Test 2: Pelvic Health Intro

Question 1

what area is defined as the pelvis and what makes up the greater and lesser portions

Answer 1

pelvis = area between trunk and lower limbs

greater pelvis = occupied by inferior abdominal organs as means of protection

lesser pelvis = skeletal framework for pelvic cavity and perineum

Question 2

what overlaps the pelvis anteriorly, posterolaterally, and inferiorly

Answer 2

anterior = inferior anterolateral abdominal wall

posterolaterally = gluteals

inferiorly = perineum

Question 3

pelvic ring is composed of what 3 bones

Answer 3

L and R coxae/coxal bones

sacrum

coccyx

pelvic ring has an inlet and an outlet

Question 4

describe the interlocking of the SI joint

Answer 4

auricular surfaces of the sacrum aid in form closure of SIJ

females have a smaller surface area than males

form closure = passive

force closure = musculature

Question 5

pelvic girdle anatomy shape males vs females

Answer 5

females = circular inlet

males = heart shaped

** lots of variation in pelvic height and girdle shape

Question 6

ways to describe the biological female/ “gynecoid” pelvic girdle

Answer 6

shorter/wider/lighter

ITs further apart

oval/tounded pelvic inlet

large pelvic outlet

wide/obtuse pubic arch and subpubic angle

obturator foramen = oval

acetabulum = small

SIJ = small joint surface

coccyx = smaller

Question 7

ways to describe biological male/”android” pelvic girdle

Answer 7

taller/narrower

thicker/heavier

heart shaped pelvic inlet

small pelvic outlet

narrow/V-shaped/acute pubic arch and subpubic angle

round obturator foramen

large acetabulum

large joint surface of SIJ

larger coccyx

Question 8

orientation of the pelvic girdle

Answer 8

L and R ASIS’s and anterior aspect of the pubic symphysis lie in the same vertical plane (anteriorly oriented)

tip of coccyx appears close to the venter of the pelvic inlet

laterally = sacral promontory is directly superior to the center of the pelvic outlet)

Question 9

describe the joint architectire of the SIJ

Answer 9

strong and weight bearing compound joint

anterior = synovial (between sacrum and ilium + articular cartilage); interlocking; limited mobility

posterior = syndesmotic between tuberosities of sacrum and ilium

joint remains stable as long as apposition (close relationship/congruency) is maintained

Question 10

how is weight transferred in SIJ

Answer 10

from axial skeleton to ilia via SI ligaments

then to femurs when standing

to ITs when sitting

Question 11

describe sacrotuberous ligaments

Answer 11

fibers from posterior margin of ilium/lateral sacrum/base of coccyx pass to IT

divides large sciatic notch (forming large sciatic foramen)

Question 12

describe sacrospinous ligament

Answer 12

fibers from lateral sacrum and coccyx pass to ischial spine

divides large sciatic foramen (created by sacrotuberous ligament) to then create lesser and greater sciatic foramen

Question 13

describe the pubic symphysis joint

Answer 13

it is a secondary cartilaginous joint

fibrocartilage disc and surrounding ligaments unite bodies of the pubis

fibers of the tendinous attachments of the rectus abdominis and external obliques strengthen the pubic symphysis anteriorly

wider in females

Question 14

describe the sacrococcygeal joint

Answer 14

secondary cartilaginous joint with intervertebral disc

fibrocartilage and ligaments join the apex of sacrum to the base of the coccyx with long strands of anterior and posterior sacrococcygeal ligaments to reinforce joints

Question 15

describe the lumbosacral joints

Answer 15

L5-S1 articulate at the inververtebral joint between IV disc between their bodies and the 2 posterior zygapophysial joints between articular processes of vertebrae

facets of S1 vertebrae face posteromedially with anterolaterally facing inferior articular facets of the L5 vertebrae

