Women's Health- Pelvic Floor Flashcards
What are the four primary layers of the pelvic floor muscles (PFM’s)? Superficial to deep
ASP2 or A Sweet Potato Pie
- Anal sphincter (continence)
- Superficial genital (sexual functioning)
- Perineal membrane (continence)
- Pelvic diaphragm (continence and pelvic support)
Anal Sphincter Muscles (Most superficial muscle)- IE
- Internal anal sphincter (smooth M)
- External anal sphincter (skeletal M)
The sphincters fuse superiorly with the
- Puborectalis component of pelvic diaphragm muscle.
Function of Anal Sphincter muscles
To provide fecal continence
Neurologic innervation Anal Sphincter muscles
4th sacral N and inferior branch of the pudendal N
Superficial Genital muscles - SIB
- Superficial transverse perineal
- Ischiocavernosus
- Bulbocavernosus
Function of Superficial Genital muscles
Aid in sexual functioning of the peroneal membrane & part of the continent mechanism
Muscles of the Perineal membrane CUSp
- Compressor Urethra
- Urethrovaginal sphincter
- Sphincter Urethra
Muscles of the Pelvic Diaphragm P2ICo
4 muscles of the levator ani are:
- Puborectalis
- Pubococcygeus muscles
- Iliococcygeus
- Coccygeus
The largest skeletal muscle group in the pelvic floor
Pelvic Diaphragm or the levator ani muscles
What are the “3 S’s” of pelvic floor function?
- Support- Organ & Trunk (prevents pelvic floor from prolapsing
- Sphincter
- Sexual
Pelvic Floor Function- Organ Support
- The PFMs provide support to the pelvic organs.
- Normal pelvic organ support is achieved by ligamentous support from above, PFMs functions from below and the structural geometry achieved by normal function of both.
- Recovery of organ support requires attention to restoring PFM functions (i.e. PFM rehabilitation) firstly and in some cases, restoring ligament support (surgery).
- Women with pelvic organ prolapse more often have deficits in the levator ani and generate less vaginal closure force than women with good organ support.
- At rest, the PFMs maintain a minimal resting tone. The forces of gravity and increased intr-abdominal pressure. (laugh, cough, sneeze, vomit, lift, strain) encourage prolapse or protrusion of the pelvic organs.
- Strong PFMs help to support the organs against increased intra=abdominal pressure and enhance normal functioning.
- The supportive funtion is primarily performed by the tonic, slow twitch muscle fibers.
Pelvic floor function- Trunk Support
- PFM and transverse abdominis muscles have been shown to co-contract.
- This co-contraction along with contraction of the deep multifidus muscles appears to enhance trunk stability.
- In addition, the PFMs have been shown to increase muscle activation before movement as pre-contraction to assist the abdominals in stabilizing the trunk.
- Many studies have documented bladder dysfunction in assoc with LBP.
Pelvic floor function- Sphincter control
(Slow and fast twitch work together)
- Prevents involuntary loss of feces, urine and gas from the urethra and rectum
- PFMs provide closure of the urethra and rectum for continence. During normal function
- Quick closure of the orifices is provided by the phasic fast twitch fibers.
- Closure during rest (i.e. static resting tone) is provided by the slow twitch muscle fibers.
- Continence is preserved when the pressure in the urethra is higher than the pressure in the bladder.
- Loss of sphincter function may lead to incontinence.
- The medical literature commonly points out that incontinence is a symptom and not a disease.
- Based on the terminology used in this book, incontinence results from impairments, not a pathologic condition.
- Interventions should be aimed at the impairments that contributes to the syndrome of incontinence.
Pelvic floor function- Sexual function
- Increases sexual appreciation and maintains erection)- the vagina has very few sensory nerve fiber.
- The PFMs provides proprioceptive sensation that contributes to sexual appreciation.
- Hypertrophied PFMs provide a smaller vagina and more friction against the penis during intercourse. Results in the stimulation of more nerve endings and provides pleasurable sensation during intercourse.
