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Ortho > Women's health > Flashcards

Women's health Flashcards

1
Q

Name the ligaments:

  1. Anchor for vagina at level of cervix
  2. anchor for uterus, Fallopian tubes, ovaries
  3. anchor for uterus, inserts into labia majora
  4. anchor for uterus to sacrum
  5. ancor for bladder anteriorly to pubic bone
A
  1. transverse ligament
  2. broad
  3. round
  4. uterosacral
  5. pubovesical
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2
Q

What are the borders of the anal triangle?

A
  1. superficial transverse muscle
  2. sacrotuberous ligament
  3. gluteus maximus
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3
Q

complex fibromuscular mass in to which many structures insert. Located between anal and urogenital triangles

A

perineal body

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4
Q

What percentage of type 1 muscles are in the periurethral region and perianal region?

A

96% in periurethral region

77% in perianal region

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5
Q

What are m’s make up the most superficial layer of the urogenital triangle?

A
  1. superficial transverse perineal m: stabilizes perineal body
  2. ischocavernosus: sides, maintains clitoral erection
  3. bulbocavernosus: figure 8, vaginal sphincter, assists in erection
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6
Q

What is the middle layer the urogenital triangle?

A
  1. deep transverse perineal (continence)

2. sphincter urethrae

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7
Q

What is the deepest layer of the pelvic floor m’s (known as the pelvic diaphragm?

A
  1. Levator ani – anterior portion: Pubococcygeus (largest of levator ani), Puborectalis (most inferior)
  2. Levator ani – posterior portion; iliococcygeus
  3. Coccygeous
  4. Obturator Internus
  5. Piriformis
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8
Q

What nerve supply levels innervate levator ani?

A

S3-5

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9
Q

What are the functions of the pelvic floor?

A
  1. Supportive: “hammock” – supports organs
  2. Sphincteric:Maintains continence
  3. Sexual: Can have no sexual pleasure OR can have sexual pain
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10
Q

What are the actions of the sympathetic NS on the bladder and sphincter m’s?

A

Stores:
1. bladder (detrussor) relaxes
2. sphincter contracts
T11-12

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11
Q

What are the actions of the parasympathetic NS on the bladder and sphincter m’s?

A

Pee
1. Bladder (detrussor) contracts
2. sphincter relaxes
S2-4

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12
Q

What is included in the lower tract of the urinary system? Upper tract?

A 
Lower:
1. bladder (detrusor)
2. urethra
3. internal/external sphincters
4. trigone (smooth muscle at base of neck of bladder)
Upper:
1. Kidneys
2. Ureters
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13
Q

What is the capacity of the bladder in adults?

A

400-600 mLs (16-20 oz)

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14
Q

What are the stages of micturition?

A
  1. Storage Phase: Bladder store and empties urine
  2. Transition Phase: Sensory stretch receptors in bladder wall, voluntarily inhibit urination, still holding on
  3. Emptying Phase - parasympathetic NS; Bladder contracts until empty with simultaneous relaxation of outlet/PF; sphincters and trigone open
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15
Q

What are the loops of CNS control in micturition?

A 
Loop I – cerebrum to brainstem
Loop II – brainstem to sacral
Loop III – Bradley’s loop* sacral to sphincter
Loop IV – sacral IA spinal reflex
- PTs make an impact in loop III
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16
Q

What are considerations to take as we age?

A
  1. Decreased bladder capacity
  2. Increases Post Void Residual: causes infection (sx = confusion)
  3. Estrogen depletion = thinner bladder
  4. Increases nocturnal urine production
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17
Q 
Definition of \_\_\_\_\_\_: condition in which involuntary loss of urine is a social or hygienic problem and is objectively demonstrable
\_\_% of women
\_\_% can be cured or improved
Avg wait \_\_\_ years for help
- <50% women discuss with physician
\_\_% of pregnant women
Females \_\_\_x incidence
A
  • incontinence
  • 82%
  • 80%
  • 7-9 years
  • 80%
  • 2x
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18
Q

involuntary leakage with increased intra-abdominal pressure (exertion, sneeze, cough)

A

stress incontinence

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19
Q

loss associated with abrupt and strong desire to void (urgency) – detrusor overactivity (Over Active Bladder; OAB)

A

Urge incontinence

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20
Q

loss associated with overdistention of bladder. Results from urinary retention. Continuous or intermittent leakage of a small amount of urine (neurologic)

A

Overflow incontinence

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21
Q

incontinence due to decreased functional mobility (can’t get to the bathroom in time)

A

functional incontinence

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22
Q

overactive bladder in patient with neuro deficits (MS, CVA, SCI)

A

neurogenic

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23
Q

What are causes of UI?

A
  1. ↑age
  2. Pregnancy/childbirth
  3. Obesity/↑BMI
  4. Constipation
  5. Smoking, chronic lung dx: chronic cough puts extra pressure on bladder
  6. Neurological disorders
  7. Pelvic surgery
  8. Radiation
  9. meds
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24
Q

What are treatment options for UI?

