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Pelvic Floor (All Lectures) Flashcards

1
Q

Roles of the Pelvic Floor

4:

A
  1. Support
  2. Sphincteric
  3. Sexual
  4. Stabilization
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2
Q

For Muscle Layers of the Pelvic Floor….

Know the Following!!!!

A
  • Layers 1-3
  • Functions of ea. layer
  • What mm’s are included
  • Diff’s in muscles bw men and women
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3
Q

Muscle Layers of the Pelvic Floor

Vaginal: 3

A
  • Layer 1→ Superficial Perineal
  • Layer 2→ Urogenital Diaphragm
  • Layer 3→ Pelvic Diaphragm
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4
Q

Muscle Layers of the Pelvic Floor

Male Muscle Differences: 3 Layers still

A
  • Layer 1→ Superficial Perineal
  • Layer 2→ Urogenital Triangle (same job, same orientation as Female)
  • Layer 3→ Pelvic Diaphragm
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5
Q

Pelvic Floor Muscles: Name Them!

Layer 1: Superficial Perineal M vs F

A
  1. Ischiocavernosus
  2. Bulbocavernosus (erectile tissue)
  3. Superficial perineal (aka Transverse Perineal mm’s)
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6
Q

Pelvic Floor Muscles: Name Them!

Layer 2: Urogenital Diaphragm/Triangle

A
  1. Deep transverse perineal
  2. Sphincter urethrovaginalis
  3. Compressor urethra
  4. External Urethra
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7
Q

Pelvic Floor Muscles: Name Them!

Layer 3: Pelvic Diaphragm (DEEPEST LAYER)

A
  1. Levator Ani Group
    1. Iliococcygeus
    2. Pubococcygeus
    3. Puborectalis
  2. Coccygeus
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8
Q

Know these Pelvic Floor Muscles M vs F and be able to IDENTIFY THEM!

A

see pics

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9
Q

KNOW THIS CHART

(broken down in further slides)

A

see chart!

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10
Q

Muscles Layers of Pelvic Floor

Superf—–→ Deep

A
  1. Superficial Perineal
  2. Urogenital Diaphragm/Triangle
  3. Pelvic Diaphragm (deepest)
    1. Think Levator Ani group
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11
Q

Muscle Layer: Superficial Perineal

Function & MM’s

A
  • Function:
    • Sexual function, Pelvic Floor support
  • MM’s
    • Ischiocavernosus, Bulbocavernosus, Superficial Perineal
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12
Q

Muscle Layer: Urogenital Diaphragm/Triangle

Function & MM’s

A
  • Function:
    • Closes urethral and vaginal openings
    • Assists in maintaining erections
  • MM’s
    • Deep Transverse Perineal, Sphincter Urethrovaginalis, Compressor Urethra, External Urethra
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13
Q

Muscle Layer: Pelvic Diaphragm (DEEPEST*)

Function & MM’s

A
  • Function:
    • Supports organs, pelvis
    • Stabilizes trunk w/ UE, LE motions
  • MM’s
    • Levator Ani group (iliococcygeus, pubococcygeus, puborectalis) *KNOW THESE!!!
    • Coccygeus
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14
Q

Male Pelvic Floor MM Differences

Layer 2 (Urogenital Diaphragm/Triangle) differs how???

A

Same Job, Same Orientation….BUT!

*Layer 2 differs in anatomical layout, the set-up is different

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15
Q

The DEEPEST pelvic floor layer, ______________, is comprised of 3 muscles within the ______________ group…..what are they and pics??? ?

A
  • Deepest Layer→ Pelvic Diaphragm
  • 3 mm’s within the Levator Ani group
    1. Iliococcygeus
    2. Pubococcygeus
    3. Puborectalis

***REMEMBER→ “Sling that holds UP the anus” Levator (lift) Ani (anus)

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16
Q

Pelvis→ complex structure containing…..

