Pelvic Health Flashcards
1
Q
Describe the detrusor muscle
A
- Wall of the bladder
- Smooth muscle
- At inferior end of bladder & is continuous with the internal urethral sphincter
- Pushes urine from bladder to urethra
2
Q
What makes up the perineum
A
- Anterior urogenital triangle
- Posterior anal triangle
3
Q
What makes up the anterior urogenital triangle
A
- Deep perineal pouch
- Perineal membrane
- Superficial perineal pouch
- Perineal fascia
4
Q
What does the deep perineal pouch contain
A
- Urethra
- External urethral sphincter
- Vagina in females
5
Q
What does the superficial perineal pouch contain
A
- Erectile tissues that form the penis & clitoris
- Ischiocavernosus muscle
- Bulbospongiosus muscle
- Superficial transverse perineal muscles
6
Q
What is the perineal fascia
A
- Continuation of abdominal fascia
7
Q
What is the perineal body
A
- Fibromuscular mass located at the junction of the urogenital & anal triangles
- Levator ani, bulbospongiosus, superficial/deep transverse perineal muscles, external anal sphincter, & external urethral sphincter muscle fibers
8
Q
What makes up the posterior anal triangle
A
- Anal aperture: opening of the anus
- External anal sphincter muscle
- Ischioanal fossae (x2): allow expansion of the canal during defecation
- Pudendal nerve
9
Q
The external sphincter is not affected by pelvic floor contraction however there is external compression of the urethra. (True/False)
A
- True
10
Q
Describe a perineal examination
A
- When pt is asked to cough or Valsalva the perineum should show no downward movement; ventral movement may occur bc of the guarding actions of the pelvic floor muscles
11
Q
Describe perineal elevation and descent
A
- Elevation: inward (cephalad) movement of the vulva, perineum, & anus (NORMAL)
- Descent: outward (caudal) movement of the vulva, perineum, & anus (ABNORMAL)
12
Q
What can be observed on a rectal examination
A
- Anal sphincter tone/strength: assessment on digital exam, as good or poor in the absence of any quantitative assessment
- Anal sphincter tear: may be recognized as a clear “gap” in the anal sphincter on digital exam
- Confirm presence or absence of fecal impaction
- Anal lesions: hemorrhoids, fissures, rectovaginal fistula, or tumor
- Females: confirm presence or absence of rectocele & if possible, differentiate from anterocele; Dx perineal body deficiecy
13
Q
Describe a vaginal examination
A
- Exam vaginal length (normal adult = 10-12cm) & mobility, presence of scarring and/or pain, & estrogenization (thickened, redundant, & pale pink appearance)
- Location of any vaginal pain should be noted
- Tenderness over the course of the pudendal nerve
14
Q
Function of the core musculature on the pelvic floor
A
- Visceral support
- Sphincteric support (urethral meatus & anus)
- Sexual contracting muscles to respond to arousal & to enhance enjoyment
15
Q
Pelvic floor muscle function can be qualitatively defined by
A
- Tone at rest & the strength of a voluntary or reflex contraction as strong, normal, weak or absent, or by a validated grading symptom
16
Q
Define enterocele
A
- Like a hernia between the vagina and the rectum
17
Q
Voluntary pelvic floor muscle contraction & relaxation may be assessed by
A
- Visual inspection
- Digital palpation (circumferentially)
- Electromyography
- Dynamometry
- Perineometry
- Ultrasound
18
Q
Describe correct and incorrect action of pelvic floor muscle contraction
A
- Correct: pelvic floor lifts, the deep abdominals draw in & there is no change in breathing
- Incorrect: pulling the belly button in towards the backbone & holding your breath can cause bearing-down on pelvic floor
19
Q
Modified Oxford Scale (MOS) grading scale
A
- 0 = no contraction
- 1 = flicker
- 2 = weak
- 3 = moderate (w/lift) increased intravaginal pressure with small cranial elevation of the vaginal wall
- 4 = good (w/lift) fingers compressed with elevation of the vaginal wall towards pubic synthesis
- 5 = strong (w/lift) firm compression of examiners fingers & fingers pulled further into vagina
20
Q
What factors should be assessed for pelvic floor muscle function
A
- Muscle strength
- Voluntary muscle relaxation: absent, partial, complete
- Musculature endurance: ability to sustain maximal or near maximal force
- Repeatability: the # of times a contraction to maximal or near maximal force can be performed
- Duration
- Coordination
21
Q
Describe a perineometer
A
- Provides a number based measurement
- Digital palpation necessary to note correct contraction
- May be used as form of biofeedback
22
Q
Define normal pelvic floor muscles
A
- Pelvic floor muscles which can voluntarily & involuntarily contract and relax
23
Q
Define overactive pelvic floor muscles
A
- Pelvic floor muscles which do not relax, or may even contract when relaxation is functionally needed, for example, during micturition or defecation
24
Q
Define underachieve pelvic floor muscles
A
- Pelvic floor muscles which cannot voluntarily contract when this is appropriate
25
Define non-functioning pelvic floor muscles
- Pelvic floor muscles where there is no action palpable
26
Define frequency volume chart (FVC)
- The recording of the time of each micturition & the volume voided for at least 24 hrs
- Ideally for 2-3 days
27
Define daytime urinary frequency
- Number of voids by day (wakeful hours including last void before sleep and first void after waking and rising).
