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Women's Health > L26: Long Term Postpartum Physiotherapy Management > Flashcards

L26: Long Term Postpartum Physiotherapy Management Flashcards

1
Q

What is stress urinary incontinence (SUI)?

A

Leakage or urine associated with increased intra-abdominal pressure in the absence of a detrusor contraction

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2
Q

What are 3 things that triggers stress urinary incontinence (SUI)?

A
  1. Cough and sneeze
  2. change direction
  3. exercise
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3
Q

What is the diagnosis for stress urinary incontience (SUI)?

A

subjective Ax, 1 hour pad weight test (standardised), bladder neck descent on RTUS, urodynamictesting.

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4
Q

What are the 4 steps of the stress continence control mechanism?

A
  1. PFM elevates and supports urethra and bladder neck (sphincter)
  2. During Increased IAP, urethra is compressed by PFM and bladder neck = no UI.
  3. PFM resists downward motion of bladder neck with increased IAP.
  4. Weakened pelvic floor (Pelvic floor not resisting) post delivery (ie. Thinned / distended / LAM injury)?
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5
Q

What does SUI look like?

A
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6
Q

PFMT program based on _____ assessment or ____ results with ____weeks minimum and “_____” before activity (ie. Lifting)

A

PERFECT; RTUS; 12; Knack

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7
Q

What is the evidence for PFMT and SUI?

A

increase hypertrophy, strength, and endurance, or PFM –there fore PFM resisting downward movement of bladder neck with increases in IAP.

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8
Q

What is a bladder neck issue?

A

If pelvic floor is strong and still having leakage

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9
Q

_____ form a cylinder while muscles of the PF and diaphragm form its base and lid.

A

TA

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10
Q

When should TA be integrated into SUI therapy?

A

Functional PFMT

Pelvic floor that can withstand IAP (eg. during squats)

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11
Q

Deep trunk muscles form a functional unit to balance changes in _____ pressure and ____ the spine.

A

intra-abdominal; stabilise

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12
Q

Scenario case: 32 year old woman with post natal SUI (6 months post delivery SVD, VE, 2nddegree tear G1P1, birth weight 3970g, 2.5 hour second stage labour.

Assessment:

  • P –1
  • E –5 seconds to fatigue
  • R –5 reps to fatigue
  • F –nil.
  • Pad weight test (12g) after 1 hour of activity
  • Vulvaldermatitis from incorrect Pads
  • No OAB, No POP 10 treatments

What should the individual progression of PFMT with SUI be in terms of treatment (7)?

A
  1. Patient Education
  2. Teach PFM contraction (Palpation, RTUS)
  3. HEP based on PERFECT scheme (5 x 5 second holds in lying) x 3 per day remember ECT (every contraction timed to fatigue)
  4. Review every fortnight to month (progress PFMT and add TA when appropriate + stability exercises.
  5. “Knack” taught to patient when fast contractions correct.
  6. Correct continence pads (TENA) for short term.
  7. Referral to GP for steriodcream to manage dermatitis.
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13
Q

What are 10 treatments for the individual progression of PFMT with SUI after 16 weeks?

A
  1. No subjective SUI / patient very happy with results
  2. Adhered to Treatment
  3. 1 hour pad weight test (normal)
  4. RTUS: 6.2 mm lift (transverse)
  5. No dermatitis noted
  6. P-4/5
  7. E-10 seconds
  8. R –10 seconds
  9. F-10 fast contractions.
  10. Continue PFMT and functional exercises for minimum 6 months and next pregnancy.
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14
Q

What is surgery for stress incontinence?

(A) TVT

(B) TVT-O urethral hypermobility

A
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15
Q

What is a pessary for SUI (ring)?

A
  • Silicon ring for prolapse of SI
  • Fold in half –> insert vaginally –> push up –> stand up, jump cough, –> if not symptoms = successful
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16
Q

When is a pessary used?

A

Silicon ring for prolapse of SI

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17
Q

What are 19 symptoms of Overactive bladder (OAB) / urge urinary incontinence (UUI)?

