Pelvic Floor Lectures Unit 2

Question 1

What is the Innominate ?

Answer 1

Ilium
Pubis
Ischium

Question 2

Lumbosacral Joint

Answer 2

L4,L5,S1
- Due to L5 being tethered securely to the Ilia by the iliolumbar ligament the sacrococcygeal joint is where the apex of the scrum is connected to the base of the coccyx

Question 3

What acts as a primary stabilizer for maintaining static and dynamic stability of the body

Answer 3

The pelvis
- The pelvis is a force generator during many movements
- Pelvis requires stable mobility for optimal function which is achieved through muscular strength and the ability to cause tension in the ligaments

Question 4

1. Greater Pelvis
2. Lesser Pelvis

Answer 4

1. The greater pelvis is located superiorly and provides support to the abdominal organs
2. The lesser pelvis is located inferiorly and provides support for pelvic organs

Question 5

Pelvic Inlet

Answer 5

• boundary between the greater and lesser pelvis
• Anterior Border = pubic symphysis
• Lateral border= arcuate ligament
• Posterior Border= sacral promontory

Question 6

Pelvic Outlet

Answer 6

• Located at the bottom of the lesser pelvic and the beginning of pelvic wall
• Anterior border= pubic arch
• Lateral border= ischial tuberosity and inferior border of the sacrotuberous ligament
• Posterior border= tip of the coccyx
• Outlet–> you can basically turn the pelvis upside down and see the outlet located at the bottom of the lesser pelvis

Question 7

Pelvic Outlet based on Gender

Answer 7

• women have a greater pelvic outlet
• Gynecoid pelvis is wider and broader
• Gynecoid pelvis is lighter in weight
• Gynecoid pelvis is oval shaped, android is heart shaped
• gynecoid pelvis has less prominent sacral spines
• Gynecoid pelvis has a sacrum that is shorter and more curved
• SI joints are further from the hip joints are flatter and smaller than the android pelvis

Question 8

Sacrospinous Ligament

Answer 8

• Connects the ischium to the sacrum
• Sacrospinous ligaments create the sciatic foramina thru which the pudendal nerve supplies the perineum
• Thin triangular ligament
• is often used as a point of fixation for the vagina during vaginal prolapse surgery called sacrospinous fixation

Question 9

Sacrotuberous Ligament

Answer 9

• Flat Triangular band of muscle
• attaches to posterior border of the ilium, and to the lower aspect of the sacrum and the coccyx
• Fibers from the gluteus maximus attach posteriorly to this ligament and the long head of the biceps femoris attaches superiorly

Question 10

Greater and Lesser Sciatic Foramen

Answer 10

• They separate the sacrospinous and sacrotuberous ligaments and create 2 openings which the greater and lesser foramina
• Think about patient who come for sciatica and nothing ortho has helped–> you can get to this anatomy both externally and internally, patient may benefit form internal treatment

Question 11

What are the nerve roots of Sciatic nerve

Answer 11

L4, L5, S1-S3
- Glute max and piriformis posteriorly
- semitendinosus
- semimembranosus
- long head of biceps
- adductor magnus
- short head of biceps

• on the internal side, obturator internus and both ligaments that come and connect there too and could potentially impact the neural pathway

Question 12

Superficial Pelvic Floor/Urogenital Triangle: First Layer

Answer 12

• Superficial Transverse Perineal
• Bulbocavernosus/Bulbospongiosus
• Ischiocavernosus

Question 13

Superficial Transverse Perineal

Answer 13

O= body of ischium
I= Perineal Body
I= perineal branch of pudendal nerve S2-S4
A= fixes the perineal body

Question 14

Bulbocavernosus / Bulbospongiosus

Answer 14

Bulbocavernosus= female
Bulbospongiosus= male
Female
- O= central perineal tendon, travels under labia
I= fascia of the corpus cavernous of the clit
I= perineal branch of pudendal nerve
A= Closes vaginal introitus and clitoral erection