A
  1. Surgical - Genuine stress incontinence; Intrinsic sphincter deficiency
  2. Pharmacological – research varied; UI - block effect of parasympathetic nerves, side effects (anticholinergic, side effects common); SUI – less beneficial; increase intraurethral closure forces (estrogen replacement therapy, alpha-adrenoceptor agonists, beta-adrenoanjtagonists, tricyclic, SRI, NERI)
  3. Behavioral and Exercise Management
  4. Interstim, tibial N stim, botox injections - implant at L4-5
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25
Q

The levator ani muscles are made up of what preventing of FT m fibers?

A

70%

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26
Q

What does continence rely on?

A

Interplay of:

  1. M’s
  2. connective tissue
  3. innervation
27
Q

What sympathetic n innervates the bladder?

A

hypogastric

28
Q

During the emptying phase of micturition, the PFM and urethra relax, the internal sphincter relaxes, and the detrusor muscle contracts. What pressure is greatest during the emptying phase?

A

bladder pressure

29
Q

The outlet of pressure is higher than the bladder pressure. what occurs?

A

storage of urine

30
Q

how would you grade the fxn’l stop test?

A 
0 = unable to deflect or slow
1 = partial deflection but no maintenance
2 = maintenance of a deflection
3 = ability to stop flow in a gravity resisted position (fair grade)
31
Q

What is the 1 hr pad test?

A

patient wears depends, walk 50yds, cimbing a step, coughing, heel bouncing, sit to stand (all repeated 5x) followed by running hand under running water x 1 m

32
Q

What are contraindications to an internal exam?

A
  1. Pregnancy
  2. active infection (bladder or vaginal)
  3. up to 6 weeks post-partum
  4. up to 6 weeks post-vaginal surgery
  5. severe atrophic vaginitis
  6. absence of patient agreement
  7. patients <18
33
Q

When doing documentation, to note trigger points what is the 12 o’clock position and what is the 6 o’clock position?

A

12 o’clock = pubic sypmphasis

6 o’clock = sacrum

34
Q

What is the grading scale of PFM on the modified Oxford scale

A

0 no response
1 flicker
2 weak contraction
3 Moderate contraction
4 good contraction, against some resistance
5 normal muscle contraction, strong squeeze and lift

35
Q

What is the grading scale of the brink scoring scale for PFM?

A

Squeeze pressure
1 = none ;
2 = weak squeeze, felt as a flick at various points along finger surface; not all the way around; 3 = moderate squeeze; felt all the way around finger surface;
4 = strong squeeze; full circumference of fingers compressed

Muscle contraction duration
1 = none;  
2 = less than 1 second ; 
3 = greater than 1 second; less than 3 seconds;  
4 = greater than 3 seconds

Vertical displacement
1 = none ;
2 = finger bases move anteriorly (pushed up by muscle bulk);
3 = whole length of fingers moves anteriorly ;
4 = whole fingers move anteriorly, are gripped and pulled in

36
Q

What are S and S of underachieve PFM?

A
  1. Stress or fecal incontinence
  2. Inability of pelvic floor to maintain continence
  3. Prolapse - anterior = cyctocele; posterior = rectocele; apical or uterine prolapse
37
Q

What are causes of underachieve PFM?

A
  1. Childbirth - 13% primips, 23% multips had anal incontinence after vaginal delivery; 10% 1st deliveries result in denervation of pudendal nerve
  2. Increased intrabdominal pressure
  3. Surgery
  4. aging
38
Q

What is PT management of underactive PFM?

A
  1. Joint alignment
  2. Neuromuscular re-ed
  3. Biofeedback
  4. Postural ed
  5. ADL training
  6. Strengthening
  7. E-stim
39
Q

Why is posture and breathing so important with treating UI?

A
  • respiration and posture are linked!
  • Diaphragm and abdominal muscles increase postural response with increased postural demand, while continuing to synchronize movement for respiration as well
  • multiple relationships between the trunk, pelvic floor, diaphragm and shoulder muscles for their role in postural stabilization during varying upright tasks
  • natural movement patterns between the pelvic floor muscles, the abdominals, the erector spinae and the diaphragm; all are activated with incr postural demand
  • Trunk control, breathing, continence and internal functions, are dependent on the ability of the trunk to generate, maintain and regulate pressure in the thoracic and abdominal chambers
40
Q

What are characteristics of overactive PFM?

A
  1. Traumatic etiology (pelvic fx, childbirth, surgery, abuse)
  2. Dysfunctional voiding pattern
  3. Psychogenic causes
  4. Joint asymmetries
  5. Inflammation, infection, disease
  6. Hemorrhoids, fissures, fistulas
  7. Bladder/Bowel disorders
41
Q

What are S and S of overactive PFM?

