Pelvic Health & Incontinence Flashcards
how many times a day is it normal to pee
</= 7x/day
at what age is it normal to have to get up 1x at night to pee
78.4yo
what is the main thing that impacts male UI
prostate CA
what mechanism is delayed in stress UI
feedforward mechanism of TrA and pelvic floor
what athletes had a higher incidence of UI
gymnasts
runners
power lifters
track and field (emphasis on field)
dancers
what are 3 demographics of pts that are inc risk for incontinence
older pts
females
athletes
why are older pts at higher risk for incontinence
dec in collagen
what is the most common type of incontinence for women
stress
- then mixed
- then urge
what are risk factors for incontinence
age
pregnancy and childbirth
menopause
depletion of estrogen
pelvic surgery
smoking
DM
eating disorders
obesity / high BMI
high impact physical activities
family hx
white
constipation
neuro conditions
prolapse
female anatomy
chronic coughing
what is functional incontinence
someone was totally continent previously, then have some injury that slows them down getting to the bathroom
stress vs urge incontinence
stress
- involuntary loss of urine during coughing, sneezing, laughing, or other physical activity that inc intra-abdominal pressure
urge
- involuntary loss of urine associated w strong desire to void
what is mixed incontinence
sx of both stress and urge
what are examples of some triggers for urge incontinence
running water
stepping into tub
rushing to toilet
key in door
what are causes of stress incontinence
hyper-mobility of urethra/bladder neck during exertion/poor urethral control
weakness / laxity of ms
- impaired pelvic supports
pregnancy/delivery surgery and or injury/menopause
what are causes of urge incontinence
bladder/urethral instability
detrusor over activity, local bladder irritation, bladder stones
cystitis - inflammation of anything in bladder/urethra
meds
over-pressure on bladder from abs
autonomic dysfunction
difference in ms between stress and urge incontinence
stress = weakness
- poor motor control/coordination
- use of big ms not pelvic floor which inc IAP w activities
urge = inc tone
- inability to relax pelvic floor quickly and/or fully
- related to mind body control
- can result from autonomic dysfunction
interventions for stress vs urge UI
stress = weakness in pelvic floor ms
- kegels
urge = inc tone
- kegels will only make tone worse as ms have a low threshold for stress placed on it
- work more on mind body relaxation control
how is mixed UI treated
address tone first, then strengthen
what are the 4 types of UI
stress
urge
mixed
overflow
what is urinary retention
failure to empty
what people can PT improve the sx and QOL in
non-surg candidate
pelvic pain
urinary/fecal incontinence
what analogy is made to how the pelvic floor ms sit
like a hammock
how does the male pelvic floor differ in its structure to the female
male tends to be more narrow and compact
- hammock doesn’t have to stretch as far
obturator internus is huge, IR hip and supports the pelvic floor
where can people get a lot of prolapses
urogenital hiatus
what 3 ms make up the levator ani ms group
puborectalis
pubococcygeus
ilio-coccygeus
what is the pelvic floor innervated by
S3-5 and pudendal nerve
what combined function do all levator ani ms have
counter-nutation of sacrum
pubococcygeus function
co-contract of TrA
puborectalis structure and function
pubic to midline sling posterior to rectum, “lifts”
iliococcygeus insertion
at internal surface of obturator internus (oblique)
coccygeus structure and function
thin flat ms inserts on coccyx from ischial spine (oblique ms)
“wags”
pubovaginalis structure and function
medial part attaches to vagina
supports vagina
what are 2 associated ms that originate in pelvis/pelvic wall but attach externally to leg
obturator internus
piriformis
what are functions of the levator ani group
closes pelvic floor
- lifts up and closes
carries weight of abdominal cavity
prevents constant strain on visceral ligs/passive supports
assists w closing sphincters and maintaining proper angles/positions for bladder/bowel
what type of fiber is the majority of pelvic floor ms and why do ms need both types
type 1 = slow twitch
need some quick acting ms (type 2) if you were to jump and land - quick force and inc pressure
- sphincter ms need to be quick
- pelvic floor is anticipatory, feed forward
what changes in pelvic floor ms are seen in 3-4wks
see changes in motor control and NM re-ed
what changes in pelvic floor ms are seen by 6-8wks
true changes in strength
- need intensive consistent training to get here
what are 4 mechanisms that a pelvic prolapse can occur
downward mvmt of organs (ie bladder, rectum, uterus)
internal “hernia”
passive and active supports no longer support organs
- gravity takes over
prolapse can occur thru urogenital hiatus