28
Define nocturnal frequency/nocturia
- Number of times sleep is interrupted by the need to micturate. Each void is preceded and followed by sleep.
29
Define 24 hr frequency
- Total number of daytime voids and episodes of nocturia during a specified 24-hr period.
30
Define 24 hr urine production
- Summation of all urine volumes voided in 24 hrs
31
Define maximum voided volume
- Highest voided volume recorded
32
Define average voided volume
- Summation of volumes voided divided by the number of voids
33
Additional information obtained from the bladder diary involves severity of incontinence in terms of leakage episodes & pad usage including
- Fluid intake
- Pad usage
- Incontinence episodes
- Degree of incontinence
- Episodes of urgency & sensation
- Activities performed during or immediately preceding the involuntary loss of urine
34
What is the best estimate for healthy fluid intake
- Drink 1/2 body weight in ounces of fluid/day
- 2/3 should be water
35
Consequences of being dehydrated
- Dehydration concentrates the urine & irritates the bladder lining
- Many elderly pts are not drinking enough fluids
- If fluid loading occurs at the end of the day, a person may have to get up more at night
- Types of fluid can affect bladder health
36
List bladder irritants
- Alcohol
- Carbonated drinks
- Caffeine
- Citrus fruits/juices
- Tomatoes
- Spiced foods
- Chocolate
- Milk/milk products
- Artificial sweeteners
37
List typically less irritating foods & beverages
- Pears
- Watermelons
- Apircots
- Papayas
- Sun-brewed teas
- Non-citrus herbal teas
38
Risk factors for urinary incontinence
- Age
- Pregnancy (both pre- and post-natal women)
- Menopause
- Obesity/ BMI
- Frequent urinary tract infections
- Constipation
- Prostatectomy* and hysterectomy
- Reduced mobility preventing person from getting to or using the toilet
- Neurological and musculoskeletal conditions such as multiple sclerosis and arthritis
- Health conditions such as diabetes, stroke, heart conditions, respiratory conditions, and prostate problems
39
What are the 4 steps/events of continence
- Bladder fills
- First sensation to void
- Normal desire to void
- Micturition
40
What occurs in the storage phase of continence
- 400-600ml
- Fills at 15 drops per minute
- Internal sphincter & pelvic floor muscles contracted, detrusor relaxed
- Outlet pressure > bladder pressure
- Should take bladder 2-4 hrs to fill
41
What occurs in the storage & first urge to void phase of continence
- 1st desire to void: 150-200ml
- Takes 3 hrs to fill
- Internal sphincter & pelvic floor muscles contracted
- Outlet pressure > bladder pressure
- Do not go on 1st urge as the bladder is less than half full typically
- Urge is delayed
42
What occurs in the normal desire to void & transition phase of continence
- Signal to void is recognized
- Voiding is postponed via Bradley's loop 3 & cortex inhibition
- Internal sphincter & pelvic floor muscles contracted
- Outlet pressure > bladder pressure
- Do not go on 1st urge as the bladder is less than half full typically
43
What occurs in the micturition or voiding phase of continence
- Pelvic floor muscles relax
- Switches on bladder: Bradley's loop #3
- Detrusor contracts & bladder pressure increases
- Empty fully: PVR 50ml or less
- Bladder pressure > outlet pressure
- In order to relax muscles, should sit or squat
44
Define incontinence
- Complaint of involuntary loss of urine
45
Define continuous (urinary) incontinence
- Complaint of continuous involuntary loss of urine
46
Define stress (urinary) incontinence
- Complaint of involuntary loss of urine on effort or physical exertion or on sneezing or coughing
47
Define urgency (urinary) incontinence
- Complaint of involuntary loss of urine associated with urgency