A 
Symptoms:
1. Obstructive voiding
2. Dyspareunia
3. Pelvic pain
Signs:
1. Absent voluntary PFM relaxation
2. Non-relaxing PFM
42
Q

hypertonus of deepest mm layer, pain, pressure, ache in vagina or rectum, caused by previous pelvic surgery, strenuous physical activity, childbirth trauma, lumbar disk surgery, pelvic infection, sexual injury. Severe sharp, knife-like, burning, aching pain (sitting on a knife). Unilateral, sitting increases pain. Women > men, 4-6th decade

A

Levator ani syndrome

43
Q

pain, pressure, ache (low back, vagina, coccyx) with defecation, constipation common, hypertonus PF muscles, ? Etiology, GU inflammatory diseases, rectal dz, trauma/surgery. Sitting/standing >30min incre. Pain; stress/tension, physical activity, intercourse, supine (worse at noc)

A

tension myalgia

44
Q

sharp, fleeting rectal pain lasting 20-30 sec to several hours. Mostly at noc, straining or with intercourse. Men > women, spasm of pubococcygeus, smooth mm, internal or external sphincter.

A

proctalgia fugax

45
Q

pain of coccyx, supragluteal & post. Thigh region. Termed by Thiele in 1937 (thiele massage). Spasm of piriformis, levator ani, coccygeus

A

Coccygodynia

46
Q

painful intercourse absent of dz. Initial penetration (adhesions or superficial skin problem) Deeper penetration (muscular problem)

A

Dyspareunia

47
Q

inability to penetrate vagina. Hypertonus of superficial and deep mm. Protective response to atrophic vaginitis (lack of lubrication), fistula(hole between bladder and ant. Vaginal wall

A

vaginismus

48
Q

pain in rectum or anus. Restricts opening of anus. Casues by fissures, hemmorrhoids, trauma

A

anismus

49
Q

ulcerations of inner bladder. Bladder and abdominal pain. Dg with scope. Bland diet

A

interstitial cystitis

50
Q

persitent unexplained pain in low abdominal and pelvic tissues without evidence of active dz. Burning, stabbing, cramping, abdominal tenderness and trigger points. Duration of 6 months or longer. Decreased functional level. 2nd most common compoaint in gyn practice

A

Chronic pelvic pain

51
Q

urethral pain, burning, sensitivity (99% go away after catheter removed). Stricture of tube by mm/sphincters. Urinary frequency, urgency, hesitancy. Sexual irriation, pelvic fx, complication of bladder suspension. Pubic symphysis hypermobility (shuffle when they walk)

A

urethral syndrome

52
Q

general term used for burning, stinging, rawness, irritation of vulva

A

vulvadynia

53
Q

pain at the vestibule inside labia minora with diffuse or local erythemia. Severe pain with touch or vaginal entry (tampon, intercourse). Rx = surgery, tryicyclic antidepressants, calcium citrate, low oxcilate diet

A

vestibulitis

54
Q

What is PT management of overactive PFM?

A
  1. Joint alignment
  2. Neuromuscular re-ed
  3. Relaxation
  4. Biofeedback (downtraining)
  5. ADL’s, postural training
  6. E-stim (hooked on evidence): Interferential ant. Ramus x 2, 80-150 Hz. Sweep x 15 min. Criss cross ASIS to distal gluteal; Glaser protocol – semi reclined. Knees apart, heels together. Squeeze pf, heels together, squeeze gluts. 10 sec on/10 off do for 20 minutes
  7. Soft tissue mob
  8. Visceral mob
  9. Trigger point therapy
  10. S/CS
  11. Behavioral training
  12. US
55
Q

What are biofeedback protocol components?

A
  1. Baseline – looking for resting tone; if someone is hypertonic and can’t relax
  2. Peak – squeeze as hard as they can; should be able to see they can disassociate the PFM from the other muscles (glutes, abdominals, etc)
  3. Endurance - hold for 10s; looking for isolated PFM without use of other muscles
  4. Recruitment patterns – see if they can contract both m groups in different patterns to check their control
  5. Positional difference – sitting, laying, cough, maybe jump; based on when they leak urine
56
Q

What are biofeedback findings for underactive PFM?

A

Poor awareness, dec. peak/net, difficulty initiating/maintaining, incr. fatigue, substitution patterns

57
Q

What are biofeedback findings for overactive PFM?

A

Elevated baseline at rest, poor awareness, instability

58
Q

What are biofeedback findings for incoordination of PFM?

A

Poor awareness of contraction, incr PF activity with Val Salva, decr. PF activity with cough, variable rise and fall time

59
Q

What Hz would you use for N< re-ed (strengthening)? detrusor inhibition?

A
  1. Neuromuscular re-ed 35-50Hz

2. Detrusor inhibition 5-10Hz

60
Q

What percentage of pts are unable to perform proper PFM contraction with verbal instruction alone?

A

40%

61
Q

What type of incontinece treatment is used for patients with poor cognition?

A

habit (timed) voiding

- caregivers are being trained

62
Q

About how long does bladder training take to have success?

A

6-12 weeks

  • looking for pt to have 50-90% success and feeling confident
  • done with bladder diary and increases or decreases in intervals btwn voiding
63
Q

What are outcome measures used in women’s health?

A
  1. Incontinence: UDI-6, urge UDI, Kings Health questionnaire, incontinence severity index, ICIQ-SF
  2. Pelvic Pain: Marinoff Sexual pain Rating, Oswestry scale
  3. Pad tests, urodynamic testing
  4. Patient reports, patient satisfaction
  5. G Codes

Ortho (10 decks)

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