A

Pelvic viscera, Urinary/GI tract, Support and Suspensory ligs, Fascial connections, Skeletal and striated mm’s

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17
Q

Structures of Bony Pelvis

4 specific articulations

A
  • R &L SI joints
  • Sacrococcygeal symphysis
  • Pubic symphysis
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18
Q

Greater & Lesser Pelvis

A
  • Greater pelvis
    • Support portion
    • Supports lower abdom viscera
  • Lesser pelvis
    • Inferior portion
    • Contains pelvic cavity and pelvic viscera
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19
Q

Pelvic INlet

Describe + Pics

A
  • Boundary bw greater & lesser pelvis
  • Pelvic brim is most superior border
  • Determines size and shape of birth canal
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20
Q

Pelvic OUTlet

Function + Pics

A
  • End of lesser pelvis
  • Inferior portion
  • Coccyx, sacrum move during childbirth to widen pelvic OUTlet
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21
Q

Male Perineum

Urogenital, Anal Triangles

A

see pics

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22
Q

Female Perineum is a passage to _______, ________, ________ systems

A

Reproductive tract; Urinary; GI Systems

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23
Q

A healthy bladder should…..

A

STRETCH!!!

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24
Q

What is Continence and What does it Require?

A

Voluntary control of bladder and bowel

  • Requires:
    • intact NS, adequate PFM contraction strength, quality, timing
    • bladder must expand to contract→ should stretch!**
    • full sensory awareness of bladder filling
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25
Know these anatomical structures for **Bladder Anatomy**
* Vesical * Detrusor * Trigone * 2 Ureters * Urethra
26
Bladder Anatomy: ## Footnote **Vesical**
Actual bladder
27
Bladder Anatomy: ## Footnote **Detrusor**
Bladder muscle
28
Bladder Anatomy: ## Footnote **Trigone + functions**
Posterior to bladder wall * **Sensitive to _stretch_** * **Can create _urgency_**
29
Bladder Anatomy: ## Footnote **2 Ureters and what do they do?**
Deposit into **superior bladder wall**
30
Bladder Anatomy: ## Footnote **Urethra is where?**
@ the **distal bladder**
31
Urethral Sphincters (2):
1. **Internal** urethral sphincter 2. **External** urethral sphincter
32
**Internal** Urethral Sphincter
* Base of bladder neck * **Autonomic, _smooth_ (internal) _muscle_ → INvoluntary**
33
**External** Urethral Sphincter
* **Inferior to** bladder neck and internal urethral sphincter * **Somatic, _skeletal_ (EXternal) _muscle_→ VOLUNTARY**
34
INTERNAL urethral sphincter muscle
Smooth muscle→ INvoluntary
35
EXTERNAL urethral sphincter muscle
Skeletal mm→ VOLUNTARY
36
Pelvic floor muscle role in continence→ **IMPORTANT!!!** In general, **PF ________ w/ _______ of urine**
PF **contracts** w/ **storage of urine**
37
Pelvic floor muscle role in continence→ **IMPORTANT!!!** In general, **PF _________ when _______ urine**
PF **relaxes** when **empties urine**
38
PF **contracts** w/ **storage** of urine ## Footnote **This is during _what stage of breathing?_**
INHALE → elevates
39
PF **relaxes** when **empties** urine ## Footnote **During what stage of breathing?**
During EXHALE → descends