48
Define mixed (urinary) incontinence
- Complaint oof involuntary loss of urine associated with urgency & also with effort or physical exertion or on sneezing or coughing
49
Define nocturnal enuresis
- Complaint of involuntary urinary loss of urine which occurs during sleep
50
Define postural (urinary) incontinence
- Complaint of involuntary loss of urine associated with change of body position, for example rising from a seated or lying position
51
Define insensible (urinary) incontinence
- Complaint of urinary incontinence where the woman has been unaware of how it occurred
52
Define coital incontinence
- Complaint of involuntary loss of urine with coitus
- This symptom might be further divided into that occurring with penetration for intromission & that occurring at orgasm
53
Bladder storage symptoms
- Increased daytime urinary frequency: complaint that micturition occurs more frequently during waking hours than previously deemed normal by the woman.
- Nocturia: complaint of interruption of sleep one or more times because of the need to micturate. Each void is preceded and followed by sleep.
- Urgency: complaint of a sudden, compelling desire to pass urine which is difficult to defer.
- Overactive bladder (OAB, Urgency) syndrome: urinary urgency, usually accompanied by frequency and nocturia, with or without urgency urinary incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology
54
Define sensory symptoms
- A departure from normal sensation or function, experienced during bladder filling
55
Sensory symptoms
- Increased bladder sensation: complaint that the desire to void during bladder filling occurs earlier or is more persistent to that previous experienced. This differs from urgency by the fact that micturition can be postponed despite the desire to void.
- Reduced bladder sensation: complaint that the definite desire to void occurs later to that previously experienced despite an awareness that the bladder is filling.
- Absent bladder sensation: complaint of both the absence of the sensation of bladder filling and a definite desire to void.
56
Define voiding symptoms
- A departure from normal sensation or function, experienced by the woman during or following the act of micturition
57
Voiding symptoms
- Hesitancy: complaint of a delay in initiating micturition.
- Slow stream: complaint of a urinary stream perceived as slower compared to previous performance or in comparison with others.
- Intermittency: complaint of urine flow that stops and starts on one or more occasions during voiding.
- Straining to void: complaint of the need to make an intensive effort (by abdominal straining, Valsalva or suprapubic pressure) to either initiate, maintain, or improve the urinary stream.
- Spraying (splitting) of urinary stream: complaint that the urine passage is a spray or split rather than a single discrete stream.
58
Voiding and postmicturition symptoms
- Feeling of incomplete (bladder) emptying: complaint that the bladder does not feel empty after micturition.
- Need to immediately re-void: complaint that further micturition is necessary soon after passing urine.
- Postmicturition leakage: complaint of a further involuntary passage of urine following the completion of micturition.
- Position-dependent micturition: complaint of having to take specific positions to be able to micturate spontaneously or to improve bladder emptying, for example, leaning forwards or backwards on the toilet seat or voiding in the semi-standing position.
- Dysuria: complaint of burning or other discomfort during micturition. Discomfort may be intrinsic to the lower urinary tract or external (vulvar dysuria).
- (Urinary) retention: complaint of the inability to pass urine despite persistent effort.