Question 16

SIJ ROM

Answer 16

greatest flexion/extension at 3 deg

1.5 deg axial RT

0.8 deg lateral flexion

Question 17

max ROM of SIJ

Answer 17

males = 1.2 deg

females = 2.8 deg

Question 18

average translation of SIJ

Answer 18

0.7-2mm

higher in unilateral vs bilateral stance

Question 19

ortho considerations for pelvic ring fxs

Answer 19

can occur with:
- crush accident
- fall from height
- MVA

often encountered post sx in acute care/IPR

unlikely to have just a single fx

pelvic fxs often result in soft tissue damage (i.e. nerves, organs, blood vessels, etc)

may result in rupture, transection, or torn urethra

Question 20

what happens to pelvic joints/ligaments with pregnancy

Answer 20

increased mobility and relaxation of ligaments

increase in intrapubic disc space

increase in flexibility of ligaments/pubic symphysis due to relaxin in latter 1/2 pregnancy

relaxation of ligaments can cause SIJ instability

side to side and transverse demensions may change but the true obstetric diameter remains unchanges

Question 21

risk factors for pelvic girdle pain

Answer 21

prior hx pregnancy

orthopedic dysfunctions

increased BMI

smoking

work dissatisfaction

lack of believe of improvement in the prognosis of pelvic girdle pain

Question 22

red flags with PGP that may indicate something more serious

Answer 22

not associated with the described clinical course of PGP

impairments failing to normalize

symptoms are worsening with increased disability

Question 23

possible comorbidities associated with PGP population

Answer 23

transient osteoporosis

MSK involvement of pelvic floor, hip, L/S

diastasis rectus abdominis (DRA)

Question 24

recommended measures for PGP

Answer 24

oswestry disability index (ODI)
disability rating index
pelvic girdle questionnaire (PGQ)
fear avoidance beliefs questionnaire (FABQ)
pain catastrophizing scale (PCS)

Question 25

antepartum pelvic girdle pain interventions (based on CPG)

Answer 25

pelvic girdle/SIJ belts - conflicting evidence - varied duration and applications exercise manual therapy - evidence emerging/weal - little/no evidence of adverse effects

Question 26

who is defined as postpartum

Answer 26

anyone 12 months post delivery or anyone still breastfeeding given the altered hormone status *pt can be altered hormone status up to 6 months post weaning

Question 27

risk factors for PGP postpartum

Answer 27

previous hx lumbar or PGP during pregnancy pain in posterior pelvis pain rolling in bed pain WBing multiparity depressive S&S higher pregnancy BMI work factors breastfeeding position

Question 28

systems screen for postpartum individuals with PGP

Answer 28

depression urinary and fecal incontinence and refer to pelvic PT of S&S are present abdominal wall, back, and hip screen

Question 29

when to refer to imaging to rule out a stress fx when pt has PGP

Answer 29

within 2 weeks of delivery with: - severe pain - decreased ability to weight bear - antalgic gait/limp - sudden onset SIJ pain, butt, or LBP

Question 30

exam components to consider with PGP

Answer 30

strong evidence for clinical presentation during fucntional mobility P4 test FABER ASLR for supine limb loading/pelvic stabilization force production, endurance, resting mm tone/length should NOT perform gaenslens withing firdt 4 weeks postpartum or beyond 4 weeks postpartum in the presence of pubic symphysis pain

Question 31

interventions for PGP postpartum

Answer 31

strong evidence for SIJ/pelvic belt MT no better than stabilization for long term involvement (>6 months) strong evidence that MT used with cointerventions can provide short term relief of pain and disability strong evidence for strengthening of pelvic floor, core, and hip strengthening

Question 32

prognosis for PGP postpartum

Answer 32

depends on initial pain and disability scores - higher scores recover quicker and return to function - low scores demonstrate minimal gains; may still have S&S 1-2 years later present to PT >3 months after delivery = minimal to low gains- ADVOCATE FOR EARLY POSTPARTUM CARE

