness in superficial layer & UG diaphragm. Autonomic dysfunction: (erectile/ejaculatory dysfunction; voiding/rectal dysfunction)
Pudendal Nerve Entrapment
Pelvic Floor and Women’s Health
Pelvic organs are primarily supported by the
PFM, the endopelvic fascia & the vagina
Pelvic Floor and Women’s Health
causes of coccydynia
- direct trauma
- injury during vaginal delivery
Pelvic Floor and Women’s Health
coccydynia
pain with:
- sitting
- palpation
- transitional mvmt
- intercourse
- defecation
Pelvic Floor and Women’s Health
coccydynia
findings:
- coccyx tender to palpation
- hip extensors and hip mm weakness
- pain with forward bending
- pain with sitting and asymmetrical pos
Pelvic Floor and Women’s Health
coccydynia category
chronic pelvic pain
Pelvic Floor and Women’s Health
function of the coccyx
- insertion of PFM
- provides tension for the PFM
- moderates all motion of the pelvis
Pelvic Floor and Women’s Health
movements of the coccyx
- flexes with levator ani contraction
- extends with levator ani relaxation, increased intra-abdominal pressure, birthing, and glut contraction.
- flexion to extension with sit to stand
Pelvic Floor and Women’s Health
Treatment to Restore Coccyx Extension
- “Stuck Drawer Technique” (bring coccyx into more flexion to get extension)
- Strain Counter Strain (hold sacrum in counter-nutation, sidebend sacrum to tender side to shorten the muscle with the other hand)
Pelvic Floor and Women’s Health
Coccyx position assessment is done in what position?
in sitting
Pelvic Floor and Women’s Health
Coccydynia Treatment
- Massage to coccygeus, piriformis & glut muscles
Pelvic Floor and Women’s Health
PFM exercises using accessory muscles:
- adductor squeeze
- hip external rotator isometrics
- NOT gluts
Pelvic Floor and Women’s Health
causes of pudendal nerve entrapment
- Ligamentous or fascial entrapment (cyclist, prolonged pushing during childbirth)
- Hypertonic PFM
- Soft tissue restrictions, scar/ adhesions where the nerve passes
- Shift in the pelvic osseous structure from trauma, sports, childbirth
- Chronic constipation, wt. lifting, valsalva
- Physical trauma to S2-S4
Pelvic Floor and Women’s Health
pudendal nerve pathway
- goes under piriformis
- goes between sacrospinous and sacrotuberous lig
- then re-enters thru lesser sciatic notch to go to pudendal canal (Alcock’s canal)
- variations in different people
Pelvic Floor and Women’s Health
branches of the pudendal nerve
- inferior rectal
- perineal nerve
- dorsal nerve of clitoris/penis
Pelvic Floor and Women’s Health
Hallmark sign of Vulvar Vestibulitis
+Q tip test
Pelvic Floor and Women’s Health
Vulvar Vestibulitis Characterized by 3 symptoms:
- pain in the vestibule to touch or vaginal entry
- tenderness to light pressure localized within the vulvar vestibule
- vestibular erythema
Pelvic Floor and Women’s Health
causes of vulvar vestibulitis
- idiopathic
- recurrent/chronic candida infection
- altered vaginal pH (normal is 4-4.5) due to a change in vaginal flora from estrogen deficiency, infection or chronic cervicitis.
Pelvic Floor and Women’s Health
PT Treatment for Vulvodynia, Dysthetic Vulvodynia & Vulvar Vestibulitis
-
Pt education:
- avoid irritants
- no tampons
- wear white cotton underwear
- relaxation techniques
- gentle exercise like yoga
- avoid pressure to perineum
- referral to talk therapy
- address the cause of yeast infection (or is it really yeast)
Pelvic Floor and Women’s Health
Vulvar discomfort characterized by burning, stinging, itching &/or rawness; symptoms similar to yeast or urinary tract infection; usually associated with dyspareunia & vaginismus.
Vulvodynia
Pelvic Floor and Women’s Health
Light touch in vulvar region is perceived as painful. Thought to have a neurologic component similar to CRPS. Need to R/O pudendal nerve entrapment due to its similarity in symptoms. May lead to musculoskeletal pain & psychological stress. No erythema
Dysthetic Vulvodynia
Pelvic Floor and Women’s Health
Irritable Bowel Syndrome (IBS);
category
visceral
Pelvic Floor and Women’s Health
Irritable Bowel Syndrome presents as
- diarrhea predominant
- constipation predominant
- or both (majority)
Pelvic Floor and Women’s Health
Chronic /recurrent pain & disturbed defecation. +bloating & distension not explained by structural or biomechanical abnormalities. Disturbance in GI enteric system & pathways within the CNS
Irritable Bowel Syndrome
Pelvic Floor and Women’s Health
treatment of Irritable Bowel Syndrome:
- Food diary
- Improve stool consistency with fiber
- stress reduction
- Referral to talk therapy esp. hypnotherapy
Pelvic Floor and Women’s Health
Interstitial Cystitis AKA
Painful Bladder Syndrome
Pelvic Floor and Women’s Health
Gold standard for diagnosis of interstitial cystitis (painful bladder syndrome)
presence of Hunner’s ulcer following hydro distension of the bladder via cystoscopy.
