Pelvic Health Flashcards
What are the important boney landmarks of the pelvis?
ASIS
PSIS
ischial tuberosity
Inferior pubic ramus
Sacrococcygeal jt
Coccyx
Pubic symphysis
What is the best way to palpate the inferior pubic ramus?
By following the adductor group proximally along the inner thigh until you feel the bony prominence
What two ligaments does the pudendal nerve run through?
Sacrotuberous ligament
Sacrospinous ligament
What does the pudendal nerve innervate?
Motor and sensory innervation of the pelvic floor
What is pudendal neuralgia?
Compression of the pudendal nerve
What can cause pudendal neuralgia?
Compression of the pudendal nerve at the greater and lesser sciatic foramen or Alcock canal
What is the alcock canal?
Tube shaped space in the pelvis that contains the pudendal nerve
What are the tissues that make up the first layer of the pelvic floor?
Ischiocavernosus/spongiosus
Bulbocavernosus/spongiosus
Superficial transverse perineal
External anal sphincter
Does the verbiage “cavernosus” indicate male or female anatomy?
Female
Does the verbage “spongiosus” indicate male or female anatomy?
Male
What tissues make up layer 2 of the pelvic floor?
Deep transverse perineal
Urethral sphincter
Compressor urethra (in females)
Sphincter urethrovaginalis (in females)
What is the fxn of the first layer of the pelvic floor?
Continence and sexual fxn
What is the fxn of the second layer of the pelvic floor?
Continence and some support
What is the fxn of the third layer of the pelvic floor?
Lift, support, and stability
T/f: bc the second layer of the pelvic floor has lot of fascia, it provides increased support
True
What tissues make up the third layer of the pelvic floor?
Lavator ani
Coccygeus
Pelvic wall muscles
What tissues make up the levator ani?
Pubovaginalis
Puborectalis
Pubococcygeus
Illiococcygeus
What are the pelvic wall muscles that contribute to the pelvic floor but are not part of the pelvic floor?
Piriformis and obturator internus
What is coccygeal movt testing for?
Test for coccyx mobility and ability to activate the pelvic floor
What positions can coccygeal movt testing be done in?
Sitting, standing, or SL (we learned in sitting)
How do we perform coccygeal movt testing?
With the heel of your hand over the sacrum and your rings and index fingers over the gluteal, have the pt perform a keigal and you should feel the coccyx flex
What is the technique we can use for a hypomobile coccyx?
The stuck drawer
What is the technique for the stuck drawer?
“Hug” the pt with one arm and palpate for the coccyx with the other
Have the pt slump and you should feel the coccyx flex
Then have the pt sit up straight and you should feel the coccyx extend
Use your hand to direct motion with slumping and sitting up
What are the five functions of the pelvic floor?
Support
Stability
Sphincteric
Sexual function
Sump pump
What is the role of the soft tissue in your pelvic floor?
To act as a hammock or shelf for you to manage load
How does the pelvic floor gain stability?
By working with neighboring muscle groups to reduce forces on the pelvic floor and spine to manage increased IAP
What PF actions HOLD urine and stool?
PFM contraction
What PF actions allow voiding of urine and feces?
Relaxation of PFM
T/f: changes in laxity, tension, strength, and mobility can affect sexual activity
True
What is the sump pump function of the pelvic floor
PFM help drain/manage fluid in the pelvis to avoid swelling by acting like a venous and lymphatic pump
What muscles and tissues form the “soda can” for IAP?
The multifidi, pelvic floor, transverse adbominis, and diaphragm
What happens to the diaphragm with inhalation?
It shortens and lowers to expand the lungs
What happens to the abdominal wall with inhalation?
Expansion as pressure increases with inhalation
What happens to the pelvic floor with inhalation?
It descends (relaxes) as IAP increases
What happens to the diaphragm with exhalation?
It relaxes and moves up as air moves out of the lungs
What happens to the abdominal wall with exhalation?
It contracts
What happens to the pelvic floor with exhalation?
It contracts
What are the requirements for urinary continence?
The bladder must expand and contract
Must have intact NS, cog fxn, sensory awareness, mobility, and dexterity
Is the hypogastric nerve sympathetic or parasympathetic?
Sympathetic
What does the hypogastric nerve do?
Inhibits the bladder
Contracts the internal sphincter/PFM to stop urination
Is the pelvic nerve sympathetic or parasympathetic?
Parasympathetic
What does the pelvic nerve do?
Contracts the bladder
Relaxes internal sphincter/PFM for voiding
What actions allow urine holding?
Relaxation of the detrusor muscle
Contraction of the sphincter and PFM
What actions allow voiding of urine?
Contraction of the detrusor muscle
Relaxation of the sphincter and PFM
How often does normal urination occur in a day?
