Test 2: Pelvic Health Intro Flashcards
what area is defined as the pelvis and what makes up the greater and lesser portions
pelvis = area between trunk and lower limbs
greater pelvis = occupied by inferior abdominal organs as means of protection
lesser pelvis = skeletal framework for pelvic cavity and perineum
what overlaps the pelvis anteriorly, posterolaterally, and inferiorly
anterior = inferior anterolateral abdominal wall
posterolaterally = gluteals
inferiorly = perineum
pelvic ring is composed of what 3 bones
L and R coxae/coxal bones
sacrum
coccyx
pelvic ring has an inlet and an outlet
describe the interlocking of the SI joint
auricular surfaces of the sacrum aid in form closure of SIJ
females have a smaller surface area than males
form closure = passive
force closure = musculature
pelvic girdle anatomy shape males vs females
females = circular inlet
males = heart shaped
** lots of variation in pelvic height and girdle shape
ways to describe the biological female/ “gynecoid” pelvic girdle
shorter/wider/lighter
ITs further apart
oval/tounded pelvic inlet
large pelvic outlet
wide/obtuse pubic arch and subpubic angle
obturator foramen = oval
acetabulum = small
SIJ = small joint surface
coccyx = smaller
ways to describe biological male/”android” pelvic girdle
taller/narrower
thicker/heavier
heart shaped pelvic inlet
small pelvic outlet
narrow/V-shaped/acute pubic arch and subpubic angle
round obturator foramen
large acetabulum
large joint surface of SIJ
larger coccyx
orientation of the pelvic girdle
L and R ASIS’s and anterior aspect of the pubic symphysis lie in the same vertical plane (anteriorly oriented)
tip of coccyx appears close to the venter of the pelvic inlet
laterally = sacral promontory is directly superior to the center of the pelvic outlet)
describe the joint architectire of the SIJ
strong and weight bearing compound joint
anterior = synovial (between sacrum and ilium + articular cartilage); interlocking; limited mobility
posterior = syndesmotic between tuberosities of sacrum and ilium
joint remains stable as long as apposition (close relationship/congruency) is maintained
how is weight transferred in SIJ
from axial skeleton to ilia via SI ligaments
then to femurs when standing
to ITs when sitting
describe sacrotuberous ligaments
fibers from posterior margin of ilium/lateral sacrum/base of coccyx pass to IT
divides large sciatic notch (forming large sciatic foramen)
describe sacrospinous ligament
fibers from lateral sacrum and coccyx pass to ischial spine
divides large sciatic foramen (created by sacrotuberous ligament) to then create lesser and greater sciatic foramen
describe the pubic symphysis joint
it is a secondary cartilaginous joint
fibrocartilage disc and surrounding ligaments unite bodies of the pubis
fibers of the tendinous attachments of the rectus abdominis and external obliques strengthen the pubic symphysis anteriorly
wider in females
describe the sacrococcygeal joint
secondary cartilaginous joint with intervertebral disc
fibrocartilage and ligaments join the apex of sacrum to the base of the coccyx with long strands of anterior and posterior sacrococcygeal ligaments to reinforce joints
describe the lumbosacral joints
L5-S1 articulate at the inververtebral joint between IV disc between their bodies and the 2 posterior zygapophysial joints between articular processes of vertebrae
facets of S1 vertebrae face posteromedially with anterolaterally facing inferior articular facets of the L5 vertebrae
SIJ ROM
greatest flexion/extension at 3 deg
1.5 deg axial RT
0.8 deg lateral flexion
max ROM of SIJ
males = 1.2 deg
females = 2.8 deg
average translation of SIJ
0.7-2mm
higher in unilateral vs bilateral stance
ortho considerations for pelvic ring fxs
can occur with:
- crush accident
- fall from height
- MVA
often encountered post sx in acute care/IPR
unlikely to have just a single fx
pelvic fxs often result in soft tissue damage (i.e. nerves, organs, blood vessels, etc)
may result in rupture, transection, or torn urethra
what happens to pelvic joints/ligaments with pregnancy
increased mobility and relaxation of ligaments
increase in intrapubic disc space
increase in flexibility of ligaments/pubic symphysis due to relaxin in latter 1/2 pregnancy
