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Specific Systems > Pelvic Floor and Women's Health > Flashcards

Pelvic Floor and Women's Health Flashcards

1
Q

Pelvic Floor and Women’s Health

bony boundaries of the pelvic floor

A
  • anterior: pubic symphysis
  • anterolateral: inf pubic ramus
  • lateral: ischial rami and ischial tubeorsity
  • posterolateral: scrotuberous ligamet
  • posterior: coccyx
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2
Q

Pelvic Floor and Women’s Health

triangles of the pelvic floor

A
  • urogenital triangle
  • anal triangle
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3
Q

Pelvic Floor and Women’s Health

blood supply to the pelvic floor

A
  • 2 pudendal arteries
  • internal pudendal artery
  • labial veins
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4
Q

Pelvic Floor and Women’s Health

The pelvis is innervated mainly by the sacral and coccygeal spinal nerves and the pelvic part of the

A

autonomic nervous system.

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5
Q

Pelvic Floor and Women’s Health

the lumbar plexus branches to the pelvis

A
  • genitofemoral
  • ilioinguinal
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6
Q

Pelvic Floor and Women’s Health

the sacral plexus branches

A
  • pudendal
  • levator ani
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7
Q

Pelvic Floor and Women’s Health

Lumbosacral nerves

A
  1. iliohypogastric (T12-L1)
  2. ilioinguinal nerve (L1)
  3. genitofemoral nerve (genital branch) (L1-L2)
  4. lateral femoral cutaneous nerve (perineal branch) (L2-L3)
  5. pudendal nerve (S2-S4)
  6. obturator L2-L4
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8
Q

Pelvic Floor and Women’s Health

detrusor muscle

A
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9
Q

Pelvic Floor and Women’s Health

Sympathetic input to the the pelvis:

A
  • Provides motor innervation to vascular smooth muscle
  • Provides constant tone in internal sphincters.
  • Detrusor relaxation for filing & storage
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10
Q

Pelvic Floor and Women’s Health

Parasympathetic input to pelvic floor

A
  • 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
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11
Q

Pelvic Floor and Women’s Health

70% of the muscle fibers in the pelvic floor are type…

A

type I (slow twitch)

30% are type II (fast twitch)

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12
Q

Pelvic Floor and Women’s Health

Layer 1 (Urogenital Triangle) muscles of the pelvic floor

A
  • perineum or superficial pouch
  • bulbocavernosus (bulbospongiosus in men)
  • ischiocavernosus
  • superficial transverse perineal
  • external anal sphincter
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13
Q

Pelvic Floor and Women’s Health

Layer 2 (Urogenital Diaphragm) muscles of the pelvic floor

A
  • urethral sphincter (in men)
  • compressor urethra (in men)
  • sphincter urethral vaginalis
  • deep transverse perineal
  • perineal membrane
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14
Q

Pelvic Floor and Women’s Health

Layer 3 (Pelvic Diaphragm) muscles of the pelvic floor

A
  • levator ani muscle (pubococcygeus, puborectalis, iliococcygeus & coccygeus)
  • Obturator internus
  • Piriformis
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15
Q

Pelvic Floor and Women’s Health

Function of the PFM

A
  • Support of the pelvic viscera
  • Sphincteric (bladder & bowel control)
  • Sexual functions
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16
Q

Pelvic Floor and Women’s Health

Abdominal Canister by Dianne Lee

A
  • 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.
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17
Q

Pelvic Floor and Women’s Health

Pelvic floor dysfunction: Janda’s principles

A

Muscle contraction properties change in response to inflammatory process or pain → hypertonicity → impaired contraction & relaxation (coordination issues) → trigger points and muscle guarding development

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18
Q

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:

A

urologic, gynecologic, &/or gastroenterologic

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19
Q

Pelvic Floor and Women’s Health

Pelvic floor dysfunction is often is a response to a 1° pain generator arising from…

A

bladder, rectal or vaginal pathology.

