WOMEN'S HEALTH & OBSTETRICS Flashcards
STUDY PAGE 3-7
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This is the interlocking ridges and grooves of the bony joint surfaces of the pelvis
Form Closure
This Fits of the wedge shaped sacrum between the ilia
Form closure
PAGE 9
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Pelvic floor muscles have 3 major fun ctions:
-Support of the pelvic organs:
bladder, urethra, prostate (males),
vagina and uterus (females),
anus, and rectum, along with the general
support of the intra-abdominal contents.
-Contribute to continence of urine and feces.
-Contribute to the sexual functions of arousal and orgasm
PAGE 11
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This is a Thin, muscular layer of tissue that forms the inferior border of the
abdomipelvic cavity
Pelvic Diaphragm
T/F The Pelvic Diaphragm is composed of a thin, cylindricalshaped sling of fascia or muscle
F, FUNNEL SHAPED
Pelvic diaphragm extends from the ________ to the ______ and from one _____ sidewall to the other
Symphysispubis
coccyx
Lateral
PAGE 13
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This is a strong, muscular membrane with triangular ligament
Urogenital Diaphragm
The urogenital diaphragm occupies the space between _______ and _____
Symphysis pubis
Ischial tuberosity
T/F The urogenital diaphragm stretches across the triangular posterior portion of the pelvic outlet
F, ANTERIOR
The urogenital diaphragm is ____and ___to the pelvic diaphragm
external and inferior
PAGE 15
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Pelvic ligaments are not actual ligaments and it is the thickening of the ________fascia
Retroperitoneal
T/F Pelvic ligaments consist primarily of blood vessels, nerves, and fatty connective tissue
T
This is the continuations of the transversalis fascia of the abdomen
Subserous fascia or endopelvic fascia
PAGE 17
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T/F Broad ligaments are thick, mesenteric-like single reflection of peritoneum
F, THIN & DOUBLE
Broad ligaments stretches from ________ to the ______
lateral pelvic sidewalls
uterus
Cardinal/Mackenrodt’s ligaments extend from the lateral aspects of ________ and the ____ to the pelvic wall
the upper part of the cervix
vagina
Uterosacral ligaments extend from the______ posteriorly to the _____
upper portion of the cervix
S3
Superficial muscles
⚬ External anal sphincter
⚬ Perineal body
⚬ Puboperineal (Transverse perinei) muscles
Deep muscles
⚬Ileococcygeus
⚬ Pubococcygeus
⚬ Coccygeus
⚬ Puborectalis
PAGE 21-23
MEMORIZE PAGE 22
T/F There are two types of anal sphincters: Internal anal/External Anal
T
This sphincter is the extension of the circular muscle layer of the rectum
Internal Anal sphincter
This sphincter is the extension of the longitudinal muscles of the rectum
External anal sphincter
T/F The external anal sphincter is not part of the levator ani muscles
F, technically part
PAGE 29
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Innervation of the pelvic floor
⚬ Pudendal nerve (S2 -S3)
⚬ Direct branch from S4
￭ Nerve to Levator Ani
T/F Pelvic floor dysfunction involves the abnormal activity or function of
the pelvic floor musculature
T
One of the largest and unaddressed issues in
women’s health care today
Genital prolapse
Urinary/Fecal incontinence
T/F If the pelvic floor is contracted, or damaged, the PFM cannot actively
support
F, is relaxed
Pelvic floor dysfunctions may lead to the following:
⚬ Urinary incontinence
⚬ Fecal incontinence
⚬ Pelvic organ prolapse
⚬ Sensory and emptying abnormalities of the lower urinary tract
⚬ Defecation dysfunction
⚬ Sexual dysfunction
⚬ Chronic pain syndromes
Boat in the Dry Dock Theory
A. Ship
B. Ropes
C. Water
- ligaments and fascia
- PFM support
- Pelvic organs
B
C
A
T/F When the PFM relaxes or is damaged, the pelvic organs must be held in
place by the ligaments and fasciae alone
T
T/F If the PFM cannot actively support the organs, over time the connective tissue will become contracted and damaged.
F, stretched and damaged
PAGE 31
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T/F Soda can theory states that the core are abdominal muscles
T
Proposed the Soda-Pop Can Model of Postural Support
Mary Massery
T/F The glottis is the bottom of the soda can.