Male
O= Central perineal tendon
I= fascia of the bulb of the penis, corpus cavernosum and spongiosum
I= perineal branch of the pudendal nerve
A= compressor of the urethra and assists in ejaculate form urethra

Question 15

Ischiocavernosus

Answer 15

Male:
O= ischial tuberosity and ramus
I= fascia of the corpus cavernosum
I= perineal branch of the pudendal nerve
A= maintains and assists with penile erection

Female:
O= ischial tuberosity
I= fascia of the corpus cavernosum
I= perineal branch of the pudendal nerve
A= clitoral erection

Question 16

Second Layer : Urogenital Diaphragm or Perineal Membrane

Answer 16

1. urethrovaginal sphincter
2. Compressor urethrae
3. Deep transverse perineal

Question 17

Urethrovaginal Sphincter

Answer 17

O= vaginal wall
I= ventral surface of the urethra
A= compresses the ventral wall and assists in continence

Question 18

Compressor Urethrae

Answer 18

O= ischiopubic ramus
I= Vaginal wall
A= compresses the ventral wall and assists with continence

Question 19

Deep Transverse Perineal

Answer 19

O= inner surface of the rami of the ischium
I= runs across to attach to the opposite side
A= aids in fixing the perineal body

Question 20

Third Layer: Levator Ani

Answer 20

• Formed by 3 muscles:
  1. Pubococcygeus
  2. Iliococcygeus
  3. Puborectalis
• Supports the pelvic viscera
• helps to raise intraabdominal pressure with cough, sneeze, and forced exhalation
• Assists with closure of the urethra, rectum and vagina

Question 21

Pubococcygeus

Answer 21

O= anteriorly to the body of the pubis and posteriorly to the ischial spine : it also attaches to the fascia of the obturator internus
I= Anococcygeal body, between the tip of the coccyx and the anal canal
I= Ventral rami of the 3rd and 4th pelvic nerve and the perineal branch of the pudendal nerve
A= supports pelvic viscera

Question 22

How can the obturator internus lead to sciatic?

Answer 22

• obturator internus muscle is often overlooked and can lead to sciatic presentation
• This Pubococcygeus attaches to the fascia of the OI and if this is tight and is pulling on the obturator that can result in sciatica

Question 23

Puborectalis

Answer 23

O= dorsal surface of the pubic bone and fascia of the obturator internus
I= Anococcygeal body, sling around junction of the rectum and anal canal
I= anterior primary rami ( perineal branch S3-S4)
A= voluntary sphincter of the anal canal, supports and aids continence of rectum by maintaining anorectal angle
- runs along side pubococcygeous/but you can see how it wraps directly back to the rectum
- Strap/loop around the rectum- and the rectum has a natural angle to it, but if pulled tight it decreases the angle and puts a kink in the chain and results in inability to empty bowels

Question 24

Iliococcygeus

Answer 24

O=Arcus tendinosis levator ani( a fibrous band suspended between the pubic bone and the ischial spine)
I= Anococcygeal body and the coccyx
I= Perineal branch of the pudendal nerve S3-S4
A= supports the pelvic viscera and the lateral coccyx

Question 25

What are some accessory muscles to the Pelvic floor?

Answer 25

Cremaster Coccygeus Iliacus Obturator Internus

Question 26

Cremaster

Answer 26

O= lower border of internal oblique and transversus abdominis in inguinal canal I= loops around spermatic cord and tunica vaginalis and some fibers return to attach to pubic tubercle I= Genital branch L2 of genitofemoral nerve L1, L2 A= retracts testis

Question 27

Iliacus

Answer 27

O= upper 2/3 of the iliac fossa, inner lip of the iliac crest, and the ala of the sacrum I= mObajority attach to the psoas major tendon, the tendon then attaches to the lesser trochanter of the femur I= femoral nerve L2-L3 A= if origin fixed flexes the hip joint. With insertion fixed it works with the psoas to pull the pelvis and trunk forward