- Strong PFM contractions occur during orgasm.
- Patients with weak PFMs often cannot achieve orgasms.
- In men, the PFMs assists in achieving and mintaining an erection
From Mincer’s class
- Proprioceptive feedback
- If muscles are toned, they provide more sensory feedback
- Orgasm and erection
Treatment of patients with PFM disfunction 3s
- Will usually be treating them for sphincteric issues
- Related to support but usually main problem is incontinence
- Teach pts exercises and then promote the sexual side to make them want to make muscles better
- Strengthening muscles will help all three s’s
What is pelvic Prolapse?
- Second largest category of medical diagnosis associated with underactive PFMs.
- The cause of prolapse may be complex and is often associated with underactive PFM and prolonged increase in intra-abdominal pressure.
- The most common types of organ prolapses are Cystocele (protrusion of the bladder into the anterior vaginal vault). Uterine Prolapse (displacement of the uterus into the vaginal canal) and Rectocele (protrusion of rectum into the posterior vaginal vault)
The second largest category of medical diagnosis associated with underactive PFMs.
Pelvic Prolapse
The cause of Pelvic Organ Prolapse
May be complex and is often associated with underactive PFM and prolonged increase in intra-abdominal pressure.
Pelvic organ prolapse- organs start descending past or out of the outlet
The most common types of Pelvic organ prolapses- CURe
- Cystocele -protrusion of the bladder into the anterior vaginal vault.
- Uterine Prolapse - displacement of the uterus into the vaginal canal) and
- Rectocele -protrusion of rectum into the posterior vaginal vault)
Cystocele
Protrusion of the bladder into the anterior vaginal vault.
Uterine Prolapse
Displacement of the uterus into the vaginal canal) and
Rectocele
Protrusion of rectum into the posterior vaginal vault)
Common symptoms of Pelvic Prolapse: P2- FeD2S2
- Painful intercourse (uterine prolapse)
- Pain or pressure in the perineum that may limit functional activities in standing
- Feeling that there is something bulging in the vagina
- Difficulty defecating (i.e. rectocele)
- Difficulty urinating (i.e. cystocele)
- Sensation of sitting on a ball
- Sensation of organs :falling out”
PT treatment for Pelvic Prolapse
Pt. education on dec. intra-abdominal pressure
Lavator Ani Syndrome
- Another diagnosis that may be used universally for pts with vaginal or rectal pain.
- Pts report pain in the (La..CoST) Coccyx, Sacrum or Thigh.
- LAI- refers to spasms and trigger points in the pelvic diaphragm layer of the PFM. Pts often reports pain with defecation and increased pain with sitting. Some pts say it feels like they are “sitting on a ball” (can also be a symptom of organ prolapse)
Lavator Ani Syndrome- areas of pain - CoST
- Coccyx
- Sacrum
- Thigh.
Coccygodynia
- Pain at coccyx bone
- Pain at the coccyx is usually not related to sacrococcygeal Joint, more often it is related to trigger points of the (GOPP) Gluteus Maximus,Obturator internus, PFMs, or Piriformis.
- Pts often have sacroiliac joint mobility impairments and less frequently have sacrococcygeal joint mobility impairments.
- Coccygodynia - a common sequence of falls directly on the buttocks. Pts report pain with sit-to-stand transfers, possibly b/c of gluteal muscle contraction or sacroiliac dysfunction. These pts have pain that limits sitting.
- The most common impairments associated with Lavator ani tension myalgia and coccygodynia include altered tone of the PFMs and associated muscles; Mobility impairments of scars, connective tissues and pelvic joints; and faulty posture especially in sitting.
All pts with this diagnosis must learn to sit with their weight balanced on the ischial tuberosities and not on the tail bone. Some pts need to use a special cushion to relieve pressure on the coccyx. The most effective cushion is a seat wedge approx. 2.5in tall with a small cutout in the posterior aspect. A typical donut cushion places direct pressure on coccyx and is therefore not recommended
The most common impairments associated with Lavator ani tension myalgia and coccygodynia FAM
- Faulty posture especially in sitting.