F, top
*If you open the top of a soda pop can, it can
easily be deflated and reshaped.
The can pressure for the soda can theory is _________
intraabdominal pressure
A can that is closed creates pressure within the can, which is crucial not
only to the shape of a soda-pop canbut that imagery also relates to the
function of your core and maintaining good postural control.
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PAGE 33
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PREDISPOSING FACTORS CAUSING PELVIC FLOOR DYSFUNCTION
gender,
genetic,
neurological,
anatomical,
collagen,
muscular,
cultural, and
environmental
GGCA
INCITING FACTORS CAUSING PELVIC FLOOR DYSFUNCTION
MNC
childbirth,
nerve damage,
muscle damage,
radiation,
tissue disruption,
radical surgery
PROMOTING FACTORS CAUSING PELVIC FLOOR DYSFUNCTION
constipation,
occupation,
recreation,
obesity,
surgery,
lung disease,
smoking,
menstrual cycle,
infection,
medicine,
menopause
COR
DECOMPENSATING FACTORS CAUSING PELVIC FLOOR DYSFUNCTION
ageing, dementia, disease,
environment, medication
T/F The PFM are only responsible for gross motor movements alone
F, but ALSO work in synergy with other trunk muscles
Pelvic floor dysfunction may lead to symptoms during movement and
perceived restriction in the ability to stay physically active.
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may lead to a change in movement patterns
during physical activities , withdrawal from regular fitness activities,
and troublesome difficulties when being active
Urinary incontinence
T/F During pelvic floor dysfunction, the PFM is subject to continuous strain throughout the lifespan
T
In particular, the pelvic floor of women is subject to tremendous strain
during _____
Pregnancy and childbirth
In addition, hormonal changes may influence the pelvic floor and pelvic
organs, and a decline in muscle strength may occur due to ageing
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The PFM may need regular training to stay healthy throughout life
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A thorough examination of the ________________ is important for differential diagnosis
lumbar spine, pelvic girdle, lower limbs, and
PFM
PELVIC FLOOR EXAM
⚬ Vaginal & Anal Exam
⚬ Neurologic exam of lower sacral segments
⚬ Assessment of internal structures (gynecologic, urologic,
colorectal)
Common patient complaints include
⚬ leaking urine or stool
⚬ problems with having a bowel movement
⚬ pressure or discomfort in the pelvis
⚬ seeing or feeling a bulge protruding out of the vagina or anus
⚬ pain while urinating or during sex
⚬ incontinence
⚬ difficulty emptying the bladder or bowels completely
Other assessments of the pelvic floor:
⚬ Vaginal/anal palpation
⚬ Electromyography
⚬ Vaginal squeeze pressure measurement
⚬ Pel vic floor dynamometry
⚬ Ultrasound of the PFM and pelvic organ descent
⚬ MRI of the PFM and Pelvic floor
Outcome Measures:
⚬ Pelvic Floor Impact Questionnaire (PFIQ-7)
⚬ Australian Pelvic Floor Questionnaire
⚬ Pelvic Pain Questionnaire
PAGE 42
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This is the involuntary leakage of urine with 3 main types
Urinary Incontinence
3 main types
￭ Stress Urinary Incontinence
￭ Urge Urinary Incontinence
￭ Mixed Urinary Incontinence
Loss of urine with increased intraabdominal pressure such as coughing, laughing, sneezing, or physical exertion
Stress Urinary Incontinence
Due to deficiencies in the PFMs, urethra, bladder, and/or sphincter, it
is difficult to maintain urethral closure pressures
STRESS URINARY INCONTINENCE
ETIOLOGY OF STRESS URINARY INCONTINENCE
pregnancy,