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20
Q

Pelvic Floor and Women’s Health

Clinical Pearl of Wisdom in Treating PFD

A

Stretch wht’s tight → strengthen what’s weak → perform neuromuscular reeducation

(Note: “sometimes is weak from reciprocal inhibition.” Dr. Q)

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21
Q

Pelvic Floor and Women’s Health

Postural Muscles Facilitation: Gets Shortened

(NOTE: Get shortened from excessive contraction)

A
  • iliopsoas
  • QL
  • pectineus
  • piriformis
  • TFL
  • lateral quad
  • rectus femoris
  • hamstrings
  • short adductors
  • PELVIC FLOOR
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22
Q

Pelvic Floor and Women’s Health

Dynamic Muscles Inhibition: gets weak

A
  • multifidi
  • gluteals
  • long adductors
  • rectus abdominus
  • TrA
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23
Q

Pelvic Floor and Women’s Health

What is muscle tone

A

Resistance to displacement at rest

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24
Q

Pelvic Floor and Women’s Health

Pelvic floor muscle tone is affected by…

A

Hormones (pregnancy, menstrual cycle, menopause)

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25
Q

Pelvic Floor and Women’s Health

True or false: pelvic muscle tone helps categorized pelvic floor dysfunction diagnoses

A

True (hypertonic, hypotonic, etc)

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26
Q

Pelvic Floor and Women’s Health

adequate tension in response to the forces working on the PF at any given moment in time

A

Normal muscle tone

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27
Q

Pelvic Floor and Women’s Health

too little tone, lax, weak

A

Hypotonic PFM

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28
Q

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

A

Hypertonic PFM

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29
Q

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.

A

Shortened PFM

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30
Q

Pelvic Floor and Women’s Health

APTA category: supportive

A
  • Urinary incontinence
  • fecal incontinence
  • pelvic organ prolapse
  • pelvic muscle weakness
  • disuse, atrophy
  • neurologic dysfunction
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31
Q

Pelvic Floor and Women’s Health

APTA category: hypertonus/pain

A
  • Pelvic pain
  • dyspareunia (painful sexual intercourse)
  • constipation
  • dysmenorrhea
  • voiding difficulty
  • pelvic tension myalgia
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32
Q

Pelvic Floor and Women’s Health

APTA category: incoordination

A
  • Urinary frequency & urgency
  • paradoxical pelvic floor
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33
Q

Pelvic Floor and Women’s Health

APTA category: visceral

A
  • Interstitial Cystitis (IC)
  • Irritable Bowel Syndrome (IBS)
  • fibroids
  • endometriosis
  • urinary tract infection
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34
Q

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

A

Chronic Pelvic Pain

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35
Q

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).

A

urinary incontinence

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36
Q

Pelvic Floor and Women’s Health

Stress incontinence

A
  • Symptoms: Leaking with cough, laugh, or sneeze
  • Mechanism: Urethral hyper mobility, pelvic floor damage damage, chronic stress to pelvic floor, decreased estrogen
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37
Q

Pelvic Floor and Women’s Health

Urge incontinence:

A
  • Symptoms: leaking when hearing running water, “key in the door” (go all the time), frequent urination
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38
Q

Pelvic Floor and Women’s Health

Mixed incontinence

A
  • Possible mechanism: combined mechanisms of stress & urge
  • Symptoms: Combined cues
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39
Q

Pelvic Floor and Women’s Health

Decreased contractility of detrusor muscle, urethral obstruction. Patient presents with chronic dribbling of urine, urinary frequency

A

Overflow incontinence

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40
Q

Pelvic Floor and Women’s Health

Risk factors for Urinary Incontinence

A
  • PFM weakness
  •  Pregnancy, vaginal delivery, episiotomy
  • Immobility associated with degenerative disease
  • Estrogen depletion
  • Medications (diuretics)
  • Chronic cough/sneezing
  • Constipation
  • Obesity
  • High impact exercise
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41
Q

Pelvic Floor and Women’s Health

PFM grades

A
  • 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
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42
Q

Pelvic Floor and Women’s Health

Weak squeeze

A

2

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43
Q

Pelvic Floor and Women’s Health

Fair squeeze with “definite lift” (moving in an upward direction)

A

3

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44
Q

Pelvic Floor and Women’s Health

Good squeeze with repeatable hold & lift

A

4

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45
Q

Pelvic Floor and Women’s Health

Strong, solid, repeatable squeeze & lift

A

5

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46
Q

Pelvic Floor and Women’s Health

The normal resting tone as measured by biofeedback (surface electrodes) less than _____ microvolts

A

2

47
Q

Pelvic Floor and Women’s Health

with presence of shortened PFM, the biofeedback electrodes will appear weak.
Should you patient perform PFM exercise?