40
What happens when PF contracts w/ storage of urine?
Bladder gets **heavier** and **PF holds it up!!!**
41
If PFM is **weak….** ## Footnote **what happens as a result?**
Pee more/clench ## Footnote **Bc PFM's are weak and cannot hold up the bladder!!!** **\*as a result of this, pts may _reduce fluid intake_==\> BAD!!!**
42
Good intervention for weak PFM's
Incremental lowering and lifting of PFMs \*Ecc. control
43
PFM Dysfunction picture
see pics
44
NS Role in PF ## Footnote **Parasympathetic is what plexus?**
Pelvic plexus * S2-S4 * M & S innervation to bladder * Detrusor contraction + bladder **emptying** * **Cholinergic receptors in bladder** **NOTE: these are medication targets!!!**
45
NS Role in PF ## Footnote **Sympathetic** **What plexus?**
Hypogastric Plexus * T10-L2 * Detrusor relaxation for **filling and storage** * **Beta adrenergic receptors in bladder** **NOTE: these are targets for medications!**
46
Normal Urinary Tract Function ## Footnote **Pushing/Straining is….**
UNNECESSARY!!!
47
Normal Urinary Tract Function ## Footnote **Post Residual Void (PRV) ==\>**
50ml OR LESS \***what's left after pee**
48
Normal Urinary Tract Function ## Footnote **When you void, it can be ____ or _____ than total bladder volume (???)**
Half OR Greater than total bladder volume ~300ml ***Bladder can hold more than 2 cups of liquid*****\*\*\***
49
Proper Voiding Habits
* Leaking is NOT a sign of aging or having kids * **5-8 voids per 24 hr→ even if drinking proper amt H2O\*** * Every 2-4hr intervals * 0-1 voids after bedtiem * **_Should_ be able to hold 2hrs**
50
Dysfunctional Voiding ## Footnote **BAD HABITS**
* “Just in case” pee * Semi squat/hovering over toilet * Dehydration/too many viscous drinks * Straining to empty * Fear of using public toilets * Post-partum habits of freq voiding
51
Types of Urinary Incontinence 3:
1. Urge 2. Stress **(most common)\*\*\*** 3. Mixed
52
Types of Urinary Incontinence: **Urge** ## Footnote **Definition, Causes, Interventions**
Strong desire to void **("urge")** w/ INvoluntary loss of urine BEFORE or AFTER the urge * **Cause:** * Detrusor instability * **Interventions** * Diaphragmatic breathing, PFMC exercises * Distraction, meditation
53
Types of Urinary Incontinence: **Stress (MOST COMMON\*)** ## Footnote **Definition, Causes, Interventions** **\*Think “stresses” PF**
INvoluntary loss of urine **during physical exertion (cough, lifting, jumping, valsalve)** * **Causes:** * Sphincter deficiency, weak or overactive PF * **Interventions:** * PFMC exercises to **relax/contract properly** * Diaphragmatic breathing
54
Types of UI: **Mixed** ## Footnote **Definition, Causes, Interventions**
Combo of urge and stress sx's * **Interventions:** * **Treat _Urge first!!!_….then SUI**
55
Urge incontinence ## Footnote **Triggers/Key Question**
* **Triggers:** * Cold, running water, key in door/waking up in AM * **Question:** Do you leak urine on the way to the toilet or with a strong urge to go? **NOTE:** May or may NOT be pelvic floor problem
56
Stress Incontinence ## Footnote **Key Questions**
* **Key Questions:** Do you lose urine when you laugh/cough/sneeze/exercise?
57
Mixed Incontinence ## Footnote **Rule of Thumb**
* **Treat Urge and Frequency FIRST!!!** * THEN treat stress incont. sx's
58
Incontinence in **Males** ## Footnote **Urinary freq or retention** **Characteristics?**