Pelvic Floor and Women’s Health
interstitial cystitis (painful bladder syndrome) category of PFD
visceral
Pelvic Floor and Women’s Health
first line of tx for intersitial cystitis (painful bladder syndrome)
antibiotics
Pelvic Floor and Women’s Health
Inflammation & ulceration on the inner bladder wall. Primarily disorder of women from 30-50 yrs old.
Interstitial cystitis (painful bladder syndrome)
Pelvic Floor and Women’s Health
symptoms usually is abrupt; pain that mimics UTI; increased frequency of urination; urethral burning; pressure over the bladder & feeling of urgency due to detrusor instability; voids can be as much as 40x in a 24 hour period; many occurring at night; pt usually have very little to no episodes of urinary incontinence;
interstitial cystitis or painful bladder syndrome
Pelvic Floor and Women’s Health
Defined as a recurrent pain during intercourse
Dyspareunia
Pelvic Floor and Women’s Health
Possible causes of dyspareunia
- vulvodynia
- vulvar vestibulitis
- episiotomy scar
Pelvic Floor and Women’s Health
Characterized by involuntary contraction/muscle spasm of the perineal muscle making penetration difficult, painful & impossible
Vaginismus
Pelvic Floor and Women’s Health
vaginismus cause
Cause usually a conditioned response to a negative experience (i.e. painful first pelvic exam or forced sexual intercourse or past sexual abuse).
Pelvic Floor and Women’s Health
dyspareunia and vaginismus;
category of PFD
hypertonic
Pelvic Floor and Women’s Health
separate hard lumps, like nuts (hard to pass)
Type I
ewwwwww! 🤢
Pelvic Floor and Women’s Health
Sausage-shaped but lumpy
Type II
Pelvic Floor and Women’s Health
Like a sausage but with cracks on its surface
Type III
Pelvic Floor and Women’s Health
Lika a sausage or snake, smooth and soft
Type 4
Pelvic Floor and Women’s Health
soft blobs with clear-cut edges (passed easily)
Type 5
Pelvic Floor and Women’s Health
Fluffy pieces with ragged edges, a mushy stool
Type 6
Pelvic Floor and Women’s Health
Watery, no solid pieces, entirely liquid
Type 7
Pelvic Floor and Women’s Health
The art of defecation steps
- Puborectalis and sphincters at rest
- defecation reflex: rectum contraction, internal and external sphincter relaxation, stool eneter the anal canal
- Inhibition of defecation: puborectalis contraction
- Defecation: puborectalis defecation, int/ext anal sphincter relaxation
Pelvic Floor and Women’s Health
defined as having less than 3x/week, +straining 70% of the time, hard/rock-like stool (Bristol Stool Chart type 1 or 2), or incomplete emptying
Constipation
Pelvic Floor and Women’s Health
constipation
category of PFD?
Hypertonic
Pelvic Floor and Women’s Health
causes of constipation
- poor water and fiber intake
- medications
- metabolic or endocrine disorder
- Neuropathic or myopathic disorders
- Increasing age
- PFM spasms resulting in resistance to defecation (i.e. paradoxical PFM contraction)
Pelvic Floor and Women’s Health
treatment of constipation
- food dairy
- abdominal massage
- manual therapy to PFM
- neuro-muscular reed to address paradoxical PFM contraction.
- pt education: proper toileting techniques
Pelvic Floor and Women’s Health
Proper Toileting techniques
Keep your pelvic floor muscle & sphincter relax. Make the anal opening wide by performing a bulging contraction. “Belly big, belly hard” while you continue to breath. You might find that making a shhh, ohhh sound makes this easier to perform as you grunt
Pelvic Floor and Women’s Health
Fecal Incontinence, prevalence as high as ___% in patients with urinary
incontinence & POP.
17
Pelvic Floor and Women’s Health
Involuntary loss of feces or gas
Fecal Incontinence
Pelvic Floor and Women’s Health
fecal incontinence
category of PFD?
hypoytonic
Pelvic Floor and Women’s Health
Important to distinguish TRUE fecal incontinence versus seepage from _______
constipation
Pelvic Floor and Women’s Health
PT Treatment for FI
- Perineal scar release post-partum
- PFM exercises (kegels) incorporate it with ADLs
- done at home with biofeedback unit (rectal sensor)
-
Pt education:
- diet to increase bulk in stool to improve consistency
- toileting techniques & posture
- hygiene & skin protection
- use of cotton ball near the anal opening for reflexive contraction of EAS
Pelvic Floor and Women’s Health
pundendal nerve comes from
S2-S4 of the sacral plexus
