pelvic health Flashcards
1
Q
what is pelvic health
A
- best possible functioning and management of the bladder, bowel, and reproductive organs
- not merely the absence of disease or weakness
- important role in complete physical, mental, social, and sexual well-being
muscles, viscera, nerves, joints, emotions, nutrition, hormones, fascia
2
Q
innervation of the pelvic bowl
PH
A
sacral plexus
* L4/5 joint S1-4
* pudendal S2-4
coccygeal plexus
pelvic autonomic nerves
* sacral sympathetic trunks
* superior hypogastric plexus
* inferior hypogastric plexus
* pelvic splanchnic nerves
3
Q
what percent of patients with back pain have pelvic floor pathology
PH
A
80%
displays the interconnectedness of body
4
Q
pudendal nerve pathway
PH
A
- S2-4 runs internal to piriformis, goes through greater sciatic foramen, comes back internal, goes external again in perineum
- has both sensory and motor components – only peripheral nerve with atuonomic and somatic fibers
“pudendal” is latin for shame
5
Q
vagus nerve function
PH
A
parasympathetic
6
Q
what are the three diaphragms
PH
A
thoracic
respiratory
pelvic
7
Q
pelvic floor muscles
PH
A
the five S’s
* sphincteric: continent, also relax
* supportive: keep organs in place
* sexual
* stabilization: force closure
* sump pump: lymphatic function
8
Q
voluntary skeletal muscles - fast and slow
PH
A
- 65% slow twitch fibers - connected to postural
- 35% fast twitch fibers
9
Q
first layer
PH
A
- superficial transverse perineal
- bulbospongiosus
- ischiocavernosus
- perineal body
- external anal sphincter (EAS)
pudendal nerve
outer muscles have a sexual role
10
Q
second layer
PH
A
- urogenotial diaphragm
sphincteric, fascial
11
Q
third layer
PH
A
- puborectalis/pubovaginalis
- pubococcygeus
- iliococcygeus
- obturator internus
- coccygeus
hip issu <-> pelvic floor issue
12
Q
pelvic floor dysfunction simplified
A
droopy pelvic floor “hammock”
* underactive: hypotonic, inhibited
taut pelvic floor “hammock”
* overactive: hypertonic, tense/gaurded
but not always this simple
13
Q
risk factors for pelvic floor dysfunction
PH
A
- surgery
- trauma: emotional, phsyical, sexual (adverse childhood events)
- pregnancy and childbirth
- hormonal: menopause, endometriosis
- aging
- central sensitization/psychophysiological disorder - hypersensitive NS
14
Q
multifactorial impacts on PH
PH
A
- hormonal
- nutritional
- orthopedic
- pelvic floor muscles
- nervous system (ANS)
- misc: MS, diabetes
15
Q
biofeedback
PH
A
- good for bowel dysfunction, bladder dysfunction, pelvic pain
- what biofeedback does not tell you: no specificity or presence of muscle imbalances within PF, no neuromuscular control ability/length/functionality
16
Q
contraindications to internal assessment
PH
A
- lack of consent (verbal and nonverbal)
- active infection
- post-operative (< 6-12 weeks)
- pediatric or patient without prior pelvic examination
- severe vaginitis or vaginal atrophy
- first trimester of pregnancy
- severe pain/allodynia
- special considerations: pregnancy, history of SA
17
Q
urination
PH
A
- brain: cerebral cortex, pons micturition center (coordinates sphincter and detrusor)
- sympathetic: T12-L2, hypogastric plexus
- parasympathetic: S2-S4, pelvic plexus
- somatic: pudendal (S2-S4)
18
Q
storage phase
PH
A
- cerebral cortex: messages not time to go
- pons micturition center: inhibited by cortex
- hypogastric nerve T10-T12 (SNS): inhibits detrusor (bladder muscle) and stimulates the internal sphincter (to close)
- pelvic nerve (PNS): is relatively quiet
- pudendal nerve: stimulates external sphincter (to be quiet)
19
Q
emptying phase
PH
A
- cerebral cortex: good to go
- pons micturition center: stimulates the pelvic nerve center
- hypogastric nerve (SNS): becomes quiet
- pelvic nerve (PNS): stimulates destrusor contraction (ACh)
- pudendal nerve: relaxes external sphincter
20
Q
normal bladder function
PH
A
- frequency: 2-4 hours depending on fluid intake, 5-8x in 24 hours, 0-1 times per night
- quality: no pushing/uninterrupted, normal capacity 500-650 cc, no hesitation, no pain with storage or voiding
21
Q
abnormal bladder function