* Linked to **prostate issues** * **HIGH PFM tone** * Prior sx * **Coord. issues of PFM** **Bottom Line:** Make sure prostate has been checked or if pt has been eval'd by urologist
59
Pharma in Incontinence--- ON BOARDS!!! IMPORTANT!!! ## Footnote **Types:**
1. **Anticholinergics \*\*\*** 2. Mirabegron 3. Imipramine 4. Duloxetine 5. Estrogen (**NOT best case scenario)** 6. OnabotulinumtoxinA (Botox)
60
Pharma in Incontinence ## Footnote **Anticholinergics** **KNOW THIS!!!**
* **BLOCK** **parasympathetic system and hence, _acetylcholine_** * ACH sends signals that trigger **detrusor contractions** (you know this!!!)
61
Pharma in Incontinence ## Footnote **Anticholinergics Mechanism of Action:** **3:**
1. **Inhibition** of bladder spasms 2. **Increase** bladder capacity 3. **Delay** initial urge to void Types: Oxybutynin (Ditropan XL), Tolterodine (Detrol), etc..
62
Anticholinergics SE's
**Dry mouth,** blurred vision, diarrhea, **Constipation,** drowsy, tachycardia
63
Anticholinergics are the MOST COMMON
MOST COMMON FRONTLINE!!!!!
64
Pharma in Incont. ## Footnote **Mirabegron (Myrbetriq)**
Relaxes detrusor to **inc amt of urine in bladder\*** INC amt you are able to urinate @ one time to empty bladder
65
Pharma in Incont. ## Footnote **Imipramine**
**Tricyclic antidepressant** Detrusor relaxation, cause **smooth mm** @ bladder neck to **contract** Treats **mixed incont.**
66
Pharma in Incont. ## Footnote **Duloxetine**
Serotonin and NE reuptake **inhibitor** Urethral sphincter **relax** Helpful for **urinary incont. and depression**
67
Pharma in Incont. ## Footnote **Estrogen** **\*NOTE: NOT best case scenario**
LOW dose topical estrogen (cream), rejuvenate deteriorating support tissues in vagina and urinary tract??? **DEC sx's thru estrogen receptors in the urethra and PFM**
68
Pharma in Incont. ## Footnote **OnabotulinumtoxinA (Botox)**
BLOCKS actions of ACh and paralyzes detrusor ## Footnote **Lasts several months (peaks 2wks)**
69
Prostate Patho's to know: ## Footnote **3:**
1. Prostat**itis** 2. Benign Prostatic Hyperplasia **(BPH)- _enlarged_ prostate** 3. Prostate Cx
70
Prostate gland function
Produce elements to **keep sperm healthy and alive**
71
What is the **most common cause** of **Prostatitis?**
BACTERIA 1.Acute 2. Chronic
72
ACUTE **bacterial** prostatitis
* **Bacteria** finds its way into the prostate from **kidneys, bladder, etc.**
73
CHRONIC **bacterial** prostatitis
* **_Mild_ bacteria** infx **lingers several mos** * **\*\*Post UTI OR _acute_ bacterial prostatitis**
74
Out of all the **Prostate pathologies……** ## Footnote **When you see _PAIN_….. think what???** **IMPORTANT!!!!!!!!**
PROSTATITIS!!!!!! ## Footnote **NOTE: Specific in _MEN_ related to _Pelvic Floor_\*\*\*\*\***
75
Sx's of Prostatitis
* **PAIN _anywhere in area\*_** * WEAK stream of urine * Diff RELEASING a stream of urine * **PAIN w/ urination\*** * “Heavy” scrotum feeling * **PAIN post-ejaculation**
76
BPH aka
Enlarged prostate
77
**Benign** Prostatic **Hyperplasia** Broken down…
* **Benign→** NOT cancerous * **Hyperplasia→** OVERgrowth of cells
78
What can **cause** BPH??
* **Hormones** * AGE causes **Dec in _testosterone_, Inc in _estrogen_** * **Aging** * Growth spurt of prostate **_again_ in middle age** * **Other** * Diet, exercise, lvl of sexual act., race, exposure to toxins, gen health
