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MSK IV > pelvic health > Flashcards

pelvic health Flashcards

1
Q

what is pelvic health

A
  • best possible functioning and management of the bladder, bowel, and reproductive organs
  • not merely the absence of disease or weakness
  • important role in complete physical, mental, social, and sexual well-being

muscles, viscera, nerves, joints, emotions, nutrition, hormones, fascia

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2
Q

innervation of the pelvic bowl

PH

A

sacral plexus
* L4/5 joint S1-4
* pudendal S2-4
coccygeal plexus
pelvic autonomic nerves
* sacral sympathetic trunks
* superior hypogastric plexus
* inferior hypogastric plexus
* pelvic splanchnic nerves

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3
Q

what percent of patients with back pain have pelvic floor pathology

PH

A

80%
displays the interconnectedness of body

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4
Q

pudendal nerve pathway

PH

A
  • S2-4 runs internal to piriformis, goes through greater sciatic foramen, comes back internal, goes external again in perineum
  • has both sensory and motor components – only peripheral nerve with atuonomic and somatic fibers

“pudendal” is latin for shame

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5
Q

vagus nerve function

PH

A

parasympathetic

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6
Q

what are the three diaphragms

PH

A

thoracic
respiratory
pelvic

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7
Q

pelvic floor muscles

PH

A

the five S’s
* sphincteric: continent, also relax
* supportive: keep organs in place
* sexual
* stabilization: force closure
* sump pump: lymphatic function

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8
Q

voluntary skeletal muscles - fast and slow

PH

A
  • 65% slow twitch fibers - connected to postural
  • 35% fast twitch fibers
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9
Q

first layer

PH

A
  • superficial transverse perineal
  • bulbospongiosus
  • ischiocavernosus
  • perineal body
  • external anal sphincter (EAS)

pudendal nerve
outer muscles have a sexual role

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10
Q

second layer

PH

A
  • urogenotial diaphragm

sphincteric, fascial

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11
Q

third layer

PH

A
  • puborectalis/pubovaginalis
  • pubococcygeus
  • iliococcygeus
  • obturator internus
  • coccygeus

hip issu <-> pelvic floor issue

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12
Q

pelvic floor dysfunction simplified

A

droopy pelvic floor “hammock”
* underactive: hypotonic, inhibited

taut pelvic floor “hammock”
* overactive: hypertonic, tense/gaurded

but not always this simple

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13
Q

risk factors for pelvic floor dysfunction

PH

A
  • surgery
  • trauma: emotional, phsyical, sexual (adverse childhood events)
  • pregnancy and childbirth
  • hormonal: menopause, endometriosis
  • aging
  • central sensitization/psychophysiological disorder - hypersensitive NS
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14
Q

multifactorial impacts on PH

PH

A
  • hormonal
  • nutritional
  • orthopedic
  • pelvic floor muscles
  • nervous system (ANS)
  • misc: MS, diabetes
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15
Q

biofeedback

PH

A
  • good for bowel dysfunction, bladder dysfunction, pelvic pain
  • what biofeedback does not tell you: no specificity or presence of muscle imbalances within PF, no neuromuscular control ability/length/functionality
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16
Q

contraindications to internal assessment

PH

A
  • lack of consent (verbal and nonverbal)
  • active infection
  • post-operative (< 6-12 weeks)
  • pediatric or patient without prior pelvic examination
  • severe vaginitis or vaginal atrophy
  • first trimester of pregnancy
  • severe pain/allodynia
  • special considerations: pregnancy, history of SA
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17
Q

urination

PH

A
  • brain: cerebral cortex, pons micturition center (coordinates sphincter and detrusor)
  • sympathetic: T12-L2, hypogastric plexus
  • parasympathetic: S2-S4, pelvic plexus
  • somatic: pudendal (S2-S4)
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18
Q

storage phase

PH

A
  • cerebral cortex: messages not time to go
  • pons micturition center: inhibited by cortex
  • hypogastric nerve T10-T12 (SNS): inhibits detrusor (bladder muscle) and stimulates the internal sphincter (to close)
  • pelvic nerve (PNS): is relatively quiet
  • pudendal nerve: stimulates external sphincter (to be quiet)
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19
Q

emptying phase

PH

A
  • cerebral cortex: good to go
  • pons micturition center: stimulates the pelvic nerve center
  • hypogastric nerve (SNS): becomes quiet
  • pelvic nerve (PNS): stimulates destrusor contraction (ACh)
  • pudendal nerve: relaxes external sphincter
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20
Q

normal bladder function

PH

A
  • frequency: 2-4 hours depending on fluid intake, 5-8x in 24 hours, 0-1 times per night
  • quality: no pushing/uninterrupted, normal capacity 500-650 cc, no hesitation, no pain with storage or voiding
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21
Q