relaxation of ligaments can cause SIJ instability
side to side and transverse demensions may change but the true obstetric diameter remains unchanges
risk factors for pelvic girdle pain
prior hx pregnancy
orthopedic dysfunctions
increased BMI
smoking
work dissatisfaction
lack of believe of improvement in the prognosis of pelvic girdle pain
red flags with PGP that may indicate something more serious
not associated with the described clinical course of PGP
impairments failing to normalize
symptoms are worsening with increased disability
possible comorbidities associated with PGP population
transient osteoporosis
MSK involvement of pelvic floor, hip, L/S
diastasis rectus abdominis (DRA)
recommended measures for PGP
oswestry disability index (ODI)
disability rating index
pelvic girdle questionnaire (PGQ)
fear avoidance beliefs questionnaire (FABQ)
pain catastrophizing scale (PCS)
antepartum pelvic girdle pain interventions (based on CPG)
pelvic girdle/SIJ belts
- conflicting evidence
- varied duration and applications
exercise
manual therapy
- evidence emerging/weal
- little/no evidence of adverse effects
who is defined as postpartum
anyone 12 months post delivery or anyone still breastfeeding given the altered hormone status
*pt can be altered hormone status up to 6 months post weaning
risk factors for PGP postpartum
previous hx lumbar or PGP during pregnancy
pain in posterior pelvis
pain rolling in bed
pain WBing
multiparity
depressive S&S
higher pregnancy BMI
work factors
breastfeeding position
systems screen for postpartum individuals with PGP
depression
urinary and fecal incontinence and refer to pelvic PT of S&S are present
abdominal wall, back, and hip screen
when to refer to imaging to rule out a stress fx when pt has PGP
within 2 weeks of delivery with:
- severe pain
- decreased ability to weight bear
- antalgic gait/limp
- sudden onset SIJ pain, butt, or LBP
exam components to consider with PGP
strong evidence for clinical presentation during fucntional mobility
P4 test
FABER
ASLR for supine limb loading/pelvic stabilization
force production, endurance, resting mm tone/length
should NOT perform gaenslens withing firdt 4 weeks postpartum or beyond 4 weeks postpartum in the presence of pubic symphysis pain
interventions for PGP postpartum
strong evidence for SIJ/pelvic belt
MT no better than stabilization for long term involvement (>6 months)
strong evidence that MT used with cointerventions can provide short term relief of pain and disability
strong evidence for strengthening of pelvic floor, core, and hip strengthening
prognosis for PGP postpartum
depends on initial pain and disability scores
- higher scores recover quicker and return to function
- low scores demonstrate minimal gains; may still have S&S 1-2 years later
present to PT >3 months after delivery = minimal to low gains- ADVOCATE FOR EARLY POSTPARTUM CARE
anterior/inferior pelvic wall is formed by what and bears the weight of what
formed by bodies and rami of the pubic bones and pubic symphysis
bears weight of bladder
lateral pelvic walls are formed by what
R and L innominates
each has an obturator foramen, closed by obturator membrane
what covers the internal aspect of the obturator membrane/foramen and pads the lateral pelvic walls
obturator internus
OI fibers converge posteriorly with other deep external rotators, pass through the lesser sciatic foramen to attach to the greater trochanter
obturator fascia has an opening to allow what to pass through
aka pudendal canal or alocks canal
pudendal nerve, internal pudendal artery, and internal pudendal vein
what forms the posterior wall/posteriorlateral wall and roof of the pelvic cavity
bony wall via sacrum and coccyx
musculoligamentous posterolateral walls = ligaments associated with B SIJs and piriformis (sacroiliac, sacrospinous, and sacrotuberous)
where does the piriformis run
from superior sacrum
passes laterally leaving pelvis via greater sciatic foramen
attaches to greater trochanter
occupies much of the greater sciatic foramen forming the posterolateral walls
where does the coccygeus mm run
ischial spine to body of pubis to inferior end of sacrum and coccyx
what muscles make up the levator ani and where do they run