A

no exercise

48
Q

Pelvic Floor and Women’s Health

Bladder re-training usually take ____ weeks

A

6-12

49
Q

Pelvic Floor and Women’s Health

limiting factor in bladder re-training

A

pt’s compliance

50
Q

Pelvic Floor and Women’s Health

normal between voiding time:

A

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

51
Q

Pelvic Floor and Women’s Health

If urge comes before the scheduled time, pt taught Urge Suppression Techniques:

A
  1. stop what you are doing & stance very still
  2. sit down if you can
  3. 5 quick PFM contraction
  4. perform diaphragmatic breathing
  5. when the urge goes away, walk normally to the bathroom
52
Q

Pelvic Floor and Women’s Health

advanced kegel exercise is to have pt perform it with…

A

TrA without holding their breath

53
Q

Pelvic Floor and Women’s Health

PFM exercises (Kegel exercises).
**Verbal cues:**
A

“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)

54
Q

Pelvic Floor and Women’s Health

PT Treatment of Urinary Dysfunction.
Pt education on:

A
  • bladder irritants (coffee, vinegar, alcohol)
  • hydration (6-8 glasses of water)
  • avoid constipation
  • effective voiding
  • skin protection
55
Q

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.

A

‘The Knack”

56
Q

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:

A
  • Coughing
  • Sneezing
  • Lifting
  • Blowing your nose
  • Rising into standing from sitting
  • Stepping down heavily.
57
Q

Pelvic Floor and Women’s Health

Prolapse or a protrusion of 1 or more pelvic organs into the vaginal canal.

A

Pelvic Organ Prolapse

58
Q

Pelvic Floor and Women’s Health

PT Treatment for Pudendal Nerve Entrapment

A
  • 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
59
Q

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)

A

Pudendal Nerve Entrapment

60
Q

Pelvic Floor and Women’s Health

Pelvic organs are primarily supported by the

A

PFM, the endopelvic fascia & the vagina

61
Q

Pelvic Floor and Women’s Health

causes of coccydynia

A
  • direct trauma
  • injury during vaginal delivery
62
Q

Pelvic Floor and Women’s Health

coccydynia

pain with:

A
  • sitting
  • palpation
  • transitional mvmt
  • intercourse
  • defecation
63
Q

Pelvic Floor and Women’s Health

coccydynia

findings:

A
  • coccyx tender to palpation
  • hip extensors and hip mm weakness
  • pain with forward bending
  • pain with sitting and asymmetrical pos
64
Q

Pelvic Floor and Women’s Health

coccydynia category

A

chronic pelvic pain

65
Q

Pelvic Floor and Women’s Health

function of the coccyx

A
  • insertion of PFM
  • provides tension for the PFM
  • moderates all motion of the pelvis
66
Q

Pelvic Floor and Women’s Health

movements of the coccyx

A
  • 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
67
Q

Pelvic Floor and Women’s Health

Treatment to Restore Coccyx Extension

A
  • “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)
68
Q

Pelvic Floor and Women’s Health

Coccyx position assessment is done in what position?

A

in sitting

69
Q

Pelvic Floor and Women’s Health

Coccydynia Treatment

A
  • Massage to coccygeus, piriformis & glut muscles
70
Q

Pelvic Floor and Women’s Health

PFM exercises using accessory muscles:

A
  • adductor squeeze
  • hip external rotator isometrics
  • NOT gluts
71
Q

Pelvic Floor and Women’s Health

causes of pudendal nerve entrapment

A
  • 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
72
Q

Pelvic Floor and Women’s Health

pudendal nerve pathway

A
  • 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
73
Q

Pelvic Floor and Women’s Health

branches of the pudendal nerve

A
  • inferior rectal
  • perineal nerve
  • dorsal nerve of clitoris/penis
74
Q

Pelvic Floor and Women’s Health

Hallmark sign of Vulvar Vestibulitis

A

+Q tip test

75
Q

Pelvic Floor and Women’s Health

Vulvar Vestibulitis Characterized by 3 symptoms:

A
  1. pain in the vestibule to touch or vaginal entry
  2. tenderness to light pressure localized within the vulvar vestibule
  3. vestibular erythema
76
Q

Pelvic Floor and Women’s Health

causes of vulvar vestibulitis

A
  • 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.
77
Q

Pelvic Floor and Women’s Health

PT Treatment for Vulvodynia, Dysthetic Vulvodynia & Vulvar Vestibulitis

A
  • 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)
78
Q

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.