vaginal delivery,
pelvic surgery,
pelvic organ prolapse, neurologic causes, active lifestyle, obesity, and
aging
This is the Involuntary leakage accompanied by or immediately preceded by the
sudden onset of the urge to void that cannot be deffered easily
Urge Urinary Incontinence
T/F Urge Urinary Incontinence can be caused by voluntary detrusor contraction that overcomes
the sphincter mechanism
F, Involuntary
Urge urinary incontinence Can also be caused by ________ that is due to the loss of the viscoelastic properties of the bladder
poor bladder compliance
Urge urinary incontience may neurogenic in nature __________,___,__,__, or idiopathic
SCIs, spinal stenosis,
MS, and stroke
Non neurogenic urger of urinary incontinence may be caused by ______
radiation
Occurs when the patient experiences both SUI and UUI symptoms
Mixed Urinary Incontinence
PAGE 48
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PERCENT PREVALENCE OF UI
34%
Risk Factors of Pelvic Floor Dysfunction
￭ Race, hormonal status, obesity, history of pregnancy or childbirth, chronic disease, constipation, family history
￭ Risk increase with smoking, increased BMI, and increased parity(SBP)
High-level female athletes
￭ SUI prevalence _____
41.5%
Characterized by pain, muscular tautbands, and trigger points that cause pain reffera l with pressure
Pelvic Floor Myofascial pain
PFMP can also be caused by the ff:
overuse,
dysfunctional postures,
weakness of PFMs
PFMP contributes to
dysparenuria,
painful sexual intercourse,
chronic pelvic pain
T/F PFMP may be d/t hx of birth trauma/sexual abuse
T
EPIDEMIOLOGY
⚬ 22% of women (14-79) with chronic
⚬ 70% of women with pregnancy related pelvic girdle pain
⚬ 52% of women with chronic lumbopelvic pain that began during
pregnancy
⚬ 25% of community dwelling adults
Mainstay treatment of Pelvic Floor Myosfascial Pain
Pelvic PT
*NSAIDs, antidepressants, other medications
GOALS OF RX for Pelvic Floor Myofascial Pain
￭ Restore muscle imbalances
￭ Improve function
￭ Improve posture
￭ Reduce pain
PAGE 53
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What are changes of the body during pregnancy
Increase in:
-anterior pelvic tilt
-body mass
-demands for the hip extensors, hip abductors, ankle plantar flexors, and PFMs
-ligamental laxity
-lumbar lordosis
-pelvic tilt
-Lengthening of the abdominal muscles
ABL
Pregnancy and Postpartum Pelvic Floor Dysfunction pain may arise from these areas:
-Lumbar spine
-Pelvic girdle
-Hip
-PFM
Most common cause of back and pelvic pain in pregnancy
Pelvic Girdle Pain
Pelvic Girdle Pain is experience between the _____ and _____
posterior iliac crest
gluteal fold
Etiologies of Pelvic Girdle Pain
mechanical, hormonal, inflammatory, collagen abnormalities, and neural
HIM
A hormone produced by the corpus luteum that relaxes the uterine musculature, ligaments, and joints to allow pelvic
expansion
Relaxin
- Epidemiology
⚬ PGP affects 20% of pregnant women
Risk factors for Pregnancy and Postpartum Pelvic Floor Dysfunction
￭ History of low back pain
￭ History of pelvic trauma
￭ Parity
￭ Workload
4 subgroups of PGP
⚬ Double-sided SIJ syndrome -6.3%
⚬ Pelvic girdle syndrome -6%
￭ Pain in all 3 pelvic joints
⚬ One-sided SIJ syndrome -5.5%
⚬ Symphisiolysis or pubic symphisis pain 2.3%
Treatment for Pregnancy and Postpartum Pelvic Floor Dysfunction
⚬ Individualized PT for realignment and stabilization
⚬ Pelvic floor PT
⚬ Pelvic manipulation and SIJ belts have shown to be beneficial
⚬ Bed rest, ice and acetaminophen
⚬ NSAIDs may be done after the pregnanc
Can be a source of CPP and can co-exist with all other pelvic floor
dysfunctions such as PFD and PMPS.