PH
A
- hesitation
- staccato peeing
- post void dribble
- uregency out of the ordinary - difficulty delaying urge
- discomfort or pain during storage or emptying phase
- leakage (common but not normal)
22
Q
bladder habits to avoid
PH
A
- hovering
- just in case peeing (JICCING)
- power peeing - pushing
- self dehydrating - concentrating urine can be irritating
23
Q
bladder issue with underactive pelvic floor
PH
A
- bladder: stress urinary incontinence, pelvic organ prolapse
- orthopedic: lumbar, pelvic girdle, hip instability
can present with combinations of tight and relaxed muscles
24
Q
bladder issues with overactive pelvic floor/nervous system
PH
A
- bladder: voiding dysfunction, pelvic organ prolapse, incomplete emptying, urinary urgency/frequency, urgency incontinence, dysuria, interstitial cystitis/painful bladder syndrome
- orthopedic: low back pain, coccydynia, SI pain, hip pain
25
bladder red flags
| PH
* haematuria
* persistnet UTI
* consitutional symptoms
* poor renal function
* saddle anaesthesia
* recent back trauma
* night pain
26
urinary incontinence
| PH
women
* 1 in 4 under 30
* 1 in 2 between 30-65 years old
female athletes
* 1 in 4 collegiate athletes
* 1 in 2 runners, cross fitters, skiers
males
* 1 in 10 up tot age 60
* 1 in 3 over 75 years old
second most common reason for NH admissions
UI associated with fall risk in the elderly
27
urinary incontinence types
| PH
* stress SUI: physical stress
* urge UUI: leakage with urgency
* mixed: always treat UUI first
* functional: can be continent but cannot get into bathroom on time
| adult diaper sales have now passed infant sales
28
overactive bladder
| PH
* type of urgency incontinence
* prevalence: 3-43%
* symptoms: sudden strong urges which may or may not lead to leakage, persistent or frequent sensation of urgency, increased urgency/frequency (>8-10x/day), nocturia (>2/night)
29
common characteristics of OAB (overactive bladders)
| PH
* bathroom mappers
* key in door syndrome
* declare they were born with small bladders
* JICCERS
* triggers - water running, cold weather, seeing toilet, dietary
* avoid drinking water
* panic pee-ers
30
risk factors for UUI or urgency/frequency in all genders
| PH
* history of abdominal or pelvic surgery
* neurological (MS, diabetes)
* history of UTI
* generalized anxiety disorder (GAD)
* clenchers
* medications
31
medical intervention for urgency incontinence/OAB
| PH
* anticholinergics (dementia?)
* beta 3 agonists
* hormonal (estradiol)
* sacral inter stim (bladder pacemaker)
32
PT interventions for urgency incontinence/urgency - frequency
| PH
* education: dietary irritants, bladder retraining, breathing, urge suppression, autonomic nervous system
* mindful voiding/urge suppression: when was the last time, count seconds of voiding, calm NS (diaphragmatic breathing), brain inhibition (counting backwards)
* voiding or bladder diary: observe patterns and habits that contribute to leakage or urgency, timed voiding
* nutrition education is part of the professional scope of practice for PTs
33
bladder irritants
| PH
* caffeine: coffee, teas, sodas, chocolate
* acidic food: spicy, citric, tomato-based, vitamin C
* alcohol (if worse, it's an irritant; if better, calmer NS)
* carbonated fluids
* artificial sweeteners, colorings, flavorings
* dairy, gluten, sugar
* nicotine
34
stress urinary incontinence
| PH
* characterized by the involuntary loss of urine with increased intra-abdominal pressure
* activities that may cause SUI: coughing, laughing, sneezing, vomiting, bending, lifting, pushing, shouting
* pressure load failure: increased abdominal pressure
35
SUI female risk factors
| PH
* anatomical: extra sphincter, weaker
* hormonal: decreased estrogen < muscular urethral support (first trimester of pregnancy, week before menses, menopause)
* pregnancy and labor: high correlation with forceps/vacuum deliveries, C-section studies, pelvic organ prolapse
* pelvic surgery
36
SUI male risk factors
| PH
* post prostatectomy surgeries
37
all gender SUI risk factors
| PH
* chronic constipation
* asthma
* allergies
* high BMI
38
the knack
| PH
