Pelvic Floor Rehab Flashcards
Pelvic Floor Overview
- 3 layers of muscles
- layers of fascia surrounding
The pelvic floor is suspended
-from the pubis to the coccyx
Superficial (1st) Layer
- pudenal nerve
- sexual function
- -contract to enlarge clitoris and penile erection
- -vaginal sphincter assists in clitoral erection
- -external anal sphincter
Middle (2nd) Layer
- Pudenal nerve
- sphincteric
- -urethral sphincter
- slow twitch
- compress urethra and 1/3 of resting urethral closure pressure
Deep (3rd) Layer
- nerve to levator ani
- supportive (pelvic diaphragm)
- constricts lower end of rectum, vagina
- supports viscera (hammock)
6 Functions of Pelvic Floor
- supportive
- sexual
- sphincteric
- stabilizing
- withstands intra-abdominal preSSure
- Allows baby’s head to Slide out
Muscle fibers in pelvic floor
- 70% slow twitch
- 30% fast twitch
Bony boundries
- Ant: symphusis pubis
- Anterolat: inferior pubic rami
- Lateral: ischial rami
- Lateral: ischial tuberosities
- Posterolat: sacrotuberous ligament
- post: coccyx
S2, S3, S4
Pudenal nerve
“S2, 3, 4 keeps the baldder off the floor”
3 First Layer Muscles
- superficial transverse perineal
- bulbocarvernosis
- Ischiocavernosis
Muscles of the 3rd Layer
- pubococcygeus
- iliococcygeus
- puborectalis
(levator ani muscles/pelvic diaphragm)
Muscles of 2nd Layer
sphincter urethrae
Other muscles of pelvic region
- coccygeus
- piriformis
- obturatur internus
Coccygeus
- flexes coccyx
- supports viscera
- stabilizes SI joint
Piriformis
- lateral hip rotator
- assist abduction with hip in flexion
Obturator Internus
- lateral hip rotator
- assist abd with hip in flexion
MMT of Pelvic Floor Muscles
- levator ani
- -index finger along vaginal wall, on thickest part of levator ani
- ask pt to contract
Grading of MMT of PFM
- 0=none, absent
- 1=flicker, trace
- 2=weak squeeze, no lift, weak
- 3=fair squeeze, definite lift, moderate
- 4=lift with squeeze, good
- 5=strong squeeze with resistance, strong
Dynamic MRI
in upright position to understand PFM function
contraction of PFM is _____
-concentric
–moving coccyx in ventral, cranial direction
Coccyx pressed ___during straining
-dorsally
Real-Tie US to visualize PFM
- trans abdominal US to assess PFM function
- assess PFM activity when invasive procedure not appropriate or possible
normal # times to go to urinate per day
4-7 times
Negative Effects of Incontinence
- embarrassing (stop socializing due to fear of accidents)
- depression
- nursing home admits
- cost ($11.2 bill spent on pads/diapers)
Why they don’t come in earlier
- belief it’s expected part of aging
- rely on incontinence products
- embarrassed
- healthcare provider never ask them
- lack of awareness for treatment
Normal Voiding
- every 2-4 hours
- 4-7x/day
- 0-1x/night
- no just in case voiding
- urine stream steady for 8 seconds
- no straining
- no leaking (even after pregnancy)
Types of Incontinence
- urinary stress incontinence (USI)
- Urinary Urge Incontinence (OAB-overactive bladder)
- Mixed Urinary Incontinence
- Fecal Incontinence
Urinary Stress Incontinence
- involuntary loss of urine with activities: laugh, cough, sneeze, run, jump, lift
- incr IAB + weak PFL = leakage
Urinary Urge Incontinence
- invol loss of urine associate with strong urge to urinate
- running water, can’t get pants down in time, key in door
- bladder instability causes contraction of bladder + weak pelvic floor = leakage
Male Incontinence
- most common after prostate surgery
- prostate adds support to bladder
- male pelvis narrow
- internal pelvic floor muscle exam (rectally)
Bladder muscle
-detrusor muscle (smooth muscle)
Micturition
-urination
When male contracts PFM:
-penis will lift upward
causes of incontinence
- weak PFM
- abdominal weakness