59
There is a correlation between urinary incontinence and female athletes (True/False)
- True
60
Behavioral techniques & lifestyle approaches for urinary incontinence (UI)
- Bladder re-training
- Treating constipation
- Weight reduction
- Fluid management
- Medication review
61
Describe bladder retraining
- For retraining habits, avoid voiding too little, too often, or prematurely
- Indicated for stress, urge, mixed UI
- Bladder diary useful for evaluation
- Goals: develop healthy fluid intake habits, normalize voiding frequency, & improve bladder capacity
62
Mechanism of benefit for bladder retraining
- Educate pt to correct habits
- Restore healthy bladder function, capacity
- Re-establish central control
- Improve suppression of urgency
- Improve PFM/bladder coordination
- Improve bladder sensation, awareness of signals
- Improve ADL function
63
Techniques to empty bladder
- Double voiding: voiding, waiting until next urge comes, voiding again (can involve standing up to move)
- Crede technique: gently pushing down on bladder while exhaling & leaning forward a bit to mechanically empty the bladder (primarily used for pts with neurologic challenges, not a primary strategy for most pts)
64
What is the recommended 1st line of treatment for an overactive bladder
- Behavioral therapy
- Bladder training, bladder control strategies, pelvic floor muscle training, fluid management
65
List characteristics of normal bladder health
- Go away 3-4 hrs
- 5-7x in 24 hrs
- No "just in case" (JIC)
- Go for 8 Mississippi
- Sit on toilet
- No straining
- No nighttime "JIC"
- Avoid constipation
- Drink enough water
- Avoid bladder irritants
- Void before, after sex
- Avoid pads
- Kegels/PFM exercises
66
Describe bladder retraining
- Bladder training requires following a fixed voiding schedule
- Urge to urinate before the assigned interval: relaxation & Kegel exercises
- As success is achieved the interval is lengthened in 15-30 minute increments until it is possible to remain comfortable for three for four hrs
67
Tools for pelvic floor muscle treatment
- Biofeedback
- Electrical stimulation
68
Describe a prostatectomy
- Transurethral prostatectomy (TURP) has minimal UI associated with procedure
- Robot assistive laproscopic prostatectomy has higher rate of UII
69
Pelvic floor muscle treatment (PFMT) better than ______ statements
- Pre & post PFMT is better than post training alone
- Adding biofeedback is better than PFMT or information alone
- Adding rectal stimulation is better than PFMT alone
70
The core muscles include the transverse abdominus, multifidi and pelvic floor (levator ani) all three must be coordinated to stabilize the pelvis. This explains
- Why females with LBP often have the symptom of urinary leakage
71
Common substitutions when trying to contract the transverse abdominus
- Posterior tilting of the pelvis
- Bulging of the abdomen
- Depression of the rib cage
- Breath holding
- Fingertips being pressed out by a strong muscular contraction (internal oblique)
72
Describe recruitment training for transverse abdominis (TrA)
- Lie on back or side with your spine in neutral
- Imagine a line that connects the inside of your two pelvic bones & think about drawing along this line as if closing a book
- Contract your pelvic floor by drawing the muscles from behind your pubic bone to your tail bone & the L/R sides of your pelvic floor together & then like a drawstring gently draw the entire pelvic floor up
- Hold contraction for 3-5 sec & then release, repeat contraction & hold for 3 sets of 10 reps 3-4x per day for 4 wks
73
Describe recruitment training for multifidi
- Lie on back or side with spine in neutral
- Imagine a line connecting your L/R SIJ & think about drawing together along this line
- Imagine a line connecting your groin to the part of multifidus in your low back you are trying to train, gently think about suspending (lifting) the lumbar spine 1 mm above the one below
- Hold contraction for 3-5 secs and then release, repeat contraction and hold for 3 sets of 10 reps 3–4x per day for 4 wks
74
Common substitutions when trying to contract the multifidus
- Anterior tilting or rotation of the pelvis
- Flexion of the hip joint
- Gripping with the big buttock muscles
75
Define a kegel
- Tightening or drawing in of the levator ani muscles
- Best performed with palpation in the rectum foot vagina but can also be palpated in the perineum
76
Helpful cues for teaching a kegel
- Females: Think of your vagina as a clock, pubis is 12, tailbone is 6, left lateral wall is 3, right lateral wall is 9. Visualize drawing the 12 to the 6, the 6 to the 12 and finally gather the 3 and 9 toward the middle of the clock and gently lift.
- Females: Nod your clitoris down toward the vaginal opening, curl your tailbone toward your clitoris, now gently imagine sucking a jellybean up off of the floor toward your head.