- Altered tone of the PFMs and associated muscles
- Mobility impairments of scars, connective tissues and pelvic joints; and
What is pain at the coccyx usually related to? GOP2
- Not sacrococcygeal Joint, but more often it is related to trigger points of the:
- Gluteus Maximus,
- Obturator internus
- Piriformis.
- PFMs
- Pts often have sacroiliac joint mobility impairments and less frequently have sacrococcygeal joint mobility impairments.
Vulvodynia (everything)
- A broad diagnosis of pain in the external genitalia, perineum and vestibule.
- Can be a severe, often idiopathic condition that may or may not be assoc with PFM dysfunctions.
- Characterized as localized or generalized. It is also described as provoked (occurring with palpation or penetration) or unprovoked (pain present at all times even without contact).
- Pt reports stabbing pain in the vagina and less commonly the rectum.
- Many pts are completely unable to have vaginal penetration of any kind (e.g. intercourse, speculum eval, tampon insertion)
- Symptoms inc. with sitting and wearing tight pants.
- Cause of Vulvodynia: complex and can include overactive PFMs. Environmental irritants and reactions. Alteration in the vaginal mucosal properties and nerve inputs in the area, or a complication of pelvic surgery. Infection by bacterial or viral organisms (yeast infection are common) commonly precede the onset of vulvodynia but their relationship to the condition is not understood.
Vulvodynia is a difficult condition to treat. A multidisciplinary approach is the best. All impairments should be considered, esp mobility impairments of the pelvic and lumbar joints, mobility impairments of scars, and altered tone of the PFMs and assoc muscles. These pts need special instructions in avoiding perineal irritants and may benefit from pain reducing modalities such as TENS at the sacral nerve roots.
Cause of Vulvodynia: BASE-O
Complex and can include:
- Bacterial or viral infection (yeast infection are common) commonly precede the onset of vulvodynia but relationship to condition not understood.
- Alteration in the vaginal mucosal properties and nerve inputs in the area
- Surgical complication- to pelvic
- Environmental irritants and reactions.
- Overactive PFMs.
Treatment of Vulvodynia
- A difficult condition to treat
- A multidisciplinary approach is the best.
- All impairments should be considered, esp mobility impairments of the pelvic and lumbar joints, mobility impairments of scars, and altered tone of the PFMs and assoc muscles.
- These pts need special instructions in avoiding perineal irritants and may benefit from pain reducing modalities such as TENS at the sacral nerve roots.
Vulvodynia (specific)
- A broad diagnosis of pain in the external genitalia, perineum and vestibule.
- Can be a severe, often idiopathic condition that may or may not be assoc with PFM dysfunctions.
- It is characterized as localized or generalized.
- It is also described as provoked (occurring with palpation or penetration) or unprovoked (pain present at all times even without contact).
- Pt reports stabbing pain in the vagina and less commonly the rectum.
- Many pts are completely unable to have vaginal penetration of any kind (e.g. intercourse, speculum eval, tampon insertion) Symptoms inc. with sitting and wearing tight pants.
Vaginasmus
- A spasm of muscle around the vagina, the superficial muscle layer or pelvic diaphragm layer.
- Pts reports symptoms similar to Vulvodynia, although to a lesser degree.
- Dyspareunia (painful intercourse)is a common symptom.
- Muscle spasms may be a secondary impairment in response to a medical condition, such as atrophic vaginasms or fistula (a small opening in the skin similar to a small cut at the corner of the mouth.)
- Primary dyspareunia may occur with vaginismus as a result of fear of penetration.
Dyspareunia
Painful intercourse
Common symptom of Vaginasmus
Dyspareunia
Why does Primary dyspareunia occur with vaginismus?
it is a result of fear of penetration.
Anismus
- Spasm of the anal sphincters.
