Pelvic Health Flashcards
Founder of Pelvic Health in PT
Elizabeth Noble in 1977
3 important ligaments on the anterior portion of the pelvis
- Sacroiliac l.
- Sacrospinous l.
- Sacrotuberous l.
Where is the pelvic floor located? Why is it important?
- Pelvic Floor is attached across the base of all things via fascia and ligaments
- When trauma or pregnancy occurs results in dysfunction and strain, leading to pelvic floor issues
What are two anatomical similarities between males and females for pelvic floor?
- Both have Urogenital Urethra and Genital Triangle
What 3 muscle compose the Levator Ani?
- Puborectalis
- Pubbococcygeus
- Illicoccygeous
These three muscle function together!
Where is the puborectalis muscle? Why is it important?
- Comes from the bone near pubic symphysis wrapping around the rectum
- Squatting places muscle on slack making it easier for things to flow out
How does the puborectalis relate to hip precaution patients?
- Having an elevated toilet seat to stay within precautions results in the muscle staying tight, making it harder to go
- May need stool softener
Obturator Internus
- Attachments
- Motions
- Referral Pattern
Motions:
- In flexion is an abductor
- In extension is an external rotator
Referral Pattern
- Near butthole/coccyx
- Below right buttcheek, down back of thigh
Why is the Obturator Internus so important in regards to pelvic health?
- It is a muscle attachment for the levator ani via fascia
- Tear results in loss of foundational support for the pelvic floor muscles
- Present with hip pain, muscle weakness, incontinence, prolapse of organs
What is a kegal?
- Pelvic Floor Muscle Contraction
- Upward and inward motion
- Involved Levator Ani
Why is the pudendal nerve important?
- Origin: S2-S4
- Sensory and Motor to the Pelvic Floor Muscles
How can you test the Pudendal Nerve?
- Perform a Tenel Test (Nerve Provacation Test)
- Tap on the nerve
- Normal: No Sx
- Positive: Aggravated Sx
- Test is performed medial to ischial tuberosity
Why is the Genitofemoral nerve important for pelvic floor?
- Origin: L1-L2
Path:
* Pierces Psoas Muscle
* Splits into two branches: Genital (through inguinal canal to scrotum or labia majora) and Femoral (Fascia lata and femoral sheath to anterior aspect to upper thigh)
- Action: Sensory and motor to cremaster muscle
- Neurodynamic mobility: SB and then pull on strotum to perform gliding and tensioning
Sympathetic and Parasympathetic - micturition
- Micturition = urination
- Sympathetic = store urine
- Parasympathetic: helps you pee; S2-4
Voluntary contraction of pelvic floor muscles provides reflex relaxation of the ____ muscle
- Detrusor
- Provides control over urge to pee
- Pro tip for car rides: Squeeze muscles to result in storing more in bladder
Pelvic Floor Medical Screening Conditions
- Cauda Equina Syndrome (Urinary retention, saddle anethesia, weakness/paralysis more than 1 nerve root) - ER
- UTI (fever, chills, sweat, blood in urine, painful/frequenct urination, sense of incomplete bladder emptying, foul smelling urine) - Urinalysis
- Pelvic Infection (abnormal discharge, vaginal itching/burning (Refer for cultures)
- Kidney Infection (Previous UTI; Results in LBP, Flank Pain)
Impairments vs Pelvic Sx
What is pelvic floor prolapse?
- Dropping down of organs
POP: Cystocele
- Bladder develops a pouch when it prolapses down
- Only in women
- Often with chronic coughing
When someone has POP you do not want to give them exercises that…
- increase abdominal pressure
POP: Uterus
- Uterus comes out
- Pain after stanfinf a long time or lifting, anything that causes pressure down
POP: Rectocele
- Prolapsed rectum
- Buldges into vagina or up into rectum causing issues with bowels
- Causes: Chronic coughing, straining, genetic history
POP is ____ common.
- Not
- 2.9%
Risk Factors for POP
- Parity (more children)
- Advancing age
- Obesity
- Hysterectomy (Uterus takes up space so taking it out leaves space)
- Race/ethnicity
– Latina and Caucasian > African American - Chronic constipation
- Connective tissue disorders
– Ehlers-Danlos syndrome (hypermobile) - Family history
- Heavy lifting
- Chronic coughing
Screening questions for POP
- Do you have a sense of pelvic pressure/heaviness or a sense of things “falling out”?
– Is it worse after prolonged standing, or near the end of the day? - Have you ever felt something bulge out of your vaginal area?