Pelvic Nerve Injuries
Nerves affected during pelvic nerve injuries
￭ Iliohypogastric
￭ Ilioinguinal
￭ Genitofemoral
￭ Pudendal
￭ May cause urinary incontinence and sexual dysfunction
Pudendal neuropathy
Nerves affected in Pfannenstiel or low transverse incision
Iliohypogastric and ilioinguinal
may be compressed during gynecologic surgery
Genitofemoral nerve
Commonly injured during vaginal delivery and may cause urinary inc & sex dysfunc
Pudendal nerve injury
* May also be injured d/t pelvic trauma, bicycle riding, and anal
intercourse
PELVIC NERVE INJURY TREATMENT
⚬ Pelvic PT and medications
⚬ Corticosteriods
⚬ Creams with ketamine or other pain medication
⚬ Radiofrequency ablation
⚬ Pulsed radiofrequency treatment
⚬ Neuromodulation at the sacral plexus or spinal cord
⚬ Impairment characterized by the separation of the two rectus
abdominis muscles along the linea alba
Diastesis Recti Abdominis
May be seen congenitally,
but most commonly develops during pregnancy and in the early post-pregnancy period
Increased inter rectus distance (IRD)
A widening of ____ at the level of the umbilicus is considered a
pathological diastasis of the rectus abdominis muscle
> 2.7 cm
T/F Diastesis Recti Abdominis Most commonly affects the women at the 2nd trimester
F, 3rd
Natural resolution and greatest recovery of DRAM occurs between _____
day and ___ weeks after delivery, after which time recovery plateaus
1
8
Incidences of DRAM has been reported ranging from 66% to 100%
during the third trimester of pregnancy, and up to 53% immediately
after delivery
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Diastesis Recti Abdominis may result in
-altered trunk mechanics,
-impaired pelvic stability
- changed posture
-lumbar spine and pelvis more vulnerable to injury
-herniation
PAGE 65-66
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Treatment for diastesis recti
⚬ Bracing
⚬ Facilitation, concentric activation, and stabilization of the abdominals
⚬ Pelvic floor muscle exercises
⚬ Maintenance of stability and mobility of the trunk
Incorporated during exercise which works as a harness, so that there is an adequate intra-abdominal force generated which can
protect the diastasis from worsening
Bracing
PAGE 68-69
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During pelvic exercises the Correct way of doing a PFM contraction:
Squeeze around pelvic openings and inward/cranial lift
⚬ Explain to patients the position of pelvic floor muscles
⚬ Remind patients to continue breathing and not to strain during the
exercise
⚬ Check for contraction of abdominals, hip muscles, and gluteals
⚬ May do in different positions such as supine, sitting, or standing with
standing being the most difficult
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Pelvic exercises May start with ____ seconds, then increase, ___ set of _and increase sets
2-3
1
10
Variations of Pelvic exercise
⚬ Kegel’s with heel slides
⚬ Kegel’s with toe taps
- Pelvic Exercise for Hypertonic PFMs
-Diaphragmatic breathing
-General relaxation exercises
-Happy Baby pose
Hypotonic
Hypertonic
- difficulty initiating or maintaining urination
- pelvic pressure or fullness
- bowelor urinaryleakage
- difficulty emptying your bladder
- constipation
- frequent urge to urinate, even if you just went
- decreased sensation in the vaginal canal
- painful vaginal penetration
- straining during bowel movements
- HYPER
- HYPER
- HYPO
- HYPER
- HYPER
- HYPO
- HYPO
8 HYPER - HYPER
Defined as a condition of 3 interrelated components that exist on a
continuum of severity
FEMALE ATHELETIC TRIAD
The female atheletic triad consists of:
￭ Energy deficiency
￭ Menstrual dysfunction
￭ Impaired bone health
All three components of the triad do not have to be present in an
athlete simultaneously to be affected by the condition or diagnosed
with it
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PAGE 77-78
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This is AKA low energy availability which experiments have shown this to be
the starting point of severe health implication
Energy deficiency
Four pathways of energy deficiency
-Clinical eating disorders
-Disorder eating (DE) patterns
-unintentional undereating d/t high energy
expenditure sports
-Intentional weight loss
CDII
⚬ Eumenorrhea -> amenorrhea
Menstrual Dysfunction
￭ When a girl has not started her first period by age 15
Primary amenorrhea
￭ When menstrual periods are absent for 3 months or 90 days
Secondary amenorrhea
Three different components can lead to HPG suppression:
*hypothalamic-pituitary-gonadal axis
-Disordered eating
-Intense exercise
-psycho. stress
PAGE 81
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Impaired bone health which is A systemic skeletal disease characterized by low bone density and microarchitectural deterioration of bone tissue with consequent increase in bone fragility
Osteoporosis
Formation and absorption rates of bone are affected by:
-Aging
-Calcium intake
-Vitamin D
-Estrogen levels
Medical consequences of Female Athlete Triad could reach other systems such as endocrine, gastrointestinal, renal, neuropsychiatric, musculoskeletal, and cardiovascular.