5-8x/day
Every 2-4 hours
0-1x at night
What defecation reflex involves distension of the rectum causing relaxation of the IAS and contraction of the EAS?
The rectoanal inhibitory reflex/ sampling reflex
What is the point of the sampling reflex in delectation
To detect solid, liquid, or gas and decide if it is the right time to void
What defectation reflex is initiated by an increased EAS tone, resulting in rectal relaxation?
The accommodation reflex
What is the point of the accommodation reflex?
To suppress the urge to defecate
How many times should you shit in a day/week?
3x/week to 3x/day
What type of stool is normal?
A type 3-4 (sausage with cracks or smooth…that grossed me out to type, I’m so sorry)
T/f: there should be no pain, straining, or bleeding with normal defectation
True
How do we perform an external PFM assessment?
Palpate the ischiocaernosus and ischiorectal fossa with breathing, PFM contraction, coughing
Or can have pt sit on a physioball for proprioceptive feedback
How can we palpate the ischiocavernosa?
By palpating the inferior pubic ramus and GENTLY curling in to feel the muscle
Confirm with PFM contraction
How can we palpate the ischiorectal fossa?
Palpate the ischial tuberosity and curl in some
Confirmation with PFM contraction
How do we do breathing with fxnal movt?
Perform squatting, lifting, pushing, and pulling
Breathe in with squat down, breathe out with standing up
If there is no pelvic floor weakness, if it necessary to do breathing with fxnal movt?
Nope
What are the “orthopelvic” conditions?
PGP, hip impingement, coccydynia
What are the pelvic health conditions for ortho therapists?
POP, UI/FI, abdominal, pregnancy
What are the specific health diagnoses that pts may have but we may not be aware of?
Dysparaunia, prostatitis, endometriosis, IBS, PCOS, IC/PBS, pudendal neuralgia
What percent of people with LBP have some degree of pelvic floor dysfunction?
95%
What is pelvic girdle pain (PGP)?
Pelvic pain bw the PSIS and gluteal folds that arises in relation to pregnancy, arthritis, or trauma that can radiate to the posterior thigh and may or may not have groin/pubic symphysis pain
Up to ____% of women in late pregnancy have PGP
70
PGP is most common bw how many weeks of pregnancy?
14-30 weeks
What are the risk factors for PGP?
Hx of multiparity
Hypermobility
Increased BMI
smoking
Ortho MSK considerations like glut med and PF dysfunction
T/f: systemic laxity can put you at risk for PGP
True
What is the pathophysiology behind PGP?
Hormonal and biomechanical factors
Stabilization of the pelvis/SIJ
T/f: Jt laxity changes the ability to manage load transfer throughout the pelvis
True
What is the average width of the pubic symphysis?
7mm width
If the pubic symphysis is >10mm in width or >5mm in length, what does it put the pt at risk for with PGP?
They are more likely to be symptomatic
What is the presentation of someone with PGP?
Pain likely at the SIJ
(+) SIJ special tests
Pain with single leg movt
What may cause hip impingement?
Anatomical abnormalities
Faulty mechanics and repetitive motions
What are the common locations of hip impingement pain?
Anterior/groin pain
Posterior/buttock pain
What actions can aggravate anterior groin pain from hip impingement?
Lunging, squatting, crossing legs, prolonged positioning in sitting or standing
What actions can aggravate posterior buttock pain from hip impingement?
Large steps
What is a common pathology that causes posterior buttock pain?
Greater trochanteric bursitis
What is the prevalence of FAI in hip impingement?
38%
What % of hip impingements are female?
67%
What is the most common age that hip impingement occurs at?
27 yo
What can we do to dx hip impingements?
FADIR
Imaging
Ant hip/groin pain/pinching
Labral catching, locking, instability
What is coccydynia?
Tailbone/coccyx pain
What are the risk factors for coccydynia?
Female
Trauma/repetitive micro trauma
Overactive PFM
Rapid weight change
Childbirth
Constipation
What is the presentation of someone with coccydynia?
Pain with sitting, STSs, BMs, reproduction with springing over the SIJ and sacrum
Pain that improve with walking
Internal/external PFM exam
External coccygeal movt tests
What are the types of urinary incontinence?
Stress incontinence
Urge incontinence
Mixed incontinence
Overactive bladder
What is stress incontinence?
Involuntary loss of urine with physical exertion
Sudden increase in IAP causes leakage
Overactive or underactive PFM
Sphincter deficit
What is urge incontinence?
Involuntary urine loss with urgency
Bladder contracts and urine leaks b4 the bladder is full
How can urge incontinence be managed?
With meds or bladder/behavioral techniques
What is mixed incontinence?
Combo of urge and stress incontinence
What is an overactive bladder?