puborectalis: pubis, around rectum, and back to pubis (most medial mm)
pubococcygeus: pubis to coccyx; wide and thin middle portion
iliococcygeus: pubis to ilia; posterolateral, more aponeurotic, blends with anococcygeal ligament
what is a urogenital hiatus
anterior gap between medial borders of levator ani on each side
passage for urethra and vagina
pelvic diaphragm is composed of what
coccygeus
levator ani mm
urogenital hiatus
what is the perineal membrane
dense fibromuscular tissue deep to the superficial pelvic floor musculature
home to striated urogenital complex
describe the striated urogenital complex
straited, known as external urethral sphincter
slow twitch that fuse with bladder and encircle the upper 2/3 of the urethra in females
lower 1/3 divides urethrovaginal sphincter and the compressor urethra
provides majority of striated mm compression at the urethra, 1/3 of the resting closure pressure
significance of male urethral location
EUS is inferior to prostate
can lose voluntary control temporarily or long term
describe the contraction of the levator ani of the pelvic floor
levator ani forms dynamic floor for supporting abdominopelvic viscera
- tonically contracted most of the time
- full relaxation should occur for defecation, urination, and parturition
-ACTIVELY contracted during forced expiration/management of intra abdominal pressure
pelvic floor roles/functions
sphincter/continence control
role in stability and posture
sexual function
load transmission (GRF up from LEs to spine)
PFM support the fetal head while the cervix is dilating; what is the clinical relevance of this info
may lead to injuries of perineum, levator ani, or ligaments of the pelvic fascia
may decrease support of vagina, uterus, bladder, ad or rectum, especially during increases in intra-abdominal pressure - stress urinary incontinence
PFM stretch over 3x normal resting length with labor; what is the relevance of this
even if a tear doesnt occur, a muscle overstretch injury may occur
perineal body may serve as protective component to overstretching/ stretching more than the mm itself
pudendal nn may also be at risk for stretch or compression injuries
describe the parietal peritoneum and its location/function with the pelvic region
parietal peritoneum is continuous with abdominal cavity but does not reach the pelvic floor
DOES reach ovaries and uterine tubes
region superior to bladder = not firmly bound to underlying structures = creates supravesical fossa depending on bladder fullness
peritoneum passes over fundus and entire posterior aspect of the uterus onto posterior vaginal wall before reflecting up to the anterior wall of rectum
how is the peritoneum different in males
peritoneal fold passes over ureter and ductus/vas deferens - separates paravesical and pararectal spaces (male equivalent of broad ligament)
describe the parietal and visceral fascia
connective tissue that occupies the space between the membranous peritoneum and muscular pelvic walls and floor not occupied by pelvic viscera
continuous, thin endoabdominal fascia that lies between mm abdominal walls and peritoneum
loose and condensed endoplevic fascia
6 main arteries that enter the lesser pelvis of females
paired internal iliac
paired ovarian arteries
unpaired medial sacral and superior rectal arteries
4 main arteries that enter the lesser pelvis of males
paired internal iliac
unpaired median sacral and superior rectal
internal iliac arteries supply what
most of the blood to pelvic viscera
some MSK portions of the pelvis
gluteal, medial thigh, and perineal regions
veins of the pelvic vasculature
pelvic venous plexus
internal ilia cvein
no veins accompany umbilical arteries between pelvis and umbilicis adn the iliolumbar veins from the iliac fossa drain the common iliac veins instead
function of the superior gluteal veins
largest tributaries of internal iliac veins except during pregnancy when uterine veins become larger
path of testicular veins
traverse greater pelvis
pass from deep inguinal ring toward posterior abdominal terminations
do not usually drain pelvic structures
function of lateral sacral veins
often disproportionally large
anastomose with internal vertebral venous plexus; provide alternate pathways to reach either the inferior or superior vena cava
