Women's Health Flashcards

1
Q

What is the detrusor muscle

A

The key part about the anatomy of the bladder is the detrusor muscle, it tells the brain how fall the bladder is, it contracts and it can be under or over active.
Detrusor muscle contracting before bladder is full when overactive

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2
Q

Nervous system control of micturition

A

Para = pour
Symp = store

Sympathetic control when detrusor muscle is quite and pelvic floor is contracted

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3
Q

Role of pelvic floor

A
  • Support pelvic organs
  • Withstand increase in IAP (to support the organs)
  • Continence
  • Contribute to urethral and anal closing pressure
  • Detrusor inhibition
  • Support with defaecation
  • Sensory function during intercourse
  • Co contraction with diagraph, TA and multifidi’s (pelvic cylinder, below)
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4
Q

Two broad categories for incontinence

A
  • Functional - Stress urinary incontinence, Over active bladder- weak pelvic floor
  • Neurogenic - MS, SCI, Parkinson’s
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5
Q

SUI diagnosis and treatment

A

Complaint of involuntary leakage on effort or exertion (increase IAP) or on sneezing or coughing

Diagnosis - subjective assessment, 1 hour pad weight test (> 12 gram increase classified as SUI), bladder neck descent, urodynamic testing

SUI is normall problem with pelvic floor (unable to counter increased IAP)

Treatment:

  • 12 weeks minimum pelvic floor program - increase hypertrophy, strength and endurance. This means the PFM can resist the downward movement of bladder neck with increases in IAP.
  • Knack before activity (lifting), bracing with pre PF contraction
  • Need to consider that TA forms cylinder while muscles of PF and diaphragm form base and lid. +/- Integrate TA treatment.
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6
Q

Other less common treatment directions for SUI

A
  • TVT surgery
  • Bulking agent injections - bladder neck
  • Ovestin cream/vagifem (oestrogen supplement)
    • Increase oestrogen within pelvic tissue (post menopause)
    • Decrease viginal atropy from reduce oestrogen
    • Improve urethral closure by increasing sphincter muscle thickness
  • Decrease BMI - decreases pressure on pelvic organs
  • SUI pessary (stops bladder neck descent)
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7
Q

OAB diagnosis

A

Detrusor muscle contracting before bladder is full when overactive

Provoked (e.g running water, key in door, glass of water) or unprovoked detrusor (need to urinate for no reason) overactivity

  • Increased frequency of voiding per day (>8)
  • Low voided volumes
  • Incomplete ballder emptying
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8
Q

Causes of OAB

A
  • Poor bladder habbits - going just in case
  • PVR - post void residual
  • Caffeine/alcholo
  • Stress/anxiety
  • Medical conditions such as endometriosis
  • Dehydration
  • UTI
  • Certain medications
  • Weak PVM (tissue atrophy post menopause)
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9
Q

OAB treatment

A

Management:

  • Most important is getting the right diagnosis, OAB often looks like UTI
  • Bladder diary, fluid diet management, time voiding and education around stims and risk factors

Treatment:

  • 2 day bladder diary
  • Bladder retraining *defer urge to void and find distraction) based on bladder diary
  • Reduce stims in diet
  • Fluid manipulation (over/underhydrated)
  • Anticholinergics
    • Decrease use of involuntary smooth muscle
    • Blocks muscarinic receptors at detrusor muscle
    • Decreases bladder wall and detrusor contractility therefore decreasing urinary urgency
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10
Q

UTI symptoms

A
  • Dysuria (painful urination) most common symptom
  • Urinary frequency
  • Urinary urgency
  • Haematuria (blood in urine)

Testing is highly recommended with ANY of the above symptoms

Treatment via antibiotics, fluid intake and rest

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11
Q

Main type of pelvic organ prolapse

A
  • Bladder (cystocele)
  • Rectum (rectocele)
  • Central (uterus and cervix)
  • Small bowel (entrocele)
  • Urethra (urethrocele)
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12
Q

Symptoms and causes of pelvic organ prolapse

A

Symptoms (when a prolapse is further down):

  • Heavy sensation or dragging in vagina
  • Something coming down or lump in vagina
  • Sexual problems of pain or less sensation
  • Your bladder might not empty as it should, weak urine stream
  • UTIs
  • Difficult emptying bowels (rectocele)
  • Lower abdominal or back ache

Causes:

  • Vaginal deliveries
  • High BMI
  • Chronic cough or constipation
  • Genetics - connective tissue
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13
Q

Treatment for pelvic organ prolapse

A
  • Ergonomic - limit heavy lifting (increases in IAP)
  • Reduce BMI
  • Reduce constipation and straining
  • Prolapse surgery
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14
Q