* forced exhalation training: intra-abdominal pressure management
* inhale
* upon a "forced" exhalation, tighten pelvic floor and transverse abdominis
* examples: SHHH, cough, hahaha, achoo, blow nose, yell
39
when to refer to pelvic health PT
| PH
* complex patient with multiple comorbidities
* patient has no clue on what the PF is doing (even after all efforts)
* no improvement or worsening symptoms after 4-6 visits
* symptoms change: pain, pelvic pressure
40
defecation
| PH
* **brain**
* **sympathetic**: hypogastric (T10-12)
* **parasympathetic/vagus**: inferior hypogastric plexus, pelvic splanchnic (S2-4)
* **somatic**: pudendal
41
normal vs abnormal bowel function
| PH
frequency
* normal: 3x a day to 3x a week
* abnormal: 5 or more a day, less than 3 a week
consistency: a 3 or 4
quality
* normal: minimal strain, 1-2 pieces
* abnormal: straining, holding breathing, sitting on toilet more than 15 minutes
42
bowel issues with underactive pelvic floor
| PH
* fecal incontinence
* flatus incontinence
* fecal smearing
* rectal prolapse
* rectocele
43
bowel issues with overactive pelvic floor/NS
| PH
* constipation (non-relaxing puborectalis)
* rectal pain
* anal fissures
* bowel urgency
* recal incontinence
* IBS
44
red flags for bowel
| PH
* blood in stool or black tarry stool
* fever and abdominal pain
* constitutional symptoms
* saddle anesthesia
* recent back trauma
* recent pelvic surgery
* night pain
* unexplained weight loss
45
constipation
| PH
* most common GI complaint
* 35% NH residents on laxatives
* $725 million spent on laxatives each year
* women > men
* 50% of those with constipation will have a pelvic floor dysfunction
46
Rome IV criteria definition of constipation
| PH
2 or more of the following:
* straining (25% of defecations)
* lumpy hard stools (25% of defecations, type 1-2)
* sensation of incomplete evacuation (25% of defecations)
* sensation of anorectal obstruction/blockage (25%)
* manual maneuvers to facilitate defecation (25%)
* less than 3 spontaneous defecations per week (without assistance)
47
risk factors for constipation
| PH
* SAD - standard american diet
* lack of activity
* stress/anxiety/depression (vagus n)
* medications
* elderly
48
types of constipation
| PH
* normal transit constipation: stool that is difficult to pass, usual culprit is poor diet
* slow transit constipation: stool moves at a decreased rate, common culprits are medications/thyroud/neuro (MS, Parkinsons)
* outlet constipation: stool is difficult to pass due to pelvic floor dysfunction
49
medical intervention for constipation
| PH
* over the counter: bulk laxatives
* prescription
* surgery: sacral nerve stimulation, colectomy
50
PT interventions for chronic constipation
| PH
* education: dietary, toilet ergonomics, nervous system calming
* manual therapy: i love you massage
51
patient education on nutrition
| PH
water
* offer suggestions for patient
* guideline: 1/2 of body weight in oz
* warm water in the AM can stimulate gastrocolic reflex
fiber
* bread is often listed as a source of fiber but is not often the best
* vegetables are the best
* berry family best in the fruit
* introduce slowly -- if too fast, it will make things worse
* 25-30 mg of fiber is recommended per day
exercise
52
toilet ergonomics
| PH
* squatty potty -- foot stool(s), box
* neutral spine
* breathing with PF relaxation
* raised toilet seat consideration
53
avoiding valsalva - proper pushing (reverse knack)
| PH
* neutral spine, leaning slightly forward
* sit and relax
* lean slightly forward, squatty potty position (knees higher than hips)
* inhale diaphragmatic breath
* keep jaw and face relaxed
* J breathing, Moo breathing, Lower glottis chanting
54
how many nerve endings do male and female genitalia have
| PH
* male is 4,000
* female is 8,000
55
risk factors for sexual dysfunction
| PH
* trauma history: sexual or surgical, childbirth
* neurological history: diabetes, CVA, MS, PD
* psychological history: D, A
* hormonal imbalance
56
treatment approach to sexual pain/dysfunction
| PH
* top down: neuro
* inside out: nutrition, joy
* bottom up: therapy