- Do you ever experience post-void dribble?
- Do you have a chronic cough?
- Were/are you a gymnast/ trampolinist?
- Do you struggle with constipation or strain to complete BMs?
- Do you regularly participate in heavy lifting?
Common questionairres for POP
- Pelvic Floor Distress Inventory (PFDI) - this is more responsive
- Pelvic Floor Impact Questionnaire (PFIQ)
POP Tx
Behavioral modifications
* Limit straining
* Limit heavy lifting
* Establish a regular bowel routine
Exercise prescription
* Kegels
* Gravity dependent vs. eliminated
* Limit jumping and overhead lifting
* Discourage continuous abdominal bracing
* Breathing
Give examples of exercises for POP, taking into account effects of force and gravity
- DO NOT have them jumping
- DO: have then do a leg press and hip bridge
Pelvic Floor muscle training for POP resulted in…
- Decreased reports of POP symptoms
- Improvement in pelvic organ support/staging
Kegels: Verbal Cueing and Prescription
Urine Stop Test
* Hold back gas
* Pull tip of urethra toward belly button
* Lift your “trunk”
Reps: 10 second hold 24 reps a day or 2 x 12 reps. Depends on individual. OR quick flicks for fast quick to overcome urgency, sneezing, coughing 5-7 reps in 10 secs.
Why is diaphragmatic breathign important?
- Improves parasympathtic
- Reduces Sympathetic
- Increases QoL (Decreasing anxiety and depression)
- Decreases inflammation (decreases C-reactive protein levels in blood)
- As you breath out you create more power and core control
- As you breathe in deep you expand down and around
Diaphragmatic Breathing Exercise Positions
Note: If obese, supine is likely not yout best option.
When should you refer someone with POP to an MD?
- Prolapse outside of the vagina
When to refer someone with POP to Pelvic Health PT
- Urine Stop Test: Pt unable to voluntarily stop or slow urine flow
- Pt reporting discomfort/inability to participate in traditional PT HEP due to pelvic heaviness/discomfort
- Pts needs exceed your level of skill, training or comfort.
What are the 5 types of incontinence
- Stress Urinary (Involuntary loss of urine with effort; typically with an increase in abdominal pressure. Lifting, sneezing, cough
- Urge (involuntary urinary loss due to environment; associated with triggers)
- Mixed (Stress and Urge)
- Functional (same urge to urinate but takes them to long to get to bathroom and can’t get there in time)
- Giggle (loss of urine during intense laughter; mostly children)
What is the #1 cause of bed wetting?
Constipation
Risk Factors for Urinary incontinence
- Post abdominal surgery
- Prostatectomy
- Hysterectomy: less support
- Increased age
- Obesity
- Diabetes Mellitus: sugar in urine can irritate the bladder
- Depression
- Sedentary lifestyle
- Constipation: as bowels get full, press on bladder
- Chronic respiratory problems
- Parity
What is a normal urinary frequency?
- Normal voids per 24 hours: 5-7
- Normal nocturnal voids: Under 65 0-1; Over 65 1-2
- Average time between vois 2-5 hours
Screening questions for urinary incontinence
- Do you lose urine with coughing, laughing, sneezing, exercise or heavy lifting?
- Do you lose urine with or preceded by urgency?
- Key in the door, running water
- Do you wear a pad?
- Frequency: How many times/day do you empty your bladder?
Drinking ____ before consuming a bladder irritanct will decrease the number of times you go to the bathroom
water
Good irritants: coffeee, carbonated beverages, alcohol, fruits
UI Tx
- Weight loss
- Kegels
- Encourage regular BMs
- Strengthen hip rotatiosn (ADD/IR and ABD/ER)
- Break association with peeing by doing alternative movements when about to approach trigger
- E-stim
Weighted Kegels are NOT recommended for people with:
- Prolapse
- Cosntipation
- Pelvic Pain (Muscle tension)
NMES for neuromuscular reeducation - UI
- 50 Hz
- Pulse duration: 300 us
- Amplitude: 60-80 mA
- Duty cycle 5 sec on/10 sec rest
- 15 -30 min, 2x/day, 16 weeks
Can use Biofeedback for this!
NMES for urge suppression
- 12 Hz
- Pulse duration: 300 us
- Amplitude: 60-80 mA
- Duty cycle 5 sec on/10 sec rest
- 15 -30 min, 2x/day, 16 weeks
Pelvic floor exercises, E-stim and vaginal cones are ____ treatments for women with UI
equally effective