Fecal urgency causes and treatment

A

Urgency of stool resulting in a rush to toiler and, passive leakage of feces.
Causes:

  • Injury to the anal sphicter during childbirth is the major cause
  • Weak pelvic floor muscles (weak sphicter control) poor rectal sensation and poor anorectal angle of puborectalis.
  • Poor stool form (Bristol chart type 6-7) → Diet

Treatment:

  • Identify normal bowel habits
  • Establish a regular bowel routine and make time to respond to the sensation of needing to empty
  • Balanced diet with regular meals
  • Adjust fibre intake
  • Caffeine may exacerbate urgency
  • PFMT to increase strength, endurance and coordination
  • Appropriate pads for fecal incontience (normal pads will cause skin irritation)
  • If no response to conservative management then referral to colorectal surgeon.
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15
Q

Causes for PGP

A

3 key joints to consider, SIJ (left and right) and PS

Occurs:

  • Hormonal factors - relaxin
  • Pre existing injury or hypermobility
  • Increased degrees of movement
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16
Q

Ordered assessment of PGP

A

Tests ordered

  • Modified Trendelenburg - PS
  • ASLR - SIJ
  • PS palpation - PS
  • LDL palpation - SIJ
  • Thigh thrust - SIJ

Pain vs tenderness, >5 seconds after removing hands = pain

17
Q

Treatment of PGP

A
  • Individually tailored programs
  • Stability exercises - especially if ligament are lax
  • Massage
  • Manipulation (may worsen)
  • Pelvic belt can be fitted to test for symptomatic relief but should only be used for short periods
    • Flexible compression is more used for pubic symphysis pain
  • Ergonomics reduce abduction → get out of car by twisting both legs, 1 leg stance, heaving lifting, extended walking ect
  • Rest
  • Pillow between legs at night
  • Heat and Ice therapy - ice is particularly useful
  • Mobility aids
18
Q

Stabilising exercises for PGP

A

Use bilateral WB exercises such as squats

Squats with yoga ball against wall are good to keep neutral spine

Exercise should be tailored to ADLs

Need to make sure PF assessment has been done and patient can tolerate increase IAP

Co activation exercises with TA

Changing postures throughout the day

19
Q

When to do antenatal exercise and some key points

A

Screen for LBP, PGP and SUI

Subgroups of patients in similar trimesters and pain levels

Education and PFM training before class

Regular exercise can reduce LBP along with other benefits, however most importantly it can make women feel like they have more energy and feel better.

Find out pre existing exercise levels

Avoid high impact, contact sport, lying on back, UL WB and heavy resistance training

20
Q

Precautions for antenatal exercise

A
  • Watch exertion level
  • Wear a bra
  • Eat carbs before exercise - blood glucose can drop faster than normal pop
  • Do not over heat!!! - take regular breaks, exercise in well ventilated area, drink water
  • No prone
  • Sugar for patients with gestational diabetes
  • No NSAIDS
  • No compressive garment over abdomen

Do not exercise on back after 16 weeks of pregnancy

Can cause the weight of baby to press down on the major veins to heart.

21
Q

What is Perineal massage

A

Increase elasticity and stretch of perineum

Do from 37 weeks

Can use hands or Epi No

22
Q

Labour positions

A

Make sure it is comfortable and safe

Can be anything patient wants

23
Q

Keys for early stage labour, 1st stage

A

Transitional

Relaxation in this stage is important to ensure you have enough energy for the second stage

Decrease stress = increase oxytocin (natural pain reliever) and increase rhythmal breathing

24
Q

Features in patients with pain cycle in labour

A
  • Breath holding
  • Facial expressions
  • Tense
  • Vocalisation - distressed speech
  • Lack of support
  • Increase pain/fear leads to increased perception of pain and reactions
25
Q

Breaking the pain cycle

A
  • Positive and empowering midwife/partner/family
  • Rapport with doctor
  • Knowledge
26
Q

Types of perineal trauma

A

1st degree tear

  • Injury to skin or vaginal epithelium only
  • May not need repair

2nd degree

  • Injury to perineum involving perineal muscles bot not EAS (external anal sphincter)
  • Requiring repair

3rd degree

  • 3a - <50% EAS
  • 3b >50% EAS
  • 3c entire EAS

4th degree

  • Perineum, EAS and IAS
27
Q

What is an episiotomy

A

Episiotomy

  • Surgical incision made between vagina and anus
  • Used when high likelihood of sever perineal trauma, accelerate birth
28
Q

Acute management of 3rd and 4th degree perineal tears

A
  • Soft tissue management similar to MSK → Ice packs, positioning, pain management, compression, swelling
  • Perineal support
  • Bowels
  • Gentle pelvic floor contractions for circulation only
  • NO IAP pressure in first 6 weeks
29
Q