Urinary urgency, frequency, and nocturia
May or may not involve UI
T/f: nocturia poses a fall risk
True
What percent of nursing home residents have UI?
> 50%
What percent of elite female athletes have UI?
51%
What is the most common cause of pediatrician visits bw ages 5-10?
UI
What is fecal incontinence?
Involuntary loss of stool
What is the prevalence of FI?
20%
What are the risk factors for FI?
Surgery/trauma
DM
IBS
Constipation
What are the risk factors for constipation?
Poor diet, PMHx, meds, POP
What is constipation?
BM that are infrequent, incomplete, and require straining or manual assist
Less than 3 BM/week
What is pelvic organ prolapse (POP)?
The descent of the anterior/posterior pelvic wall, uterus, or apex of the vagina
What is the prevalence of POP?
40% of women over 50yo
What are the risk factors for POP?
Pregnancy and childbirth
Chronic constipation
Pelvic floor dysfunction
COPD/asthma
Why does COPD and asthma pose a risk factor for POP?
Bc chronic coughing puts pressure on the pelvic floor
What is the presentation of POP?
Report of bulging/pressure that is worse at the end of the day
Pelvic pain
B/B dysfunction
What is DRA (diastasis recti abdominis)?
Separation of the rectus abdominis muscles at the linea alba
What percent of pregnant women have a DRA by their due date?
100%
What percent of women have a DRA still weeks to years into postpartum?
39%
What is a positive palpation for DRA?
2.5 finger widths and depth
What is the most common abdominal surgery?
C section
How do we treat and manage UI/FI?
Address ortho/MSK deficits
Pressure management with fxnal activities
Treat constipation
Bladder retraining
Urge suppression
Remove bladder irritants
Toileting
Bowel massage
What are common bladder irritants?
Coffee, acidic foods, citrus, alcohol
How can we make toileting easier?
Bring the knees above the level of the hips
What is the Laslett cluster?
A cluster of special tests for the SIJ
What tests are included in the Laslett cluster?
Distraction, thigh thrust, compression, gaenslen, sacral thrust
How do we perform the thigh thrust test?
Flex the hip and apply pressure straight down
How do we perform distraction in the Laslett cluster?
In supine, cross your arms across their ASIS and apply downward pressure
What are the SIJ tests?
Laslett cluster
FABER
FADIR
ASLR (active SLR)
Squat
Trendelenburg
How do we perform the FABER?
Flex, abduct, and ER the hip and apply pressure to the knee and opposite ASIS
How do we perform the compression test?
In SL, apply a downward pressure at the iliac crest
How do we perform the Gaenslon test?
Bring one knee to chest and then pull apart the two legs bringing the one further to the chest and the other down towards the floor
What are the most common MSK concerns with pregnancy?
Round lig pain
CTS
Thoracic outlet
LBP
Pelvic girdle pain (PGP)
Sciatica
A common MSK change in pregnancy is _____ lumbar lordosis and ____pelvic tilt
Increase, anterior
A common MSK change in pregnancy is ____ thoracic kyphosis and forward head
Increased
Where does the COM shift during pregnancy?
Anterior
What are the CVP changes that occur in pregnancy?
Increase in BP
Increase in HR
Difficulty breathing
What VS should we be watching during exercise with pregnant patients?
HR, BP, SPO2
We should not exercise a pregnant pt is their HR is above ____, or if resting BP is above _______
120 bpm, 180/105mmHg
What is pre-eclampsia?
Increased BP>140/90 after 20 weeks of pregnancy
Protein in urine
Significant HA, heartburn, and changes in vision
What are the s/s of pre-eclampsia?
BP >140/90
Significant HA, heartburn, and changes in vision
What is a medical emergency in pregnant pts that we should be aware of with exercise?
Pre eclampsia
What are the absolute contraindications to exercise in pregnancy?
Hemodynamically significant heart disease
Restrictive lung disease
Cervical insufficiency/cerclage
Multiple gestation at risk of premature labor
Persistent 2nd/3rd trimester bleeding
Placenta previa after 26 weeks gestation
Premature labor during current pregnancy
Ruptured membranes
Pre eclampsia
What are the relative contraindications to exercise during pregnancy?
Severe anemia
Poorly controlled HTN
Intrauterine growth restriction, miscarriage, premature birth/labor
Poorly controlled hyperthyroidism
Unevaluated maternal cardiac arrhythmia
Chronic bronchitis or other respiratory disorders
Poorly controlled type 1 DM
BMI>40 or <12
Orthopedic limitations
Poorly controlled seizure disorder
If a patient is pregnant and was not previously very active, should they start a new workout routine during pregnancy?
No!
What exercises can be done during pregnancy?
CV training
Strength training
Positioning
Pregnant women should perform _______ minutes of moderate intensity aerobic activity per week
150
Pregnant novice and intermediate athletes should do CV training at what HRmax level?
