Pelvic Floor and Women's Health Flashcards
(113 cards)
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
2
Q
Pelvic Floor and Women’s Health
triangles of the pelvic floor
A
- urogenital triangle
- anal triangle
3
Q
Pelvic Floor and Women’s Health
blood supply to the pelvic floor
A
- 2 pudendal arteries
- internal pudendal artery
- labial veins
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.
5
Q
Pelvic Floor and Women’s Health
the lumbar plexus branches to the pelvis
A
- genitofemoral
- ilioinguinal
6
Q
Pelvic Floor and Women’s Health
the sacral plexus branches
A
- pudendal
- levator ani
7
Q
Pelvic Floor and Women’s Health
Lumbosacral nerves
A
- 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
8
Q
Pelvic Floor and Women’s Health
detrusor muscle
A
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
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
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)
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
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
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
15
Q
Pelvic Floor and Women’s Health
Function of the PFM
A
- Support of the pelvic viscera
- Sphincteric (bladder & bowel control)
- Sexual functions
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.
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
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
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.
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)
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
22
Q
Pelvic Floor and Women’s Health
Dynamic Muscles Inhibition: gets weak
A
- multifidi
- gluteals
- long adductors
- rectus abdominus
- TrA
23
Q
Pelvic Floor and Women’s Health
What is muscle tone
A
Resistance to displacement at rest
24
Q
Pelvic Floor and Women’s Health
Pelvic floor muscle tone is affected by…
A
Hormones (pregnancy, menstrual cycle, menopause)
25
# Pelvic Floor and Women's Health
True or false: pelvic muscle tone helps categorized pelvic floor dysfunction diagnoses
True (hypertonic, hypotonic, etc)
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# 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
27
# Pelvic Floor and Women's Health
too little tone, lax, weak
Hypotonic PFM
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# 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
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# 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
30
# Pelvic Floor and Women's Health
APTA category: supportive
* Urinary incontinence
* fecal incontinence
* pelvic organ prolapse
* pelvic muscle weakness
* disuse, atrophy
* neurologic dysfunction
31
# Pelvic Floor and Women's Health
APTA category: **hypertonus/pain**
* Pelvic pain
* dyspareunia (painful sexual intercourse)
* constipation
* dysmenorrhea
* voiding difficulty
* pelvic tension myalgia
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# Pelvic Floor and Women's Health
APTA category: incoordination
* Urinary frequency & urgency
* paradoxical pelvic floor
33
# Pelvic Floor and Women's Health
APTA category: **visceral**
* Interstitial Cystitis (IC)
* Irritable Bowel Syndrome (IBS)
* fibroids
* endometriosis
* urinary tract infection
34
# 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
35
# 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**
36
# 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
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# Pelvic Floor and Women's Health
Urge incontinence:
* Symptoms: leaking when hearing running water, “key in the door” (go all the time), frequent urination
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# Pelvic Floor and Women's Health
Mixed incontinence
* Possible mechanism: combined mechanisms of stress & urge
* Symptoms: Combined cues
39
# Pelvic Floor and Women's Health
Decreased contractility of detrusor muscle, urethral obstruction. Patient presents with chronic dribbling of urine, urinary frequency
Overflow incontinence
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# 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
41
# 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
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# Pelvic Floor and Women's Health
Weak squeeze
2
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# Pelvic Floor and Women's Health
Fair squeeze with “definite lift” (moving in an upward direction)
3
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# Pelvic Floor and Women's Health
Good squeeze with repeatable hold & lift
4
45
# Pelvic Floor and Women's Health
Strong, solid, repeatable squeeze & lift
5
46
# Pelvic Floor and Women's Health
The normal resting tone as measured by biofeedback (surface electrodes) less than _____ microvolts
**2**
47
# 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**
48
# Pelvic Floor and Women's Health
Bladder re-training usually take ____ weeks
**6-12**
49
# Pelvic Floor and Women's Health
limiting factor in bladder re-training
pt's compliance
50
# 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
51
# Pelvic Floor and Women's Health
If urge comes before the scheduled time, pt taught **Urge Suppression Techniques:**
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
# Pelvic Floor and Women's Health
**advanced** kegel exercise is to have pt perform it with...
TrA without holding their breath
53
# 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)
54
# 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
55
# 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"**
56
# 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.
57
# Pelvic Floor and Women's Health
Prolapse or a protrusion of 1 or more pelvic organs into the vaginal canal.