A

Vulvodynia

79
Q

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

A

Dysthetic Vulvodynia

80
Q

Pelvic Floor and Women’s Health

Irritable Bowel Syndrome (IBS);
category

A

visceral

81
Q

Pelvic Floor and Women’s Health

Irritable Bowel Syndrome presents as

A
  • diarrhea predominant
  • constipation predominant
  • or both (majority)
82
Q

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

A

Irritable Bowel Syndrome

83
Q

Pelvic Floor and Women’s Health

treatment of Irritable Bowel Syndrome:

A
  • Food diary
  • Improve stool consistency with fiber
  • stress reduction
  • Referral to talk therapy esp. hypnotherapy
84
Q

Pelvic Floor and Women’s Health

Interstitial Cystitis AKA

A

Painful Bladder Syndrome

85
Q

Pelvic Floor and Women’s Health

Gold standard for diagnosis of interstitial cystitis (painful bladder syndrome)

A

presence of Hunner’s ulcer following hydro distension of the bladder via cystoscopy.

86
Q

Pelvic Floor and Women’s Health

interstitial cystitis (painful bladder syndrome) category of PFD

A

visceral

87
Q

Pelvic Floor and Women’s Health

first line of tx for intersitial cystitis (painful bladder syndrome)

A

antibiotics

88
Q

Pelvic Floor and Women’s Health

Inflammation & ulceration on the inner bladder wall. Primarily disorder of women from 30-50 yrs old.

A

Interstitial cystitis (painful bladder syndrome)

89
Q

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;

A

interstitial cystitis or painful bladder syndrome

90
Q

Pelvic Floor and Women’s Health

Defined as a recurrent pain during intercourse

A

Dyspareunia

91
Q

Pelvic Floor and Women’s Health

Possible causes of dyspareunia

A
  • vulvodynia
  • vulvar vestibulitis
  • episiotomy scar
92
Q

Pelvic Floor and Women’s Health

  Characterized by involuntary contraction/muscle spasm of the perineal muscle making penetration difficult, painful & impossible

A

Vaginismus

93
Q

Pelvic Floor and Women’s Health

vaginismus cause

A

Cause usually a conditioned response to a negative experience (i.e. painful first pelvic exam or forced sexual intercourse or past sexual abuse).

94
Q

Pelvic Floor and Women’s Health

dyspareunia and vaginismus;
category of PFD

A

hypertonic

95
Q

Pelvic Floor and Women’s Health

separate hard lumps, like nuts (hard to pass)

A

Type I

ewwwwww! 🤢

96
Q

Pelvic Floor and Women’s Health

Sausage-shaped but lumpy

A

Type II

97
Q

Pelvic Floor and Women’s Health

Like a sausage but with cracks on its surface

A

Type III

98
Q

Pelvic Floor and Women’s Health

Lika a sausage or snake, smooth and soft

A

Type 4

99
Q

Pelvic Floor and Women’s Health

soft blobs with clear-cut edges (passed easily)

A

Type 5

100
Q

Pelvic Floor and Women’s Health

Fluffy pieces with ragged edges, a mushy stool

A

Type 6

101
Q

Pelvic Floor and Women’s Health

Watery, no solid pieces, entirely liquid

A

Type 7

102
Q

Pelvic Floor and Women’s Health

The art of defecation steps

A
  1. Puborectalis and sphincters at rest
  2. defecation reflex: rectum contraction, internal and external sphincter relaxation, stool eneter the anal canal
  3. Inhibition of defecation: puborectalis contraction
  4. Defecation: puborectalis defecation, int/ext anal sphincter relaxation
103
Q

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

A

Constipation

104
Q

Pelvic Floor and Women’s Health

constipation

category of PFD?

A

Hypertonic

105
Q

Pelvic Floor and Women’s Health

causes of constipation

A
  • 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)
106
Q

Pelvic Floor and Women’s Health

treatment of constipation

A
  • food dairy
  • abdominal massage
  • manual therapy to PFM
  • neuro-muscular reed to address paradoxical PFM contraction.
  • pt education: proper toileting techniques
107
Q

Pelvic Floor and Women’s Health

Proper Toileting techniques

A

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

108
Q

Pelvic Floor and Women’s Health

Fecal Incontinence, prevalence as high as ___% in patients with urinary
incontinence & POP.

A

17

109
Q

Pelvic Floor and Women’s Health

Involuntary loss of feces or gas

A

Fecal Incontinence

110
Q

Pelvic Floor and Women’s Health

fecal incontinence
category of PFD?

A

hypoytonic

111
Q

Pelvic Floor and Women’s Health

Important to distinguish TRUE fecal incontinence versus seepage from _______

A

constipation

112
Q

Pelvic Floor and Women’s Health

PT Treatment for FI

A
  • 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
113
Q

Pelvic Floor and Women’s Health

pundendal nerve comes from

A

S2-S4 of the sacral plexus

Specific Systems (9 decks)

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