Follow up for 3rd and 4th degree tears and what long terms concerns co be important

A

Follow up:

  • Wound healing
  • Pelvic floor progression at 6 weeks to strength parameters
  • Treat any SUI, OAB or POP
  • LAM

Low term risk factors:

  • LAM → will heal but may have limited contractility in pelvic floor
  • Fecal incontinence
  • Fecal urgency
  • Flatus
30
Q

Acute care for viginal delivery

A
  • Perineal ice every 2-3 hours for 10-15 mins
  • Limit prolonged sitting or putting the bed head up as this may increase perineal swelling → need to encourage laying in supine
  • Gentle PF contractions for swelling control and stimulate circulation (10x 2 second hold)
  • Passive support of perineum by putting hand over pants when doing activates that increase IAP such as coughing, standing or emptying bowels
  • Minimise IAP (lifting, straining for bowels)
  • Appropriate underwear to reduce friction
  • Perineal support underwear or garments may be helpful
  • No haemorrhoid rings or rolled towels as this can increase swelling
  • Pain relief
  • DRAM assessment and management
  • Bladder and bowel advice around toilet positioning and voiding
  • Epidural headache vs MSK pain (leaking of CSF can put pressure on brain stem, pain worse when they sit up then lay down)
  • Other acute MSK pain, shoulder or neck stiffness and soreness
31
Q

LSCS acute care

A
  • DVT check
  • LL circulation exercises
  • LSCS wound support
  • Bed mobility → roll and sit on side of bed
  • Pain relief well controlled?
  • Fluid intake may need to increase or decrease
  • Bladder dysfunction → make sure patient uses toilet every 2 hours
  • Minimise IAP
  • Support garments may be helpful if DRAM
  • MSK pain post LSCS, epidural headache
  • Bowels, constipation of wind → abdominal massage for wind
32
Q

Long term care for post natal women

A
  • Pelvic floor program (6 months min)
  • Bladder habbits
  • Reduce risk of other MSK conditions (poor positioning in breast feeding)
  • Manage any evidence of DRAM (abdominal support)
  • Activity
    • 0-6 pain/swelling tolerated walking
    • 6-12 all low impact exercise ok
    • 12 and beyond can start high impact trials
  • Screen for other issues that may require outpatient physio
    • SUI
    • LAM
    • Fecal incontinence
    • Prolapse
    • OAB
    • Chronic constipation
33
Q

What is trial or void

A

Assess bladder function after IDC removed

6 hours to void 400 mls with 2 voids

IDC only removed during day

If failed TOV then following may all stimulate:

  • Running water
  • Shower
  • Supra pubic pressure
  • Education on TOV
  • Defecation potions
  • Hydration levels
  • Don’t strain

If these don’t work then IDC back in

34
Q

LAM injury and risk factors

A

Avulsion of puborectalis from inferior pubic ramus in women who delivered vaginally

Muscle attaches directly to bone and can tear off

Risk factors:

  • Forceps
  • igh maternal age >40
  • Prolonged second stage (>2 hours)
  • Birth weight >4kg
  • 3 and 4 degree perineal tears
  • Episiotomy
35
Q

DRAM injury and management

A

Condition where rectus abdominis separates at the linea alba (connective tissue)

Very common for women to have DRAM immediately post partum (2-4 days) but abnormal at 5-7 weeks

Management:

  • Assessment → 2 fingers spaces above belly button, neck to chest and lift head up to conc abs. Then relax and press
  • External abdominal support
  • Patient needs to monitor throughout activities
36
Q

Cocxy pain

A
  • Due tp physical trauma during birth or previous injury
  • Common with OP presentations (occiput first)
  • Minimise WB on coccys
  • Side lying most comfortable
  • Ice as tolerated
37
Q

Thoracic and LBP

A
  • Some just DOMS after labour
  • Posture advice
  • Stretches
  • Mobilisation
38
Q

Return to exercise (0-2, 2-6, 6-12)

A

Day 0 - wk 2

  • PF, TrA, stretches
  • Gentle walks

wk 2 - wk 6

  • Progress walking
  • Continue PRM and TrA
  • Light weights from 4-5 weeks (not LCSC patients)
  • Monitor for symptoms of UI

wk 6 - wk 12

  • Progress walking
  • Low impact exercise
  • Continue PFM and TrA
  • Trial high impact

Need to consider:

  • Low oestrogen and breastfeeding so more prone to injury
  • Don’t overexert as this may effect breastmilk
39
Q

Normal BMI range

A

18.5 to 24.9