79
BPH is NOT
Cx
80
Sx's of BPH ## Footnote **What is NOT on list?**
PAIN!!! ## Footnote **So.. if you see _pain_, you know its NOT BPH !!**
81
Sx's of BPH
* **Enlarged prostate _restricts_ normal urine flow** * Frequency * Diff releasing a stream of urine * DEC in stream * WEAK flow * Urinary _retention_
82
Sx's of BPH ## Footnote **Things you _need to know_!**
* **_PAIN_ is NOT on list\*\*\*\*** * **\*\*Cx vs. BPH** * _Biopsy_ will show Cx, therefore we know its NOT BPH * **Sx's are _similar_ SO… people will wait too long to do anything or have it examined thinking its BPH**
83
PSA Density Test ## Footnote **Normal ==== ?**
4-10 ng/mL
84
Prostate Density Test
**Normal= 4-10 ng/mL** * Determines if **elevated PSA is _cancer_ or _benign_** * \*\*70-80% of cases w/ elevated PSA→ **biopsy shows NO EVIDENCE OF Cx**
85
Digital Rectal Exam
Palpating for **nodules/size**
86
Medical Mgmt of BPH ## Footnote **Methods to do so:**
* Medication * Prevention * Monitoring * Sx * Other
87
Medical Mgmt of BPH ## Footnote **Medication**
* **5 alpha-reductase inhibitors→** Stops _enlargement_ * **Alpha 1-adrenergic blockers→** Relaxes **smooth mm of prostate and bladder neck** * **Propecia/proscar→** blocks DHT? (she had an issue w/ this one in lecture so I wouldn't memorize this one, just recognize its on list\*\*\*)
88
Medical Mgmt of BPH ## Footnote **Prevention**
* **Diet** * Anti-oxidants, LOW Fat * **Vitamins** * Anti-inflammatory\*\*\*
89
Medical Mgmt of BPH ## Footnote **Monitoring**
IF blockage NOT severe
90
Medical Mgmt of BPH **Surgery**
* **Blockage IS SEVERE ENOUGH where bladder is NOT FULLY EMPTYING** * TURP (GOLD STANDARD\*\*\*) * Prostatectomy
91
Medical Mgmt of BPH ## Footnote **Other Tx's**
* Microwave, laser, stent placement
92
GOLD STANDARD PROCEDURE FOR BPH MGMT
TURP
93
TURP Procedure ## Footnote **\*BPH**
* **GOLD STANDARD PROCEDURE** * **T**rans**U**rethral **R**esection of the **P**rostate * Gen anesthesia, OP basis * Catheter 1-3d * **Full recovery in _3 weeks_** * **Retrograde ejaculation** due to **damage of bladder neck sphincter is a _RISK_!**
94
Prostate Cx ## Footnote **Can start as what ?**
Can start as a **tumor on prostate** Can **enlarge to block urethra**
95
Prostate Cx ## Footnote **Causes/Dx**
**NO _known_ causes** * **Diagnosis** * Digital rectal exam * PSA\*\*\* (remember #'s will be elevated with BOTH BPH and prostate cx) * Transrectal US * Biopsy\*\*
96
Medical Mgmt: **Prostate Cx** ## Footnote **Methods:**
* Radiation * Hormone Therapy * Cryotherapy (outdated, painful) * Radical Prostatectomy * Laparoscopic Radical Prostatectomy
97
Medical Mgmt: **Prostate Cx** ## Footnote **Radiation**
External beam Seed implants
98
Medical Mgmt: **Prostate Cx** ## Footnote **Radical Prostatectomy**
Suprapubic/perineal incision
99
Medical Mgmt: **Prostate Cx** ## Footnote **Laparoscopic Radical Prostatectomy**
Robotic
100
Prostate Cx: **Radical Prostatectomy**
* Resection of **prostate, ligaments, urethra** * Urethra **repaired and reconstructed** * Urethra can **narrow after healing**
101
Prostate Cx: **Laparoscopic Radical Prostatectomy**
* Robotic arm * SAME **resection and anastamosis (**collateral blood supply)
102
Post-Op Considerations: **Prostatectomy** ## Footnote **ALL:**