A
  1. Provoked or unprokoveddetrusoroveractivity
  2. Urinary urgency / incontinence
  3. Increased frequency of voiding per day (normal 4-6) with 1.5L of fluid. Commonly > 8.
  4. Low voided volumes (<100mls)
  5. Incomplete bladder emptying / post void residuals (PVR)
  6. Key in the door
  7. Running water
  8. Drinking a glass of water
  9. Poor bladder habits
  10. PVR
  11. Caffeine / alcohol stimulants in diet
  12. Stress / anxiety
  13. Endometriosis
  14. Dyspareunia
  15. Dehydration
  16. Weak PFM ?
  17. POP
  18. Post menopausal
  19. Certain medications
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18
Q

What are UUI/MUI/SUI?

A
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19
Q

What is Urgency / urge incontinence / nocturia?

A

> 60 yrs old- able to get up once in the night to go to the bathroom

< 60 yrs old- should not be getting up to go to the bathroom

20
Q

What does an overactive bladder look like?

A
21
Q

What does the management of OAB look like?

A
22
Q

What 8 treatment of OAB?

A
  1. 2-day bladder diary (see example)
  2. Bladder retraining (defer urge to void and find a distraction) based on bladder diary
  3. Reduce stimulants in diet
  4. Fluid manipulation (overhydrated / dehydrated)
  5. PFMT
  6. Hold onto PFM when urgent
  7. Don’t panic when you have urgency- Stress makes it worst (adrenaline)
  8. Anticholinergics(Vesicare, Ditropan, Oxytrolpatches) dry mouth ?
23
Q

What does pelvic organ prolapse?

A
24
Q

What are the 5 grades of pelvic organ prolapse?

A
  1. Grade 1 –asymptomatic
  2. Grade 11a –symptomatic (before introitus)
  3. Grade 11b –beyond introitus
  4. Grade 3 –large grade POP (surgical)
  5. Grade 4 –large grade POP (surgical)
25
Q

What are the 4 types of pelvic organ prolapse?

A
  1. Cystocele-Bladder
  2. Uterine –uterus / cervix
  3. Rectocele–rectum
  4. Entrocele–small bowel

POP –Q vs. stage grading vagially

26
Q

What are 10 symptoms of a pelvic organ prolapse?

A
  1. a heavy sensation or dragging in the vagina
  2. something ‘coming down’ or a lump in the vagina
  3. a lump bulging out of your vagina, which you see or feel when you are in the shower or having a bath
  4. sexual problems of pain or less sensation
  5. your bladder might not empty as it should, or your urine stream might be weak
  6. urinary tract infections might be reoccurring, or
  7. it might be hard for you to empty your bowel.
  8. lower abdominal or back ache
  9. difficulty emptying bowels (rectocele)
  10. dysfunctional voiding (stop / start stream)
27
Q

What are 7 Potential causes of pelvic organ prolapse?

A
  1. Vaginally parous women
  2. LAM injury ++
  3. High BMI
  4. Chronic cough
  5. Chronic constipation
  6. Hysterectomy?
  7. Genetics
28
Q

What are 9 treatment for POP?

A
  1. PERFECT scheme assessment ( as for SUI)
  2. Ergonomics (limit heavy lifting / increases in IAP)
  3. Reduce constipation and straining
  4. Weight reduction
  5. Pessary
  6. Prolapsesurgery (consider LAM and PFMT before)
  7. Anterior repair
  8. Posterior repair
  9. Hysterectomy +/-sacrospinouscolpoplexy
29
Q

What is the metaphor for POP?

A
30
Q

What is Levator ani muscle injury (LAM)?

A

Avulsion of puborectalis from inferior pubic ramus / os pubis in vaginally parous women.

Can be unilateral or Bilateral.

31
Q

What are 6 Intrapartum risk factors for Levator ani muscle injury (LAM)?

A
  1. Forceps (esp. high rotational)
  2. Maternal age > 40 years at first delivery
  3. Prolonged second stage labour
  4. Birth weight > 4000g 3
  5. 3rdand 4thdegree perineal tears
  6. Episiotomy ?
32
Q

What is Fecal urgency and incontinence?

A

Urgency of stool resulting in a rush to the toilet and urge faecalincontinence indicates damage to the EAS.

Passive leakage of faecesor flatus is associated with internal-sphincter damage Incontinence due to faecal impaction and overflow of faecal material is a differential diagnosis (plain x-ray) for fecal loading endo anal USS for EAS and IAS disruption.