Question 33

anterior/inferior pelvic wall is formed by what and bears the weight of what

Answer 33

formed by bodies and rami of the pubic bones and pubic symphysis bears weight of bladder

Question 34

lateral pelvic walls are formed by what

Answer 34

R and L innominates each has an obturator foramen, closed by obturator membrane

Question 35

what covers the internal aspect of the obturator membrane/foramen and pads the lateral pelvic walls

Answer 35

obturator internus OI fibers converge posteriorly with other deep external rotators, pass through the lesser sciatic foramen to attach to the greater trochanter

Question 36

obturator fascia has an opening to allow what to pass through

Answer 36

aka pudendal canal or alocks canal pudendal nerve, internal pudendal artery, and internal pudendal vein

Question 37

what forms the posterior wall/posteriorlateral wall and roof of the pelvic cavity

Answer 37

bony wall via sacrum and coccyx musculoligamentous posterolateral walls = ligaments associated with B SIJs and piriformis (sacroiliac, sacrospinous, and sacrotuberous)

Question 38

where does the piriformis run

Answer 38

from superior sacrum passes laterally leaving pelvis via greater sciatic foramen attaches to greater trochanter occupies much of the greater sciatic foramen forming the posterolateral walls

Question 39

where does the coccygeus mm run

Answer 39

ischial spine to body of pubis to inferior end of sacrum and coccyx

Question 40

what muscles make up the levator ani and where do they run

Answer 40

puborectalis: pubis, around rectum, and back to pubis (most medial mm) pubococcygeus: pubis to coccyx; wide and thin middle portion iliococcygeus: pubis to ilia; posterolateral, more aponeurotic, blends with anococcygeal ligament

Question 41

what is a urogenital hiatus

Answer 41

anterior gap between medial borders of levator ani on each side passage for urethra and vagina

Question 42

pelvic diaphragm is composed of what

Answer 42

coccygeus levator ani mm urogenital hiatus

Question 43

what is the perineal membrane

Answer 43

dense fibromuscular tissue deep to the superficial pelvic floor musculature home to striated urogenital complex

Question 44

describe the striated urogenital complex

Answer 44

straited, known as external urethral sphincter slow twitch that fuse with bladder and encircle the upper 2/3 of the urethra in females lower 1/3 divides urethrovaginal sphincter and the compressor urethra provides majority of striated mm compression at the urethra, 1/3 of the resting closure pressure

Question 45

significance of male urethral location

Answer 45

EUS is inferior to prostate can lose voluntary control temporarily or long term

Question 46

describe the contraction of the levator ani of the pelvic floor

Answer 46

levator ani forms dynamic floor for supporting abdominopelvic viscera - tonically contracted most of the time - full relaxation should occur for defecation, urination, and parturition -ACTIVELY contracted during forced expiration/management of intra abdominal pressure

Question 47

pelvic floor roles/functions

Answer 47

sphincter/continence control role in stability and posture sexual function load transmission (GRF up from LEs to spine)

Question 48

PFM support the fetal head while the cervix is dilating; what is the clinical relevance of this info

Answer 48

may lead to injuries of perineum, levator ani, or ligaments of the pelvic fascia may decrease support of vagina, uterus, bladder, ad or rectum, especially during increases in intra-abdominal pressure - stress urinary incontinence

Question 49

PFM stretch over 3x normal resting length with labor; what is the relevance of this

Answer 49

even if a tear doesnt occur, a muscle overstretch injury may occur perineal body may serve as protective component to overstretching/ stretching more than the mm itself pudendal nn may also be at risk for stretch or compression injuries

Question 50

describe the parietal peritoneum and its location/function with the pelvic region

Answer 50

parietal peritoneum is continuous with abdominal cavity but does not reach the pelvic floor DOES reach ovaries and uterine tubes region superior to bladder = not firmly bound to underlying structures = creates supravesical fossa depending on bladder fullness peritoneum passes over fundus and entire posterior aspect of the uterus onto posterior vaginal wall before reflecting up to the anterior wall of rectum