may also provide a path for metastasis for prostate or ovarian cancer
rectal blood supply
superior rectal = top of rectum
R and L middle rectal aa (from internal iliac) = middle and inferior
blood from rectum drains into what veins
superior, middle, and inferior rectal veins
rectal venous plexus
innervation of rectum
sympathetic = lumbar splanchnic nn and hypogastric/pelvic plexus
parasympathetic = S2-S4 SC passing via pelvic splanchnic nn and L and R inferior hypogastric plexus
describe the external iliac lymph nodes
above pelvic brim, along external iliac vessels
recieve lymph from inguinal nodes, pelvic viscera, superior pelvic region specifically
do not recieve drainage from parallel nodes
describe the internal iliac lymph nodes
clustered around anterior and posterior divisions of internal iliac artery and origins of gluteal arteries
receive drainage from inferior pelvic viscera, deep perineum, and gluteal region and drain into common iliac nodes
describe the sacral lymph nodes
in concavity of sacrum, adjacent to medial sacral vessels
recieve from posteroinferior pelvic viscera and drain into internal or common iliac nodes
describe common iliac lymph nodes
superior to pelvis along common iliac blood vessels
recieve from external iliac, internal iliac, and sacral lymph nodes
urinary organs that make up the pelvic viscera
pelvic portions of ureters
bladder (rests on pubic bones and symphysis and on the prostate in males)
length of ureters in men vs women
men = 18-22 cm
women = 4cm
describe the bladder/its position
apex points to pubic symphysis
fundus/back of bladder is separated from rectum in males by a fascial septum but it is directly related to the superior anterior wall of the vagina in females
bladder primarily composed of detrusor mm
internal urethral sphincter is at the bladder neck
what is the rectum connected to/where is it located relatively
continuous with sigmoid colon; junction is approximately at S3
rectum ends at tip of coccyx/anal sphincter
female internal genital organs
ovaries
uterine tubes
uterus
vagina
male internal genital organs
epidymides/epidymis
ductus deferens/vas deferens
seminal glands
ejaculatory ducts
prostate
bulbourethral glands
what is benign prostatic hypertrophy
prostate continues to grow and BPH will affect virtually all males over 80
common after mid life
obstructions may occur; increases risk for UTI; can be relieved endoscopically
TURP (transurethral resection of the prostate) may be used in episodes of prostate cancer or in severe obstruction cases of BPH (risk of urinary incontinence and loss of sexual function)
reasons for urinary referrals in pelvic health
stress
urge
mixed incontinence
retention
reasons for bowel referrals in pelvic health
constipation
fecal incontinence
reasons for pelvic pain referrals in pelvic health
pain at rest
dyspareunia
pain with activity (vulvodynia, vaginismus)
pelvic organ prolapse
coccydynia
what hx questions to ask in a pelvic floor eval
OBGYN hx
bladder/bowel hx/S&S
pain symptoms
sexual activity
tobacco
falls/trauma
abuse
meds
sx
imaging
objective measures for pelvic floor
pelvic floor distress intentory PFDI modules (pain, urinary, bowel, prolapse)
Oswestry disability index
LEFS/lower extremity functional scale is an option with concomitant LE impairment
depression inventories
different portions of the pelvic floor exam
sensory
- light touch
-sharp/dull (if necessary)
reflexes
-anal wink
- cremaster reflex (males)
external
- perineal body mobility testing (ROM of pelvic floor)
internal
- strength test via laycock’s perfect scale
- prolapse testing
coordination
PF mm interventions
uptrain with respiratory coordination
downtrain with respiratory coordination
coordination training
strategy training/return to activity
exercise with PFM coordination/timing
modalities
- biofeedback
-Estim
-rehabilitative US imaging
tools
- dilators
- therapeutic wands
encourage general mobility/activity
how to structure goals with PF therapy and examples
should be pt specific and reflectve of objective measures gathered
i.e.
- decrease incontinence pad use
- pain reduction
- fiber/water intake
- SUI goals
- change in PFDI, oswestry, etc