- Females: Visualize ‘squeezing’/close off the urethra (as if to stop urine flow), hold this while you ‘squeeze’/close the anus (as if to stop flatulence) and gently lift.
- Males: visualize gently drawing your testicles up and forward into your abdomen. (aka ‘bring the boys home’).
- Males or Females: Think about a guy wire or line from the anus up to the back of your pubic bone and connect along this line.
77
Describe Hold Em's
-Breathe in (widen your lower rib cage) then breathe out using your PF cue. Engage and hold the contraction for 3-5 seconds, while breathing normally.
- Repeat 10x. Perform these in supine, hands and knees, sitting and standing.
78
Describe Speed Em's
- Breathe in (widen your lower rib cage) then breathe out using your PF cue. Perform a quick contraction/lift then immediately let go and relax.
- Repeat 10x (work towards 15-20-30 reps). Perform these in supine, hands and knees, sitting and standing.
79
Facilitators for pelvic floor contraction
- Hip external rotation
- Transverse abdominis
- Diaphragmatic breathing (Exhale)
80
Describe Hold Em's with functional movement
- Heel Slides: Lie on your back with your hips and knees bent. Perform a ‘hold em’ then slowly slide one leg straight while maintaining your PF contraction and breath. Slide the leg back to its original position. Repeat with the opposite leg. Repeat 5x/side.
- Wipers: in the same position as above, perform a ‘hold em’. Keep your low back and pelvis level and slowly move one bent knee out to the side. Maintain your PF contraction and exhale to bring your leg back to neutral. Repeat this with the opposite leg. Repeat 5x/side.
- Leg lifts: in the same position as above, perform a ‘hold em’. Slowly bring one knee toward your chest. Maintain your PF contraction and on the exhale return the leg to the floor and repeat this with your opposite leg. Repeat 5x/side.
81
Progressions for Hold Em's
- Each progression begins with a proper co-activation of all muscles of the deep system (TrA, multifidus and your pelvic floor) and this co-contraction should be held throughout the movement. Remember to MOVE WITH YOUR BREATH - Exert with exhalation, breathe in to rest or hold.
82
Proprioceptive devices for pelvic floor contraction
- Catheter with balloon inflated
- Condom with marbles
- Using EMG or pressure devices
- ES electrode or vaginal weights in supine
- PF educator: contraction indicator
- Devices patient owns
83
List the different exercise protocols
- Laycock MMT grade: overload specific model
- Bo: intensive training model
- Hulme: accessory exercise model
- Contraction type: concentric, isometric, eccentric, accessory
84
Functional applications for pelvic floor exercises
- During ADL's
- After using the toilet
- With sexual activity
- With exercise regimens
85
Progressive functional pelvic bracing
- Supine to sit
- Sit to stand
- Standing
- Cough/Sneeze
- Reaching
- Partial Squat
- Squat with resistance
- Stairs
- Walking level, uphill and downhill
- Jog/ Run
86
Functional activities for pelvic floor exercises
- Use varied LE positions for exercise
- Progress to more difficulty: add balance challenges or resistance increases
87
Progressing pelvic floor exercises
- Advance endurance of contraction or repetitions: 3/5/7/10 second progressions
- Advance via position changes, training schedule
- Advance via co-contraction with the other pelvic girdle muscles to support abdominal cylinder
- Functional retraining: sit to stand, stand to sit, squeeze with sneeze, lifting, etc.
- Incorporate into current fitness activities and exercise
- Eventually: maintenance program
88
A minimum of how many pelvic floor muscle exercises per day can be effective in maintaining & improving urinary incontinence & associated bladder symptoms following a successful course of biofeedback & electrical stimulation
- 10 pelvic floor muscle exercises per day
89
Summary of urinary pelvic floor muscle exercise
- Exercise prescription is based on muscle exam
- Research for exercise is based on UI model
24-80 pelvic floor contractions/day can significantly decrease UI episodes
- Intensity of exercise: moderate to maximum
- 3/5/7/10 second progressions
- Training muscles functionally is key
90
Summary of urinary incontinence exam & behavioral training
- Pelvic floor is an integral part of a system
- Each person has their own habits and strategies
- Research has guided exercise training guidelines
- Different approaches are needed for non-functioning, under active muscles, or overactive muscles
- Coordination and functional integration are key
91
Define pelvic organ prolapse
- The descent of one or more of the anterior vaginal wall, posterior vaginal wall, the uterus (cervix), or the apex of the vagina (vaginal vault or cuff scar after hysterectomy).