33
Q

Obstetric injury is classified as a _____, when partial or complete rupture of the EAS occurs or ____-, when the anal mucosa and IAS are involved.

A

3rd; 4th

34
Q

Injury to the _______ during childbirth is the major cause of faecalincontinence in women.

A

anal sphincter

35
Q

What are 9 treatment for Fecal urgency and incontinence?

A
  1. Identify ‘normal’ bowel habits. Establish a regular bowel routine and make time to respond to the sensation of needing to empty the bowel.
  2. Eat a balanced diet with regular meals. Initiate a bowel action in the morning while at home.
  3. Adjust the intake of fibreto achieve a consistency of stool that can be controlled. (eg. Metamucil)
  4. Ensure a fluid intake of more than 2L a daywhen breastfeeding.
  5. Caffeine, found in coffee, tea, coke, and some chocolate is a gut stimulant and may exacerbate urgency.
  6. PFMT to increase strength, endurance, and co-ordination following pregnancy and FI.
  7. Fast Twitch PFMT.
  8. Appropriate pads for FI –decrease skin irritation.
  9. Referral to colorectal surgeon if no response to conservative management (sphincter revision).
36
Q

What is Dyspareunia?

A

any pain or soreness that occurs during sexual intercourse. ( deep pain or superficial / spasm pain)

37
Q

When can post partum / post gynaecological surgery dyspareunia occur?

A
  • Can occur following childbirth (physical or psychological) or a combination of both.
  • Secondary to scar tissue formation.
  • Poor repair following perineal trauma
  • Trauma or vaginal dryness (breastfeeding).
    • Breastfeeding = lower oestrogen levels = skin can be different (eg. dry)= can cause pain or soreness
38
Q

What are 8 treatments for dyspareunia?

A
  1. Pelvic floor assessment of increased tone (PV) and down training (relaxations)
  2. Myofasicaltrigger point therapy PFM.
  3. Vaginal dilators
  4. Endep, Lyrica, Gabapentin, Ovestincream
  5. Pudendalnerve blocks / Botox in severe cases of PFM
  6. Relaxation
  7. Return to pain free movement.
  8. Multi-disciplinary approach to treatment is very important!
39
Q

What is the dyspareunia/ vaginismus cycle?

A
40
Q

What are 6 characteristics of Gynaecological surgery?

A
  1. TVT –TVT –O (SUI)
  2. Anterior repair (cyctocele)- Repair vaginal wall –> so bladder cannot fall (if pelvic floor is weak)
  3. Posterior repair (rectocele)
  4. Uterine prolapse (hysterectomy (Stops the descent) +/-sacrospinouscolpoplexy. SSC- stitch through the old cervix –> stitch to sacrospinous ligament
  5. Urethral bulking agents (EAS / bladder neck)
  6. Total abdominal hysterectomy (TAH), laproscopicand vaginal hysterectomy.
41
Q

What is TVT and TVT-O?

A
42
Q

What is an anterior and posterior prolapse repair?

A
43
Q

What does Sacrospinous colpoplexy offer?

A

offers support to the upper vagina minimizing risk of recurrent prolapseat this site

44
Q

Buttock pain on the side that the ______ sutures have been passed occurs in 5-10% women

A

sacrospinous

45
Q

What are 3 Post gynaecological physiotherapy management?

A
  1. TVT –PFM as tolerated, bladder & bowel function
  2. Anterior / posterior repair –no PFMT for 6 weeks, then PFMT for 6 months to increase success of repair. Bladder and bowel function.
  3. Hysterectomy without repair –PFM as tolerated, bladder and bowel function.
46
Q

What are 7 bladder management?

A
  1. Urinary retention post IDC removal
  2. Fluid intake
  3. Timed voiding if decreased urge to void
  4. Bladder triggers
  5. Control surgical pain
  6. Positioning to empty bladder
  7. Double void if needed.
47
Q

What are 8 bowel management?

A
  1. Avoid constipation !
  2. Movicol, lactulose
  3. Positioning to empty bowels
  4. No straining
  5. Fluid intake
  6. Control surgical pain
  7. Medication that increases constipation (endone)
  8. Diet advice

Women's Health (7 decks)

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