Women's Health Flashcards
(39 cards)
What is the detrusor muscle
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
Nervous system control of micturition
Para = pour
Symp = store
Sympathetic control when detrusor muscle is quite and pelvic floor is contracted
Role of pelvic floor
- 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)
Two broad categories for incontinence
- Functional - Stress urinary incontinence, Over active bladder- weak pelvic floor
- Neurogenic - MS, SCI, Parkinson’s
SUI diagnosis and treatment
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.
Other less common treatment directions for SUI
- 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)
OAB diagnosis
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
Causes of OAB
- 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)
OAB treatment
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
UTI symptoms
- 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
Main type of pelvic organ prolapse
- Bladder (cystocele)
- Rectum (rectocele)
- Central (uterus and cervix)
- Small bowel (entrocele)
- Urethra (urethrocele)
Symptoms and causes of pelvic organ prolapse
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
Treatment for pelvic organ prolapse
- Ergonomic - limit heavy lifting (increases in IAP)
- Reduce BMI
- Reduce constipation and straining
- Prolapse surgery
Fecal urgency causes and treatment
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.
Causes for PGP
3 key joints to consider, SIJ (left and right) and PS
Occurs:
- Hormonal factors - relaxin
- Pre existing injury or hypermobility
- Increased degrees of movement
Ordered assessment of PGP
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
Treatment of PGP
- 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
Stabilising exercises for PGP
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
When to do antenatal exercise and some key points
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
Precautions for antenatal exercise
- 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.
What is Perineal massage
Increase elasticity and stretch of perineum
Do from 37 weeks
Can use hands or Epi No
Labour positions
Make sure it is comfortable and safe
Can be anything patient wants
Keys for early stage labour, 1st stage
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
Features in patients with pain cycle in labour
- Breath holding
- Facial expressions
- Tense
- Vocalisation - distressed speech
- Lack of support
- Increase pain/fear leads to increased perception of pain and reactions
