Pelvic Floor Lecture Flashcards
History
● Chief Complaint
● PMH
● Obstetric History
● Urinary symptoms
● Bowel symptoms
● Pain (Vulvovaginal, penile, rectal)complaints
● Sexual dysfunction complaints
● Fluid Intake and diet
● Employment/Social (what are the patient’s
functional requirements)
MSK Exam
● Functional screening (gait, balance)
● Movement and posture analysis
● Breathing assessment
● Range of motion
● Flexibility testing
● Muscle testing
● Joint mobility
● Soft tissue assessment
goal examples for PF
○ Patient is able to run 3 miles without leakage
○ Patient is able to increase time between voids to 2 hours in order to reduce
interruptions at work
what % of PFM are fast twitch? slow twitch?
fast: 30%
slow: 70%
“wall” of the pelvic floor
obturator internus
piriformis
functions of PF
Support
Sphincter
Sexual
Stabilize
Sump Pump (blood/lymph)
normal input from kidney and which mm activates / relaxes
- 1 mL/min input from kidney
- pelvic floor relax
- bladder contracts and empty all the way
- bladder relax and pelvic floor / sphincter return to normal tone
normal voiding
4-8 voids / day
or
interval of every 3-4 hrs
night time voids
NONE
1x normal for over 65
poor bladder habits
“just in case” peeing
semi squat
straining
drive by peeing (pushing to pee)
pelvic floor exercise on the toilet
post partum nocturnal habit
○ Leakage of urine with increased intra-abdominal
pressure
○ Cough, sneeze laugh, exercise, change in position
stress incontinence
○ Leakage associated with a strong urge, often on the
way to the bathroom
urge incontinence
over active bladder
is urgency and frequency without leakage
Leakage from a full bladder, urge to void missed or
blockage to urethra
overflow
Patient with mobility issues preventing getting to the
bathroom in time
functional incontinence
what are bladder irritants?
● Caffeine
● Alcohol
● Carbonation
● Artificial sweeteners
● Citrus juices/foods
● Tomatoes
● Spicy foods
● Chocolate
“just do kegals”
● 40% women are unable to perform a pelvic floor muscle contraction with
verbal instructions alone
● Squeeze of posterior muscles, anterior muscles and cranial lift present for
correct contraction
● Full relaxation is important
● Where things go wrong
○ Preconceived ideas
○ Stop Test as practice
T/F strength train an overactive pelvic floor is recommended
FALSE
pt complains of:
Feeling of heaviness in pelvis, feeling of
something in the vagina (ball or stuck tampon)
● Tissue laxity assessed anterior, apical and posterior
● Associated Levator avulsion - 13% of births
prolapse
ways to treat prolapse
● PT trials 12-16 week: PFMT, behavioral modifications resulted in improved
symptoms and staging of prolapse
● PT + pessary (device to help with POP)
Pelvic floor mm training
○ Coordination
○ Strength and endurance
○ Address breathing
behavior modifs
○ Address poor voiding and defecation mechanics
○ Fluid Management and reduce bladder irritants
○ Bladder Diary
○ Timed Voiding
○ Weight Loss
○ Urge Distraction Techniques
○ Address constipation if present
cueing for correct contraction
● General
○ Stop the flow of urine
○ Picture urethra as turtle head drawing back into shell
○ Try to stop from passing gas
○ Close the front passage / close the back passage
○ Tighten around the anus
● Female specific
○ Pick up marble/blueberry/raisin with your vagina
○ Try to close the labia as if they were saloon doors
● Male Specific
○ Shorten the penis
○ Contract the muscle like when you sit on a cold toilet seat
○ Lift the scrotum
○ Elevate the bladder
urge mgmt techniques
○ Breathing
○ Quick Flicks
○ Distraction
■ Counting backwards by 7 from 100
■ Thinking of shopping list
as a PT choosing appropriate interval (if patient going to bathroom every 15 min then 2 hours
is not an appropriate interval, importance of building confidence in
themselves)
normal bowel movement
3x/day to 3x/week
favorable consistency of stool
Type 3,4,5 easiest to pass
T/F stool form is a better indicator of transit time than defacation frequency
T
fecal incontinence Tx
pelvic floor training especially EAS
normalizing bowel consistency
treat dyssnergia (coordination of the mm)
rectal pain
coccyx pain
Unsatisfactory defecation due to infrequent stools, difficult stool passage or both
constipation
(considered part of aging but not caused by aging)
constipation prevalence
● 1⁄5 of population
● 2-3 times more common in ____ and in____
● More common in non-caucasians and lower SES
● Common in ____ 0.7%-29.6%
women and elderly
peds
contributing factors to constipation
● Metabolic Problems
● Fiber Deficiency
● Anorectal problems
● Medications
dysnergia / outlet constipation
puborectalis unable to relax or is contracting when attempting to defecate
work on coordination