60-80% HRma
Trained athletes should do CV training at what HRmax level?
80-90% HRmax
We should avoid exercising any pregnant patient in aerobic training above what HRmax level?
90% HRmax
T/f: there are adverse fetal/maternal effects of performing strength training during pregnancy
False
What special considerations are there for strength training with pregnant patients?
Watch to avoid Valsalva as it can produce rapid increase in BP and HR, temporarily reducing blood flow to the fetus and harming the pelvic floor
What are the positioning recommendations for pregnant patients?
Sitting, SL, standing, quadruped, semi-recumbent/semi-fowlers
We should avoid sitting in what position for pregnant patients?
Supine
Why should we avoid supine positioning with pregnancy patients?
Bc they can develop supine hypotension syndrome
What is supine hypotension syndrome?
Inferior vena cava compression
What are the s/s of supine hypotension syndrome?
Cyanosis, SOB, diaphoresis, syncope, dizziness, nausea, numbness/coldness in limbs, muscle weakness or twitching
What are some warning signs to stop exercise with pregnant patients?
Vaginal bleeding or amniotic fluid leaking
Regular contractions
HA, dizziness, chest pain
Muscle weakness
Calf pain/swelling
When are postpartum patients generally cleared for exercise?
At 6 weeks postpartum
What is a high priority item to work on postpartum?
Ankle DF bc for literally no reason, women loose about 5 deg ankle DF during the third trimester and it fucks with their gait
What are the causes of pelvic pain?
Dyspareunia
Vaginismus
What is dyspareunia?
Pain with vaginal penetration
What is vaginismus?
Spasm in the outer third of the pelvic floor leading to pain with penetration
What is prostatitis/BPH?
Inflammation/enlargement of the prostate
Where is the pain typically with prostatitis/BPH?
Rectum, pelvis, LB, groin
What are the urinary symptoms of prostatitis/BPH?
Urgency, frequency, hesitation, reduced stream, incomplete emptying
What is endometriosis?
Chronic inflammatory estrogen dependent and progressive disease where the endometrial tissue grows outside of the uterus with unknown etiology
What is IBS?
Abdominal pain associated with change in bowel habits and certain foods and stress
Can be constipation type or diarrhea type
What is PCOS?
Hormonal/endocrine disorder, ovulatory dysfunction, hyperandrogenism causing pelvic pain and fertility issues
What is IC (interstitial cyctitis)/PBS (painful bladder syndrome)?
Chronic pelvic pain related to the bladder with urinary symptoms
Avg 16.5 voids/day
What are the symptoms of pudendal neuralgia?
Pain, burning, itching along the nerve distribution
Worse in sitting
Reduced in standing and laying down
Feels like sitting in a ball
What is involved in the PMH screening for pelvic health?
Asking about prior pregnancies/births
If currently pregnant, ask about trimester and OB
What do we need to screen in a general orthopelvic exam?
Lumbar and hip A/PROM
LE MMT
LE flexibility
Neuro (neural tension/sensation/reflexes)
Palpation of boney landmarks and soft tissues
Observation for any incisions/scars (esp at abdomen)
External PFM assessment
Special fxnal tests
What special fxnal tests may we want to include in screening general orthopelvic conditions?
Trendelenburg
Laslett cluster
FABER
FADIR
ASLR
PSLR
squat
What are possible orthopelvic differential diagnoses for the lumbar, sacral, coccyx?
Radiculopathy
SIJ, PGP
Coccydynia
PLBP (pregnancy LBP)
What are possible orthopelvic differential diagnoses for the hip?
Impingement
Labrum
OA
Piriformis syndrome
Bursitis
What are possible orthopelvic differential diagnoses for the pubic symphysis?
Separation
What are possible orthopelvic differential diagnoses for the pelvic floor?
Over/underactivity
POP
UI/FI
Pelvic pain
What are possible orthopelvic differential diagnoses for the abdomen?
DRA
Scar tissue
Fascia restrictions
What are red flags to look out for in pelvic health?
Unexplained weight loss
Unexplained change in urinary fxn
Blood in urine/stool
Cauda equina symptoms
Leaking w/o sensation/knowledge
UTI/STI, urinary retention, decreased BMs
What are the symptoms of cauda equina?
Urinary/bowel/retention/incontinence
Saddle anesthesia
LBP
When should we refer pts to pelvic health PT?
Pregnant pts
Urinary/fecal incontinence, constipation
Suspected pelvic organ prolapse (POP)
Pre/post op for urology, gyn, abdominal surgery
Chronic LBP, hip, SIJ, abdominal, pelvic girdle pain, or any other orthopelvic diagnoses
What will someone feel with a POP?
Pressure/heaviness/bulge sensation in pelvic floor