92
Describe organ prolapse staging (Hymen is the reference)
- Stage 0: No prolapse is demonstrated.
- Stage I: Most distal portion of the prolapse is more than 1 cm above the level of the hymen.
- Stage II: Most distal portion of the prolapse is 1 cm or less proximal to or distal to the plane of the hymen.
- Stage III: The most distal portion of the prolapse is more than 1 cm below the plane of the hymen.
- Stage IV: Complete eversion of the total length of the lower genital tract is demonstrated.
93
Symptoms of pelvic organ prolapse (POP)
- Generally worse at the times when gravity might make the prolapse worse (long periods of standing) & better when gravity is not a factor (supine)
- Prolapse may be more prominent at times of abdominal straining
- Vaginal bulging: Complaint of a ‘‘bulge’’ or ‘‘something coming down’’ towards or through the vaginal introitus. The woman may state she can either feel the bulge by direct palpation or see it aided with a mirror.
- Pelvic pressure: Complaint of increased heaviness or dragging in the suprapubic area and/or pelvis.
- Bleeding, discharge, infection: Complaint of vaginal bleeding, discharge, or infection related to dependent ulceration of the prolapse.
- Splinting/digitation: Complaint of the need to digitally replace the prolapse or to otherwise apply manual pressure, for example, to the vagina or perineum (splinting), or to the vagina or rectum (digitation) to assist voiding or defecation.
- Low backache: Complaint of low, sacral (or ‘‘period-like’’) backache associated temporally with POP.
94
Pelvic floor muscle spasm occurs from trauma to and or around pelvis, back and abdomen such as
- joint malalignment
- pelvic fracture
- strenuous physical activity
- childbirth
- sexual abuse
- surgery
- pelvic inflammation
95
Lists the different pelvic floor dysfunctions
- Dyspareunia: p! with intercourse
- Vulvodynia/Vulvar Vestibulitis
- Vaginissmus
- Levator ani syndrome
- Coccygodynia
- Pudendal Nerve Entrapment
- Scar adhesions
- Overactive pelvic floor
96
Symptoms and grades of severity
- Symptoms: pain with initial entry, pain with deep penetration, friction with thrusting
- Grades: (1) discomfort but has intercourse; (2) frequently limits intercourse; (3) incapacitating problem/abstinence
97
Define the different types of dysparunia
- Superficial (introital) dyspareunia: Complaint of pain or discomfort on vaginal entry or at the vaginal introitus
- Deep dyspareunia: Complaint of pain or discomfort on deeper penetration (mid or upper vagina)
- Obstructed intercourse: Complaint that vaginal penetration is not possible due to obstruction
- Vaginal laxity: Complaint of excessive vaginal laxity.