Chronic pelvic pain defined as pain in abdomen and /or pelvis that has
lasted longer than ____, and is not caused by diseases or conditions
such as dyspareunia, dysmenorrhea or endometriosis
● 90% pain with intercourse
● 50% depressed
● 1 in 7 American women
● 61% no diagnosis
● Vulvodynia 3-15% of women
3 months
vulvovaginal pain
● Post-delivery scar pain (sulcus, periurethral, perineal tears)
● Overactivity
● Vaginismus
● Shortened pelvic floor muscles due to pathology
○ Lichen Sclerosis, Planus, Simplex
○ Radiation
○ Surgery
● Pain in vulva not related to a specific, identifiable disorder
● Pt c/o discomfort with sensations of burning, irritation or rawness, knife-like
pain
● Many contributing factors
○ Hormonal (including OCP use)
○ Neuroproliferative factors
○ Abnormalities of embryonic development
○ genetic/immune factors
○ infection
vulvodynia and vestibulodynia
pain treatment
● Pain Neurophysiology Education
● Downtraining of pelvic floor
○ Biofeedback
○ Breathing instruction
○ Physiological quieting/ progressive relaxation
● Graded exposure
○ Manual treatment
○ Speculum training
○ Sensate focus
● Dilator program
● Stretching
● Manual therapy
○ Joint mobilizations/manipulations
○ Soft tissue (muscle or connective tissue) mobilization
T/F you can do manips and mobs during first trimester
FALSE (b/c that’s when most miscarriges happen)
patient c/o pain with transition from STS and feels a stretching sensation that causes the pain
round ligament pain
normal BP for pregnant women
140/90
PT tx during pregnancy
● Body Mechanics training
● Specific exercise
● Cardiovascular Exercise
● Manual Therapy
● Pain Science Education
● Sacroiliac belts, support bands, kinesiotaping
What is Diastasis Recti?
● How much separation is normal?
● DRA or hernia?
● How do I know if I have one?
● Abdominal wall separation between rectus muscle bellies at the linea alba
- 1-2 finger separation normal. 2 1/2 indicates consult w/ MD
- DRA is a separation of the abdominal muscles with no organ protrusion, while a hernia involves an actual protrusion of abdominal contents through a weakness in the wall.
- perform a DR check test
DRA associated with
LBP
Incontinence
prolapse
constipation
DRA risk factors
Female
○ Age > 33
○ Multiparity or multiple gestation
○ Large baby
○ Greater weight gain
○ C-section birth
● Male
○ Obesity
○ Abdominal straining
○ Post abdominal aortic aneurysm surgery
Orthopedics
-
-
-
● LBP with UI
● Orthopedic considerations for Intercourse
● Exercise Prescription
- proalpse
- diastasis
- incontinence
- labral and pelvic floor issue
PEDIATRICS
● ____ is the primary cause of urinary accidents and bedwetting
● May have neurological conditions such as spina bifida or tethered cord that
contribute to bowel or bladder dysfunction
● Questions to ask:
○ Do they have a history of reflux, abdominal pain, pain with bowel movements,
bloating, poor appetite or fear of the toilet?
○ Do they ever have any leakage of any kind during the day or at night (including a
smear or poop in their underwear?)
○ Are they wearing pull ups past the age of ____?
○ Do they wet the bed or notice peeing while laughing or playing?
○ “I don’t ever want you to touch the poop, but if you were to pretend to smoosh it into a ball, would that ball of poop be bigger than your child’s fist?”
constipation
4
GERIATRICS
● ____ is the 2nd reason for nursing home admissions
● Many older people have accepted their ____ because they have not
been presented with treatment options
● Many may have already had a failed surgery
● ____ is embarrassing and many people are not forthcoming with
information
● Screen for fecal ____
incontinence
Low back and hip pain
always ask urinary, constipation, pain with sexual activity, abdominal pain
Specific Screening questions
● Older adults - Are you having any loss of urine or stool beyond your control?
● Patients on pain medications - How often are you having a bowel
movement? Are you straining or do you have pain with a bowel movement?
● Patients with Diabetes with peripheral neuropathy: Erectile dysfunction,
increased urgency, frequency, nocturia, weak stream, incomplete emptying
primary care screening ROS
● Do you ever have any urinary leakage (even a small amount)?
● Do you feel a strong urge to urinate or have to rush to the bathroom?
● How frequently do you urinate? / Do you urinate more than 10 times/day?
● Are you able to have a bowel movement at least 3 times / week without
pain or excessive straining or pushing?
● Do you have pelvic, vulvar or vaginal pain, or penile pain?
● Do you have any pain in the pelvis or pain with sexual activity
● If you are sexually active, are you able to be intimate the way you want to
be without pain?