abnormal bladder function

PH

A
  • hesitation
  • staccato peeing
  • post void dribble
  • uregency out of the ordinary - difficulty delaying urge
  • discomfort or pain during storage or emptying phase
  • leakage (common but not normal)
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22
Q

bladder habits to avoid

PH

A
  • hovering
  • just in case peeing (JICCING)
  • power peeing - pushing
  • self dehydrating - concentrating urine can be irritating
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23
Q

bladder issue with underactive pelvic floor

PH

A
  • bladder: stress urinary incontinence, pelvic organ prolapse
  • orthopedic: lumbar, pelvic girdle, hip instability

can present with combinations of tight and relaxed muscles

24
Q

bladder issues with overactive pelvic floor/nervous system

PH

A
  • bladder: voiding dysfunction, pelvic organ prolapse, incomplete emptying, urinary urgency/frequency, urgency incontinence, dysuria, interstitial cystitis/painful bladder syndrome
  • orthopedic: low back pain, coccydynia, SI pain, hip pain
25
Q

bladder red flags

PH

A
  • haematuria
  • persistnet UTI
  • consitutional symptoms
  • poor renal function
  • saddle anaesthesia
  • recent back trauma
  • night pain
26
Q

urinary incontinence

PH

A

women
* 1 in 4 under 30
* 1 in 2 between 30-65 years old

female athletes
* 1 in 4 collegiate athletes
* 1 in 2 runners, cross fitters, skiers

males
* 1 in 10 up tot age 60
* 1 in 3 over 75 years old

second most common reason for NH admissions
UI associated with fall risk in the elderly

27
Q

urinary incontinence types

PH

A
  • stress SUI: physical stress
  • urge UUI: leakage with urgency
  • mixed: always treat UUI first
  • functional: can be continent but cannot get into bathroom on time

adult diaper sales have now passed infant sales

28
Q

overactive bladder

PH

A
  • type of urgency incontinence
  • prevalence: 3-43%
  • symptoms: sudden strong urges which may or may not lead to leakage, persistent or frequent sensation of urgency, increased urgency/frequency (>8-10x/day), nocturia (>2/night)
29
Q

common characteristics of OAB (overactive bladders)

PH

A
  • bathroom mappers
  • key in door syndrome
  • declare they were born with small bladders
  • JICCERS
  • triggers - water running, cold weather, seeing toilet, dietary
  • avoid drinking water
  • panic pee-ers
30
Q

risk factors for UUI or urgency/frequency in all genders

PH

A
  • history of abdominal or pelvic surgery
  • neurological (MS, diabetes)
  • history of UTI
  • generalized anxiety disorder (GAD)
  • clenchers
  • medications
31
Q

medical intervention for urgency incontinence/OAB

PH

A
  • anticholinergics (dementia?)
  • beta 3 agonists
  • hormonal (estradiol)
  • sacral inter stim (bladder pacemaker)
32
Q

PT interventions for urgency incontinence/urgency - frequency

PH

A
  • education: dietary irritants, bladder retraining, breathing, urge suppression, autonomic nervous system
  • mindful voiding/urge suppression: when was the last time, count seconds of voiding, calm NS (diaphragmatic breathing), brain inhibition (counting backwards)
  • voiding or bladder diary: observe patterns and habits that contribute to leakage or urgency, timed voiding
  • nutrition education is part of the professional scope of practice for PTs
33
Q

bladder irritants

PH

A
  • caffeine: coffee, teas, sodas, chocolate
  • acidic food: spicy, citric, tomato-based, vitamin C
  • alcohol (if worse, it’s an irritant; if better, calmer NS)
  • carbonated fluids
  • artificial sweeteners, colorings, flavorings
  • dairy, gluten, sugar
  • nicotine
34
Q

stress urinary incontinence

PH

A
  • characterized by the involuntary loss of urine with increased intra-abdominal pressure
  • activities that may cause SUI: coughing, laughing, sneezing, vomiting, bending, lifting, pushing, shouting
  • pressure load failure: increased abdominal pressure
35
Q

SUI female risk factors

PH

A
  • anatomical: extra sphincter, weaker
  • hormonal: decreased estrogen < muscular urethral support (first trimester of pregnancy, week before menses, menopause)
  • pregnancy and labor: high correlation with forceps/vacuum deliveries, C-section studies, pelvic organ prolapse
  • pelvic surgery
36
Q