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T/F Intermittent amenorrhea or luteal deficiency leaves women infertile
since there is no follicular development, ovulation, or luteal function
F, Persistence
T/F Osteoporosis makes bones more fragile and more prone for fracture
T
TREATMENT FOR OSTEOPOROSIS
-Prevention is key
-Early recognition = early dx
-early detection and rx = optimizing bonehealth
-Clinical ED warrants a referral to a mental health practitioner and or a
sport dietician
-Regular weightbearing exercises should also be considered both as a
preventive measure or as a management option among all sports
First line of treatment is addressing the elements that cause LEA and
the restoring normal energy balance
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PAGE 85 -86
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An endocrine disorder characterized by changes in hormone levels
Polycystic ovarian syndrome
Polycystic Ovarian Syndrome is associated with increased prevalence ofserious clinical problems such
as:
Anxiety
Cardiovascular risk
Depression
Diabetes
Dyslipidemia
Hypertension
Insulin resistance
Obesity
Reproductive implications
ADH
Most common reproductive symptoms of PCOS:
-anovulatory infertility
-high production of male hormones
-irregular menstruation
-pregnancy complications
88-89
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High levels of insulin stimulate ovaries to increase ________ secretion
and have inhibitory effects on the hepatic production of _______
androgenic
sex hormone binding globulin (SHBG)
T/F Insulinresistance affects ovulation and decrease the risk of infertility
F, increase
Lifestyle modification such as diet and physical activity can reduce
insulin resistance, improve metabolism, and improve reproductive
function.
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PAGE 91
TREATMENT FOR PCOS
-Exercise
-Weight reduction =improve glucose tolerance
Women with PCOS may also present with the following:
- Lowback/Sacral Pain
- Lowerquadrantabdominal pain
Beaware that glucose intolerance and insulin resistance may affect the
patient’s abilitytoparticipateinactivities
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Medication that induce insomnia, vomiting, blurry vision, and frequent urination
Clomephene citrate
Commonly referred to as menstrual cramps
Primary dysmenorrhea
T/F Primary dysmnorrhea is defined as the pain occurring in the lower abdomen before or during the menstrual cycle, in the absence of any other pelvic pathology (e.g.,
endometriosis)
T; Prevalence rate of 20 to 90%
Systematic symptoms of primary dysmenorrhea may include:
Diarrhea
Fatigue
Fever
Headache or light-headedness
Nausea
Vomiting
Dysmenorrhea Thought to be caused by increased levels of _______ and
_________
prostaglandins
vasopressin
Treatment for dysmenorrhea
NSAIDS
Modalities (Heat therapy and TENS)
*Several studies have reported beneficial effects of exercise,
including stretching, aerobic exercise (e.g., jogging), yoga
and kegel exercises, to treat primary dysmenorrhea
⚬ Gender-affirming surgery for transgender women
VAGINOPLASTY
⚬ Gender affirming surgery for transgender men
PHALLOPLASTY
Both surgeries require reconstruction of the genitals and require
dissection through the superficial and deep pelvic floor musculature
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T/F Surgical disruption can cause problems with the urethral sphincter and
may affect bowel and continence as well
T;*SUI from vaginoplasty has been reported as 16-33%
- Pelvic floor PT has been shown to help with pelvic pain and pain-related
sexual dysfunctions and can help treat urinary incontinence - PTs can also evaluate and educate patients preoperatively for better
functional outcomes
-
PTs may assist with _____ as some are trained to use dilators
neovaginal dilation
T/F The higher prevalence of pelvic floor dysfunction (postoperatively) may be
attributed to tucking, avoidance of public restrooms, hormone
replacement surgery, and sexual assault
F; PREOPERATIVELY
EVALUATIONSINCLUDE
⚬ Postural assessment (looking at your posture);
⚬ Muscle testing;
⚬ Internal muscle and fascial palpation of the pelvic floor
muscles (seeing if the muscles inside your pelvic floor move
correctly);
⚬ EMG testing
⚬ Checking for scar and soft tissue restrictions, gait, and
movement patternS
- Goals for PT Treatment
⚬ Having fewer bathroom accidents (incontinence);
⚬ Having less pain when urinatin g or go to the bathroom
⚬ Having less pain while sitting, walking, standing, and during
sex