Question 28

Coccygeus

Answer 28

O= apex of pelvic surface tip of ischial spine and the sacrospinous ligament I= coccyx and fifth sacral spinal cord segment I= sacral plexus S3-S4 A= works with the levator ani in forming the pelvic diaphragm. Assists with raising intraabdominal pressure with coughing, vomiting and expiration

Question 29

Obturator Internus

Answer 29

O= inner surface of obturator membrane and rim of pubis and ischium bordering membrane I= middle part of medial aspect of greater trochanter of femur I= L5, S1, S2 A= Laterally rotates and stabilizes hip

Question 30

Obturator Internus is a common source of

Answer 30

common source of referral to the lumbar spine, glutes, hamstrings region and hip - inside stabilizer and runs very similarly to the piriformis

Question 31

What is the length tension relationship of the pelvic floor

Answer 31

- if you have a muscle that is short and tight ( fibers overlapped so tightly that they cant produce force) , doesn't produce any force if any - If a muscle is lengthened or on stretch and goes to activate, it doesn't produce force

Question 32

Urinary Incontience

Answer 32

- any involuntary loss of urine that is a social or hygienic problem - anything from 1-2 drops to full loss of bladder

Question 33

What is required for bladder control?

Answer 33

- Intact NS - Intact urinary system - Cognitive ability to recognize a need to void - physical capacity to make it to the bathroom

Question 34

Stress Incontinence

Answer 34

- Loss of urine during physical exertion or when the intravesical pressure exceeds the maximum urethral pressure due to an increase in intra-abdominal pressure in the absence of detrusor contraction - laugh -cough - sneeze - jump - what happen is you have pressure change through the abdomen and pelvis and then pushes on the bladder resulting in urine being forced downward into the urethra and if the pelvic floor is not strong enough to combat that, you have a leak

Question 35

Bladder Dysfunction; Urge Incontinence

Answer 35

- the most common type of incontinence in elderly - Most distressing - Involuntary loss of urine that occurs with a strong desire to urinate (urgency) with few seconds to minutes of warning. The bladder contracts and there is an involuntary loss of urine - typically comes with a trigger

Question 36

Bladder Dysfunction: Mixed Incontinence

Answer 36

- patient displays signs and symptoms of both stress and urge incontinence

Question 37

Bladder Dysfunction: Functional Incontinence

Answer 37

- patient is aware of the need to urinate but functionally unable to make it to the restroom in time due to physical or cognitive limitations - loss can be small to large mounts of urine Possible Causes: - physical deficits, gait, weakness, balance - environmental barriers (stairs or something preventing access) - difficulty or inability to remove clothing due to dexterity - Lack of supportive equipment for safe mobility - Inability to communicate the need to use the restroom - cognitive decline

Question 38

what are normal age related bladder changes?

Answer 38

- decreased bladder capacity - decreased ability to postpone voiding - increased post void residual - decreased estrogen resulting in decreased urethral mucosa - decreased estrogen resulting in decreased vascularity - loss of smooth muscle fibers

Question 39

What are healthy bladder habits

Answer 39

- hydration - avoiding bladder irritants - timed voiding - positioning - fully empty/diaphragmatic breathing/relax PF - No hovering - double void - no starting/stopping stream - urge suppression techniques

Question 40

daily average of urination

Answer 40

4-10 times a day

Question 41

What ware healthy bowel habits

Answer 41

- hydration - food diary - stool consistency - postures for bowel emptying - diaphragmatic breathing/relaxation PF - movement

Question 42

Cystocele=

Answer 42

Bladder prolapse

Question 43

Cystourethrocele=

Answer 43

bladder and urethra

Question 44

Rectocele=

Answer 44

rectal prolapse

Question 45

Enterocele=

Answer 45

intestinal prolapse

Question 46

Uterine prolapse=

Answer 46

uterus prolapse