SUI male risk factors

PH

A
  • post prostatectomy surgeries
37
Q

all gender SUI risk factors

PH

A
  • chronic constipation
  • asthma
  • allergies
  • high BMI
38
Q

the knack

PH

A
  • forced exhalation training: intra-abdominal pressure management
  • inhale
  • upon a “forced” exhalation, tighten pelvic floor and transverse abdominis
  • examples: SHHH, cough, hahaha, achoo, blow nose, yell
39
Q

when to refer to pelvic health PT

PH

A
  • complex patient with multiple comorbidities
  • patient has no clue on what the PF is doing (even after all efforts)
  • no improvement or worsening symptoms after 4-6 visits
  • symptoms change: pain, pelvic pressure
40
Q

defecation

PH

A
  • brain
  • sympathetic: hypogastric (T10-12)
  • parasympathetic/vagus: inferior hypogastric plexus, pelvic splanchnic (S2-4)
  • somatic: pudendal
41
Q

normal vs abnormal bowel function

PH

A

frequency
* normal: 3x a day to 3x a week
* abnormal: 5 or more a day, less than 3 a week

consistency: a 3 or 4

quality
* normal: minimal strain, 1-2 pieces
* abnormal: straining, holding breathing, sitting on toilet more than 15 minutes

42
Q

bowel issues with underactive pelvic floor

PH

A
  • fecal incontinence
  • flatus incontinence
  • fecal smearing
  • rectal prolapse
  • rectocele
43
Q

bowel issues with overactive pelvic floor/NS

PH

A
  • constipation (non-relaxing puborectalis)
  • rectal pain
  • anal fissures
  • bowel urgency
  • recal incontinence
  • IBS
44
Q

red flags for bowel

PH

A
  • blood in stool or black tarry stool
  • fever and abdominal pain
  • constitutional symptoms
  • saddle anesthesia
  • recent back trauma
  • recent pelvic surgery
  • night pain
  • unexplained weight loss
45
Q

constipation

PH

A
  • most common GI complaint
  • 35% NH residents on laxatives
  • $725 million spent on laxatives each year
  • women > men
  • 50% of those with constipation will have a pelvic floor dysfunction
46
Q

Rome IV criteria definition of constipation

PH

A

2 or more of the following:
* straining (25% of defecations)
* lumpy hard stools (25% of defecations, type 1-2)
* sensation of incomplete evacuation (25% of defecations)
* sensation of anorectal obstruction/blockage (25%)
* manual maneuvers to facilitate defecation (25%)
* less than 3 spontaneous defecations per week (without assistance)

47
Q

risk factors for constipation

PH

A
  • SAD - standard american diet
  • lack of activity
  • stress/anxiety/depression (vagus n)
  • medications
  • elderly
48
Q

types of constipation

PH

A
  • normal transit constipation: stool that is difficult to pass, usual culprit is poor diet
  • slow transit constipation: stool moves at a decreased rate, common culprits are medications/thyroud/neuro (MS, Parkinsons)
  • outlet constipation: stool is difficult to pass due to pelvic floor dysfunction
49
Q

medical intervention for constipation

PH

A
  • over the counter: bulk laxatives
  • prescription
  • surgery: sacral nerve stimulation, colectomy
50
Q

PT interventions for chronic constipation

PH

A
  • education: dietary, toilet ergonomics, nervous system calming
  • manual therapy: i love you massage
51
Q

patient education on nutrition

PH

A

water
* offer suggestions for patient
* guideline: 1/2 of body weight in oz
* warm water in the AM can stimulate gastrocolic reflex

fiber
* bread is often listed as a source of fiber but is not often the best
* vegetables are the best
* berry family best in the fruit
* introduce slowly – if too fast, it will make things worse
* 25-30 mg of fiber is recommended per day

exercise

52
Q

toilet ergonomics

PH

A
  • squatty potty – foot stool(s), box
  • neutral spine
  • breathing with PF relaxation
  • raised toilet seat consideration
53
Q

avoiding valsalva - proper pushing (reverse knack)

PH

A
  • neutral spine, leaning slightly forward
  • sit and relax
  • lean slightly forward, squatty potty position (knees higher than hips)
  • inhale diaphragmatic breath
  • keep jaw and face relaxed
  • J breathing, Moo breathing, Lower glottis chanting
54
Q

how many nerve endings do male and female genitalia have

PH

A
  • male is 4,000
  • female is 8,000
55
Q

risk factors for sexual dysfunction

PH

A
  • trauma history: sexual or surgical, childbirth
  • neurological history: diabetes, CVA, MS, PD
  • psychological history: D, A
  • hormonal imbalance
56
Q

treatment approach to sexual pain/dysfunction

PH

A
  • top down: neuro
  • inside out: nutrition, joy
  • bottom up: therapy

MSK IV (8 decks)

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