- pregnancy
- vaginal delivery
- episiotomy
- estrogen depletion
- meds
- infections
- high impact activity
- diabetes
- stroke
- obesity
- pelvic nerve injury
- prior surgeries
- organ prolapse
- neuro conditions (MS)
POP
- Pelvic Organ Prolapse
- tested in supine with bearing down
Exam of POP
- 2 fingers into vagina and bear down
- observe/feel for displacement of tissue
- -anterior: bladder (cystocele)
- -apical: uterus (uterine prolapse)
- -posterior: rectum (rectocele)
Cystocele
-displacement of bladder creating bulge into ant vaginal wall
Rectocele
-displacement of rectum creating a bulge into posterior vaginal wall
Uterine Prolapse
-displacement of uterus downward into vaginal vault
Grades of Organ Prolapse
Grade I: mild bulge (25%)
Grade II: mod bulge (50%)
Grade III: severe bulge, into vaginal opening (introitus)
Grade IV: bulge completely out
PT for grade I and II
Precautions/Contraindicatoins for Internal PFM Exam
- pregnancy
- immediate post-partum (6 weeks)
- active infections
- severe pelvic pain
- history of sexual abuse
- inadequate training of PT
- absence of pt agreement
- menses not necessarily a contraindication
PFM Contraction
- accessory muscle use
- hold time (endurance)
- repetitions
- Fast contraction (how many fast before fatigue)
- PERFECT Score
PERFECT Score
- power
- endurance
- repetitions
- fast
Anal Wink Reflex
- stroke side of anal sphincter
- should contract
Rectal branch of pudenal nerve
PT for Incontinence
- muscle re-ed (kegel, abdominal)
- biofeedback
- diet (avoid bladder irritants–acidic)
- postural education/ortho
- E-stim
- diaphragmatic breathing
Vaginal Weights
- sensory feedback to muscle contraction
- progressive resistive exercise
- 5 progressive weights (20-70g)
- progress supine to standing
Bladder Irritants
- alcohol
- carbonated
- caffeine
- artificial sweeteners
- dairy
- coffee, tea, (even decaf)
- tomatoes
- tomato based products
- spicy foods
- citrus
- chocolate
- sugar/honey
bladder training technique
- scheduled voiding
- pt education for urgency control
- self monitoring with bladder diary
- reinforcement
Pelvic floor exercises
- contract: close sphincters, vagina and rectum
- Rela: open sphincters, vagina, rectum
- Bulge/expand/drop: for bowel movements/voiding
Kegel Exercises
- ID correct muscle
- do not contract abdominal, gluteal or hip addcutors
- pull up and in with PFM
Quick Flicks
-PFM hold 1 sec
Slow Holds
-PFM 10 second hold
Pelvic Floor Instruction
- life, draw up and in, squeeze and close
- wink the anus, move the penis
- pull underwear/tampon in
- lift your perineum off the chair
- hold back gas
Pelvic Floor Educator
- device to improve pt understanding and motivation
- used with HEP
- plastic piece with stick so pt can see it move with contraction
When doing Kegels:
-push to limit and a little beyond but never to fatigue
to make a change
-do 40-60 PFM contractions per day
Average ____ visits over ____
4-8 visits
2-3 month period
2nd most common complaint in GYN
-pelvic floor pain
Levator Ani Syndrome
-spasming of levator ani Mm
PFM Disorders
- levator ani syndrome
- coccyodynia
- connective tissue dysfunction
- vaginismus/vulvodynia
- pelvic floor tension myalgia
Vaginismus
-can’t open vaginal opening bc muscles too tight
Organic Diseases
- interstitial cystitis (painful bladder syndrome)
- endometriosis
- pelvic inflammatory disease
-subsequent pelvic floor pain
Typical Complaints
- feels like insides falling out
- pressure in pelvis
- constipation/trouble starting urine
- vagina aches deep inside
- feels like sitting on golf ball
Questions to ask?
- prior injuries
- surgeries/childbirth
- pn with or after sexual intercourse
- pain/pressure/aching in suprapubic, vaginal or rectal area
- abuse