- Similar to vaginismus in that it may be a secondary impairment caused by trauma, fissure, fistula or hemorrhoid at the anal opening.
- Pts report severe pain with defecation, which often leads to constipation because pts delay defecation. Other PFMs may or may not spasm
Anismus aka
Nonrelaxing puborectalis syndrome
Symptoms of Anismus
- Pts report severe pain with defecation, which often leads to constipation because pts delay defecation.
- Other PFMs may or may not spasm
Dyspareunia
- Symptom of painful penetration and can be assoc with all of the diagnosis previously described.
- Can be divided into 2 categories:
- Pain at initial penetration- may be caused by superficial muscle spasm (vaginismus) Skin irritation (vulvodynia) or adhered, painful Episiotomy
- Pain with deep penetration- may be related to spasm of the PFMs (e.g. Lavator Ani Syndrome, tension myalgia) or organ prolapse with visceral adhesions.
The most common impairments found in vaginismus, anismus, and dyspareunia and altered tone of the PFMs and assoc muscles and mobility impairments of scars and connective tissue.
2 categories of Dyspareunia
- Pain at initial penetration- may be caused by superficial muscle spasm (vaginismus) Skin irritation (vulvodynia) or adhered, painful Episiotomy
- Pain with deep penetration- may be related to spasm of the PFMs (e.g. Lavator Ani Syndrome, tension myalgia) or organ prolapse with visceral adhesions.
What are the risk factors for underactive PFM’s? 13
US C2LA2IM2eD VaN
- Urinary incontinence is assoc, with LBP in both sexes. (78% of 200 females reporting to PT with CC of LBP & UI
- Pelvic Surgery, previous hysterectomy
- Chronic or prolonged coughing (as with pulmonary disease, smoking)
- Chronic constipation
- Long term incorrect lifting or straining with a valsalva maneuver (inc IAP with bearing down) inc. incorrect straining with exercise
- Arthritis, functional impairments, hip fx, falls
- Inc BMI, Inc waistline
- Menopause and estrogen use
- Medical comorbidities such as DM, PVD, CHF, Thyroid problems
- Decreased awareness of PFMs with disuse atrophy
- Vaginal childbirth, pregnancy
- Age- although UI increased with age it is not a sig factor after adjustment for confounding conditions. UI does occur in young women especially athletes
- Neurologic dysfunctions that may affect peripheral nerves of pelvis and many CNS diseases inc. dementia
Innervation of ALL PFM
Perineal branch of pudendal S2-S4
Muscle fibers of the pelvic diaphragm muscles (PICo)
70% Slow twitch (type 1) with 30% fast twitch (type 2)
What does underactive PFM results from?
Loss of strength and integrity of contractile tissues: dysfunction icauses weakness and sagging of the PFMs.
Common medical diagnosis often associated with underactive PFM (3) PMS
- Pelvic organ prolapse
- Mixed incontinence
- Stress incontinence
2 categories of underactive PFM
- Incontinence
- Organ Prolapse
Both can be extremely complex conditions with many assoc. Impairments and comorbidities
What is overactive PFM?
complex category related to pain and spasm of the PFMs.
Associated conditions include impairment of body structures and cannot be changed by PT
The most common condition medical diagnosis assoc with OPFMs include: (9) C2LAP- V3D
- Chronic Pelvic Pain CPP
- Coccygodynia
- Levator Ani Syndrome
- Anismus
- Pelvic floor tension myalgia
- Vulvodynia
- Vestibulitis
- Vaginismus
- Dyspareunia
Any impairment may be significant. Failure to address them will limit the pts progress
Each pt should be examined thoroughly, impairments identified, and treatment plans developed based on severity and significance of each impairment.
OPFM may result from: (3)
- Pelvic joint dysfunctions
- Hip muscle imbalance
- Abdominopelvic adhesions and scars affecting the PFM function
Pelvic floor anatomy
- Muscular and fascial hammock between the coccyx, pubis, and ischial tuberosity’s
- Innervation is generally S2-S4 and the pudendal nerve
- 70% of the muscle fibers are slow twitch and 30% of the muscle fibers are fast twitchWhy both?