98
Define vaginismus
- Involuntary tightness of the vagina during attempted intercourse
- Surgical or sexual trauma & protective response
99
Symptoms and causes of vulvodynia
- Chronic vulvar discomfort
- Sx: burning, stinging, irritation or rawness
- Causes: yeast infections, STD, eczema, lichens, chemical induced reaction (spermicides, detergents, vaginal sprays, deodorants), chronic alteration of vaginal ph, vulvar trauma, surgery
100
What is the Friedrich's Triad
- Reported painful penetration
- Q tip test positive for tenderness
- -/+ vestibular erythema
101
Describe Levator Ani Syndrome
- Spasm of the levator ani
- Sx: pain, pressure or ache in vagina & rectum; referred pain to thigh/coccyx/sacrum/lower abdomen; repeated straining during defecation can promote pain/throbbing
- Men often misdiagnoses with prostatitis: can lead to erectile dysfunction
102
Describe Coccygodenia
- Pain on the coccyx or rectum
- Causes: injury from fall, arthritic changes, pelvic floor muscle spasm, birthing in lithotomy position
103
Describe Pudendal Neuralgia
- Burning vaginal or vulva (anywhere b/w anus & clitoris) pain associated with tenderness over the course of the pudendal nerves
104
Common symptoms of Pudendal Neuralgia
- Compression of the pudendal nerve in Alcock's canal = severe pain on sitting, which is relieved by standing, & absent when recumbent or when sitting on a toilet seat
- Endometriosis of the pelvic nerves increases
- Sacral compartment syndrome = increase in pelvic venous pressure (prolonged standing or sitting, the Valsalva maneuver)
105
What is the 5 essential criteria for Pudendal Neuralgia
- Pain in the anatomical region of pudendal innervation
- Pain that is worse with sitting
- No waking at night with pain
- No sensory deficit on examination
- Relief of symptoms with a pudendal block
106
Pudendal nerve entrapment sites
- B/w Sacrotuberous & Sacrospinous ligaments
- At pudendal canal the nerve can be compressed by the falciform process of the Sacrotuberous ligament
- If thickened the nerve can be compressed by the obturator fascia
- Obturator internus can compress nerve at Alcock's Canal
107
Describe scar tissue adhesions
- Restricted mobility of myofascial tissue of abdomen, low back, pelvic floor
- Sx: burning pain
- Causes: tearing with child birth, episiotomy, abdominal surgeries
108
Post menopausal changes
- Decrease in estrogen levels as women approach & pass menopause
- Dryness/thinning of vaginal tissues can cause intercourse to be painful
- W/o sufficient lubrication can lead to tearing & bleeding of vaginal tissues
- May use estrogen cream or ring in vagina following menopause to improve vaginal health
- Vaginal atrophy is common
109
Describe an overactive pelvic floor in women
- Not being able to feel a PFM contraction or release
- Pelvic pain that can include urethral, vaginal, rectal, lower abdominal pain
- Urinary urgency or frequency
- Slower urinary flow or the feeling of incomplete emptying
- Inability to have sex or pain with sex, either with initial or deep penetration
- Difficulty or pain with emptying the bowels or passing ‘skinny stools’
- Stress urinary leakage in some cases
110
Describe an overactive pelvic floor in men
- Not being able to feel a PFM contraction or release
- Pain in the penis, testicles and/or rectum
- Urinary urgency or frequency
- Slower urinary flow or the feeling of incomplete emptying
- Difficulty or pain with emptying the bowels or passing ‘skinny stools’
- Erectile dysfunction
- Premature ejaculation
111
List treatment options
- Stretching
- Pain: desensitization, trigger points using pelvic wand, manual stretching
112
Patient & partner education
- Lubrication choices: slippery stuff
- Relaxation prior to initiation
- Stretching of the vaginal wall prior to intercourse
- Positions: sidelying
113
Prostate pathology symptoms
- Weak or interrupted flow of urine
- Nocturia
- Trouble starting flow of urine
- Trouble emptying bladder
- Pain while urinating
- Blood in urine or semen
- LBP/ Pelvic pain
114
Describe prostatitis
- Any condition that causes inflammation of the prostate gland
- Risk factors: age (50% of all men)
- S/S: prostate discharge, burning, increased frequency of urination & possible reduction in sexual potency, LBP, nagging sacral ache with radiation down the involved leg if the seminal vesicle is involved
115
Treatment for acute prostatitis
- Anti-inflammatories
- Muscle relaxants
- Biofeedback for pelvic floor relaxation
116
Describe prostate cancer
- When cells in the prostate become malignant they usually form small islands of cancer confined to the prostate
- Risk factors: 33% of all men, Age >50, if man's brother/father has been diagnosed with prostate CA has a 2-3x more likely to develop the disease
117
Signs and symptoms of prostate cancer
- Dull, vague, diffuse ache localized to the lower lumbar spine or upper sacral regions
- Only after the tumor has grown to sufficient size to comprise the urethra, will urinary Sx be noted by the patient
118
Treatments for prostate cancer
- Monitoring & Tx to relieve Sx: older adults Stage 1 and 2