**Pelvic Organ Prolapse**
58
# 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
59
# 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**
60
# Pelvic Floor and Women's Health
Pelvic organs are primarily supported by the
PFM, the endopelvic fascia & the vagina
61
# Pelvic Floor and Women's Health
causes of **coccydynia**
* direct trauma
* injury during vaginal delivery
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# Pelvic Floor and Women's Health
**coccydynia**
pain with:
* sitting
* palpation
* transitional mvmt
* intercourse
* defecation
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# Pelvic Floor and Women's Health
coccydynia
## Footnote
**findings:**
* coccyx tender to palpation
* hip extensors and hip mm weakness
* pain with forward bending
* pain with sitting and asymmetrical pos
64
# Pelvic Floor and Women's Health
coccydynia **category**
chronic pelvic pain
65
# Pelvic Floor and Women's Health
function of the coccyx
* insertion of PFM
* provides tension for the PFM
* moderates all motion of the pelvis
66
# 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
67
# 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)
68
# Pelvic Floor and Women's Health
Coccyx position assessment is done in what position?
in sitting
69
# Pelvic Floor and Women's Health
Coccydynia Treatment
* Massage to coccygeus, piriformis & glut muscles
70
# Pelvic Floor and Women's Health
PFM exercises using accessory muscles:
* adductor squeeze
* hip external rotator isometrics
* **NOT gluts**
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# 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
72
# 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
73
# Pelvic Floor and Women's Health
branches of the pudendal nerve
* inferior rectal
* perineal nerve
* dorsal nerve of clitoris/penis
74
# Pelvic Floor and Women's Health
Hallmark sign of **Vulvar Vestibulitis**
**+Q tip test**
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# Pelvic Floor and Women's Health
Vulvar Vestibulitis Characterized by **3 symptoms:**
1. pain in the vestibule to touch or vaginal entry
2. tenderness to light pressure localized within the vulvar vestibule
3. vestibular erythema
76
# 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.
77
# 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)
78
# 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**
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# 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
80
# Pelvic Floor and Women's Health
Irritable Bowel Syndrome (IBS);
**category**
visceral
81
# Pelvic Floor and Women's Health
Irritable Bowel Syndrome presents as
* diarrhea predominant
* constipation predominant
* or both (majority)
82
# 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**
83
# 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
84
# Pelvic Floor and Women's Health
Interstitial Cystitis AKA
Painful Bladder Syndrome
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# 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.
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# Pelvic Floor and Women's Health
interstitial cystitis (painful bladder syndrome) **category of PFD**
visceral
87
# Pelvic Floor and Women's Health
first line of tx for intersitial cystitis (painful bladder syndrome)
antibiotics
88
# 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)
89
# 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**
90
# Pelvic Floor and Women's Health
Defined as a recurrent pain during intercourse
**Dyspareunia**
91
# Pelvic Floor and Women's Health
Possible causes of **dyspareunia**
* **vulvodynia**
* **vulvar vestibulitis**
* episiotomy scar
92
# Pelvic Floor and Women's Health
Characterized by involuntary contraction/muscle spasm of the perineal muscle making penetration difficult, painful & impossible
Vaginismus
93
# 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).
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# Pelvic Floor and Women's Health
dyspareunia and vaginismus;
**category of PFD**
hypertonic
95
# Pelvic Floor and Women's Health
separate hard lumps, like nuts (hard to pass)
**Type I**
**ewwwwww! 🤢**
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# Pelvic Floor and Women's Health
Sausage-shaped but lumpy
**Type II**
97
# Pelvic Floor and Women's Health
Like a sausage but with cracks on its surface
**Type III**
98
# Pelvic Floor and Women's Health
Lika a sausage or snake, smooth and soft
**Type 4**
99
# Pelvic Floor and Women's Health
soft blobs with clear-cut edges (passed easily)
Type 5
100
# Pelvic Floor and Women's Health
Fluffy pieces with ragged edges, a mushy stool
**Type 6**
101
# Pelvic Floor and Women's Health
Watery, no solid pieces, entirely liquid
**Type 7**
102
# Pelvic Floor and Women's Health
The art of defecation steps
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
# 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**
104
# Pelvic Floor and Women's Health
constipation
category of PFD?
Hypertonic
105
# 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)
106
# 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
107
# 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
108
# Pelvic Floor and Women's Health
Fecal Incontinence, prevalence as high as \_\_\_% in patients with urinary
incontinence & POP.
**17**
109
# Pelvic Floor and Women's Health
Involuntary loss of feces or gas
Fecal Incontinence
110
# Pelvic Floor and Women's Health
fecal incontinence
**category of PFD?**
hypoytonic
111
# Pelvic Floor and Women's Health
Important to distinguish TRUE fecal incontinence versus seepage from \_\_\_\_\_\_\_
constipation
112
# 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
113
# Pelvic Floor and Women's Health
**pundendal** **nerve** comes from
S2-S4 of the **sacral plexus**