what are 4 types of pelvic prolapses
cystocele = bladder
rectocele = rectum
uterine prolapse = uterus
enterocele = small bowel
what direction does a cystocele often happen in and what is the significance of this
falls posteriorly into vagina
bladder might not fully empty on toilet and will stay partly full and will feel it when you change positions
what might pts w a prolapse c/o
feel something there
painful
heavy/pressure
can’t fully empty
can’t insert tampon
how are prolapses graded in women
how quickly they come out of the vagina
what tells your body you need to go
stretch receptors in visceral detrusor ms
what ms are contracted when the urine stays inside the body
sphincter and pelvic floor ms have a tonic contraction
detrusor bladder ms is relaxed
describe the guarding reflex
stress activities (coughing or lifting) produces sudden bladder pressure
pelvic n. or brain stimulates the pudendal motor neurons which releases Ach causing the urethral sphincter to contract
what happens during bladder filling
as bladder fills, pelvic nerve is stim and norepinephrine is released to relax the bladder and contract urethral smooth ms
sympathetic vs parasympathetic in filling or emptying bladder
sympathetic = stores pee
parasympathetic = pee
- parasympathetic is rest and digest, and pee
what is an overactive bladder
damaged nerves may send signals to bladder at the wrong time, causing ms to squeeze w/o warning
when nerves work poorly, what are 3 types of bladder control problems
urinary frequency
urinary urgency
urge incontinence
what is urinary frequency
urination > 9x/day or 2+ times at night
what is urinary urgency
sudden, strong need to urinate immediately
what is urge incontinence
leakage of urine that follows sudden strong urge (parasympathetic system)
what happens during bladder emptying
bladder full and sending strong stretch impulses to SC via pelvic n.
-> pontine micturation center activated and impulses sent to sacral parasympathetic nucleus
Ach released by pelvic n. causing bladder contractions and inhibits sphincter contractions
_______ training is key to improvement
breathing
what makes up the pelvic pyramid
multifidi
pelvic flow
transverse abdominis
what are 3 modifiable factors when it comes to managing UI
behavioral factors
MSK factors
motor control factors
what are 3 structural systems contributing to the management of urinary incontinence
urethral support system
intrinsic urethral closure system
lumbopelvic stability system
what motor control factors can contribute to UI (4)
PFM dysfunction
posture
LBP/pelvic pain
breathing disorders
a dec in what MSK factors can contribute to UI (3)
ROM
strength
endurance
what behavioral factors can contribute to UI (4)
chronic elevated IAP
physical inactivity
abnormal fluid intake/void habits
poor psychosocial health
what are pt education points
anatomy
type
risk factors/behaviors
what are lifestyle/behavior changes to make for UI
timed voiding
bladder diary
< caffeine intake
fluid intake
what are breathing instructions to give
diaphragmatic/lateral (segmental)
- relaxation / physiological quieting
- autonomic nervous system
what are general POC interventions for UI
pt ed
lifestyle modification
breathing
posture re-training
stretching
inhibition
manual interventinos
what are 3 examples of manual interventions
quick stretch/facilitation
scar massage
joint mob / MET
what is your first line of defense w ther-ex
pelvic floor exercises/kegel
teach isolation of PFM
focus on timing and co-activation
what activation should be avoided if you are teaching them to isolate PFM
rectus
IO/EO/gluts
what co-activation should you teach when isolating PFM
isolation of PFM + proper breathing
isolation of PFM + TrA + breathing
what is a typical prescription for kegals if the goal is to strengthen and inc force production of PFM
quick contractions 5 pre/post
slow contractions 5-10 sec hold
- 25-50reps/day, 5-10sec rest b/w
3-5x/wk
for 15-20wks
- then maintenance after
what is “the knack”
protective contracture prior to inc abdominal pressure
- timing of urethral closure and PFM contraction has been critical
what has estim found to be helpful in
<3/5 and gravity assisted
what are nearby ms to treat as PFM isolation has been achieved
multifidi
LE rotation
glut max/med - proper breths
pelvic/lumbo stability/posture
what outcomes have been found w intensive PFM strength training
hypertrophy and inc stiffness of PFM connective tissues to improve recruitment efficacy
elevate levator plate position to higher position in pelvis
facilitate an automatic PFM contraction during rises in IAP
what are components to include when setting goals
ms isolation/coordination
urinary/fecal control
pelvic floor strength/response time
dec accessory ms contractions
dec hyperactivity of ANS
dec pain
pt goals obvi
success rates of pelvic PT?
good
outcomes largely depends on pt