* Catheter 5-6d * **Weak** or **absent** urge * **Continual leakage←→ leakage only w/ _mvmt_** * **\*\*Can see a PT 6wks post-op** * PSA rechecked * **Erectile Dysfunction?** * **Post-Prostatectomy Incontinence (PPI)**
103
Post-Op Considerations: **Prostatectomy** ## Footnote **Can see a PT when????**
6 WEEKS POST-OP\*\*\*\*\*\*
104
Post-Op Considerations: **Prostatectomy** ## Footnote **Erectile Dysf???**
IF had it **pre-operatively,** MAY be present post-op \*depends on Sx and **fibrosis of tissue**
105
Post-Op Considerations: **Prostatectomy** ## Footnote **Post-Prostatectomy Incontinence (PPI)**
1.5-87% ## Footnote **Damage to sphincter can cause _incont._**
106
REMEMBER….. ## Footnote **DO NOT PANIC IF _PSA ELEVATED_!!!**
MAY be BPH\*\*\*\*
107
PT Interventions for **Prostatectomy**
* **SEE THEM _BEFORE_ SURGERY!!!\*\*\*** * NO **straining for BM** and **lifting: Breath work** * Abdom wall mobilization * Bladder re-training * Biofeedback and strengthening * **Coord. of pelvic floor WITH core mm's\*\*\***
108
PT interventions for **Prostatectomy** ## Footnote **When should WE see them?**
BEFORE SURGERY!!! **Then can see PT _6 weeks Post-Op_\*\*\***
109
Examination of Pelvic Floor ## Footnote **Key Points\***
* Professional responsibility * **Privacy & _Consent_\*** * Communication * Education * **Internal exam? Why?** * Decipher if mm's are actually **contracting, relaxing, or bearing down→** Specialized training\*\*\*
110
Pelvic Floor Exam ## Footnote **Key components\***
* Spine/hip evals * Functional mvmt screen (FMS) * EXT mm palpation * Perineum observ + sensory testing * INT mm palpation * Rectal and/or vaginal
111
TRAINING the Pelvic Floor\*\*\* ## Footnote **IMPORTANT!!!!** **Goals/objectives**
* **Goal:** Move pt in an **active-dynamic way** * NO isometric stability * Use PFMC during **functional acts→** squat, lifting, exercise * **\*INC _awareness_ of PF w/in pt** * “Clenching” * ***Once pt is _aware_ of PF, it is MUCH EASIER to train\*\****
112
Pelvic Floor Dysfunctions ## Footnote **HypERtonic, discoord. and weak PF mm's can contribute to:**
* **Elimination deficits** of **GI system** * **Prolapse** and **pelvic organ descent** * Chronic **pelvic pain** * Bladder disorders * Sexual dysf, **pain (dyspareunia)**
113
Training the PF ## Footnote **Look @ the PF like a \_\_\_\_\_\_\_\_\_**
CANNISTER \*\*\*
114
Training the PF ## Footnote **Goal and what does it do?**
Goal: **Move pt in an active-dynamic way** **\***Promotes **flexibility and function,** NOT _tension_
115
Training the PF ## Footnote **_Treat_ the PF as an _______ issue**
Orthopedic \*\*\*\*
116
Training the PF ## Footnote **Look @ PF like a \_\_\_\_\_\_\_** **And what is this made up of?**
CANNISTER!!! ## Footnote **Diaphragm, PFM, abdominals and multifidi**
117
PF (Cannister) **components**
Diaphragm PFM Abdominals and Multifidi
118
Training the PF ## Footnote **INC _awareness_ where??**
Awareness of the PF !!! * **NOTE:** * **No mvmt, laziness, MSK prob bw hip/shoulder→ SCREEN “CANNISTER” !!!**
119
Other pelvic muscles to include in PF examination
* Piriformis & Obturator Internus * **Diaphragm, TA** * **Coccyx: Important muscle attachment** * **Insertion site for PF mms'** * when PF mm's **contract→** coccyx pulls **_FORWARD_**

Medcon Rehab IV (18 decks)

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