- Surgery: transurethral resection of the prostate (TURP) or radical prostatectomy - remove prostate & seminal vesicles (lymph nodes); retropubic prostatectomy = incision in abdominal wall; perineal prostatectomy = incision b/w scrotum & anus
119
Surgical complications of a prostatectomy
- Incontinence: bowel and bladder
- Impotence
- Inguinal hernia: first 2 years following radical prostatectomy
120
Define erectile dysfunction
- Inability to achieve or maintain an erection sufficient for satisfactory sexual performance (for both partners)
- Mild: satisfactory sexual performance 7-8 attempts out of 10
- Moderate: satisfactory sexual performance 4-6 attempts out of 10
- Severe: satisfactory sexual performance 0-3 attempts out of 10
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Erection hardness scale
- (1) penis is large but not hard
- (2) penis is hard but not hard enough for penetration
- (3) penis is hard enough for penetration but not completely hard
- (4) penis is hard & completely rigid
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Risk factors for erectile dysfunction
- *Weak pelvic floor muscles
- Psychological
- Vascular
- Neurological
- Endocrinological
- Diabetic
- Drug related
- Surgical trauma
- Lower. urinary tract symptoms (LUTS)
- Prostatic
- Lifestyle related
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Describe the 3 different types of erections
- flexogenic erection: Reflexogenic erection originates from tactile stimulation to the genitalia. Impulses reach the spinal erection center via sacral sensory nerves (S2–S4) and thoracic nerves (T10–L2)
- Psychogenic erection: Psychogenic erection originates from audiovisual stimuli or fantasy. Signals descend to the spinal erection center to activate the erection process.
- Nocturnal erection: Nocturnal erection occurs mostly during the rapid eye movement stage of sleep. Most men experience three to five erections lasting up to 30 minutes in a normal night’s sleep. Central impulses descend the spinal cord (through an unknown mechanism) to activate the erection process
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Describe the vascular phases of an erection
- Flaccidity: A state of low flow of blood and low pressure exists in the penis in the flaccid state. The ischiocavernosus and bulbocavernosus muscles are relaxed.
- Filling phase: When the erection mechanism is initiated, the parasympathetic nervous system provides excitatory input to the penis from efferent segments S2–S4 of the sacral spinal cord; the penile smooth arterial muscle relaxes and the cavernosal and helicine arteries dilate enabling blood to flow into the lacunar spaces.
- Tumescence: The venous outflow is reduced by compression of the subtunical venules against the tunica albuginea (corporal veno-occlusive mechanism) causing the penis to expand and elongate but with a scant increase in intracavernous pressure
- Full erection: The intracavernous pressure rapidly increases to produce full penile erection.
- Rigidity: The intracavernous pressure rises above diastolic pressure and blood inflow occurs with the systolic phase of the pulse enabling complete rigidity to occur. Contraction or reflex contraction of the ischiocavernosus and bulbocavernosus muscles produce changes in the intracavernous pressure. When full rigidity is achieved, no further arterial flow occurs
- Detumescence: The sympathetic nervous system is responsible for detumescence via thoracolumbar segments (T10–T12, L1–L2) in the spinal cord. Contraction of the smooth muscle of the penis and contraction of the penile arteries lead to a decrease of blood in the lacunar spaces and contraction of the smooth trabecular muscle leads to a collapse of the lacunar spaces and detumescence.
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What are the 3 types of erectile dysfunction
- Psychogenic
- Organic: the events leading to full erection do mot happen due to insufficient blood reaching the penis or blood escaping from the penis
- Mixed
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What 2 pelvic floor muscles are non-voluntary
- Ischiocavernosus
- Bulboocavernosus
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Association with weak pelvic floor muscles and erection
- 3 RCT: PFMT cured or improved erectile dysfunction
- Associated with increased anal pressure
- PFMT performed better than Viagra
- One RCT included men following radical prostatectomy with improvement
- Limitation: all RCT only included heterosexual men
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Pelvic floor muscle training for males
- Diaphragmatic breathing
- Quick exercises/flicks: max intensity, 1 sec hold, 10 reps, at least 6x per day
- Slow exercises/Hold: submax intensity, 10 sec hold, 10 reps, at least 6x per day
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Instructions for pelvic floor muscle training for males
- (1) shorten the penis/retract the penis (scrotum should lift up)
- (2) try to stop the flow of urine
- (3) tighten your anus but keep the buttocks relaxed (patient may palpate contraction at base of penis)