- Slow twitch gives that resting tone to support organs up
- Fast twitch to hold pee when you have to go, sex, and response to quick increase in intra-abdominal pressure
- So when we do exercises with this population we need to address both of these fibers
3s- Supportive
Resting muscle tone
- Just like your erector spinae that are postural muscle
Tone Increases if IAP increases
- If you cough, pick up a box off of the floor, jump, etc.
- Your abdomen put pressure on the bladder which if it has urine in it will want to empty
Muscles work with ligamentous support to organs
- Inside of your pelvic cavity that are attached to organs
- Suspensory ligaments not musculoskeletal ligaments
- Boat at the dock page 436
- Ropes tying the boat are the suspensory ligaments
- When the water level is where it is supposed to be, the ropes work together
- Ligaments over time will adaptively lengthen
- If the pelvic floor isn’t doing it’s job, the ligaments will take over
- But, overtime, the ligaments will lengthen and then the organs will descend and put more stress on the pelvic floor
- Pelvic floor is not designed to hold a lot of weight up bc they are not big ass muscles-They are either wide and thin or strappy
- Boat at the dock page 436
- Contain extensive fascia
How long do the average male or female person go with symptoms of incontinence before they seek help?
- Males- Not very long- days (less than a week)
-
Females- Decades
- Getting better now bc it is more well known that PT’s can help with this problem
3 phases of normal micturition
-
Storage
- Transition: when you decide that you need to go
- Emptying
- Post Void
3 Phases of micturation- Storage
- Bladder fluid volume: @ 150 ml, get first sensation to pee, Detrusor muscle is quiet relaxed, Pelvic floor muscle contracts minimally to maintain resting tone
- Bladder fluid volume: 200-300 ml, Increased activation of bladder stretch receptors; increased urge. Detrusor muscle is quiet relaxed, Pelvic floor muscle contracts minimally to maintain resting tone
- Bladder fluid volume: 400-550 ml, Severe urge. Detrusor muscle is quiet relaxed, Pelvic floor muscle contracts minimally to maintain resting tone
Transition phase: between storage and emptying phase- Sensation is NA- transport to toilet, remove clothes
3 phases of micturation- Emptying Phase
- Detrusor muscle contracts (no inc. in IAP)
- Pelvic floor muscle relaxes
3 Phases of micturation- Post Void
Bladder fluid volume; 0-50 ml residual (a little bit is ok)
Detrusor muscle; quiet/ relaxed
Pelvic floor muscle: normal tone
Normal Mechanisms for Maintaining continence
-
Organ position relative to outlet position
- Fluid in your bladder is not directly over the hole that it will come out
- Uterus is not directly over the vaginal opening
- Same thing with rectum
-
Colorectal angle
- Related to organ position
- Also helps with fecal continence
- Pelvic floor muscle chokes the rectum and will help you not release the contents before it is time to go
- The smaller the angle (more acute/sharper), the more likely you are to be continent
- Pelvic floor muscles are built with resting tone
- Increased tone in response to increased intra-abdominal pressure (normal reflex)
- Proximal urethra is within the IAP pressure zone
- When they contract, they will squeeze the urethra closed
- If the bladder is in it’s normal spot, when the IAP increases, it will squeeze on the bladder but will also squeeze the proximal urethra closed
- Both autonomic and voluntary control of phincters
- Reflex inhibition of detrusor in response to PF contraction
- When the detrusor is relxed and filling, the pelvic floor is contracting
- The fuller the bladder gets the more the pelvic floor will adapt
- Compliance/relaxation of detrusor to allow filling
- Spasticity of the bladder- problem in SCI patients
- Won’t allow the bladder to fill
- Spasticity of the bladder- problem in SCI patients
- Spongy, viscoelastic urethral walls (related to estrogen levels)
How do we treat incontinence from a PT perspective?
As a muscle dysfunction