Question 51

how is the peritoneum different in males

Answer 51

peritoneal fold passes over ureter and ductus/vas deferens - separates paravesical and pararectal spaces (male equivalent of broad ligament)

Question 52

describe the parietal and visceral fascia

Answer 52

connective tissue that occupies the space between the membranous peritoneum and muscular pelvic walls and floor not occupied by pelvic viscera continuous, thin endoabdominal fascia that lies between mm abdominal walls and peritoneum loose and condensed endoplevic fascia

Question 53

6 main arteries that enter the lesser pelvis of females

Answer 53

paired internal iliac paired ovarian arteries unpaired medial sacral and superior rectal arteries

Question 54

4 main arteries that enter the lesser pelvis of males

Answer 54

paired internal iliac unpaired median sacral and superior rectal

Question 55

internal iliac arteries supply what

Answer 55

most of the blood to pelvic viscera some MSK portions of the pelvis gluteal, medial thigh, and perineal regions

Question 56

veins of the pelvic vasculature

Answer 56

pelvic venous plexus internal ilia cvein no veins accompany umbilical arteries between pelvis and umbilicis adn the iliolumbar veins from the iliac fossa drain the common iliac veins instead

Question 57

function of the superior gluteal veins

Answer 57

largest tributaries of internal iliac veins except during pregnancy when uterine veins become larger

Question 58

path of testicular veins

Answer 58

traverse greater pelvis pass from deep inguinal ring toward posterior abdominal terminations do not usually drain pelvic structures

Question 59

function of lateral sacral veins

Answer 59

often disproportionally large anastomose with internal vertebral venous plexus; provide alternate pathways to reach either the inferior or superior vena cava may also provide a path for metastasis for prostate or ovarian cancer

Question 60

rectal blood supply

Answer 60

superior rectal = top of rectum R and L middle rectal aa (from internal iliac) = middle and inferior

Question 61

blood from rectum drains into what veins

Answer 61

superior, middle, and inferior rectal veins rectal venous plexus

Question 62

innervation of rectum

Answer 62

sympathetic = lumbar splanchnic nn and hypogastric/pelvic plexus parasympathetic = S2-S4 SC passing via pelvic splanchnic nn and L and R inferior hypogastric plexus

Question 63

describe the external iliac lymph nodes

Answer 63

above pelvic brim, along external iliac vessels recieve lymph from inguinal nodes, pelvic viscera, superior pelvic region specifically do not recieve drainage from parallel nodes

Question 64

describe the internal iliac lymph nodes

Answer 64

clustered around anterior and posterior divisions of internal iliac artery and origins of gluteal arteries receive drainage from inferior pelvic viscera, deep perineum, and gluteal region and drain into common iliac nodes

Question 65

describe the sacral lymph nodes

Answer 65

in concavity of sacrum, adjacent to medial sacral vessels recieve from posteroinferior pelvic viscera and drain into internal or common iliac nodes

Question 66

describe common iliac lymph nodes

Answer 66

superior to pelvis along common iliac blood vessels recieve from external iliac, internal iliac, and sacral lymph nodes

Question 67

urinary organs that make up the pelvic viscera

Answer 67

pelvic portions of ureters bladder (rests on pubic bones and symphysis and on the prostate in males)

Question 68

length of ureters in men vs women

Answer 68

men = 18-22 cm women = 4cm

Question 69

describe the bladder/its position

Answer 69

apex points to pubic symphysis fundus/back of bladder is separated from rectum in males by a fascial septum but it is directly related to the superior anterior wall of the vagina in females bladder primarily composed of detrusor mm internal urethral sphincter is at the bladder neck

Question 70

what is the rectum connected to/where is it located relatively

Answer 70

continuous with sigmoid colon; junction is approximately at S3 rectum ends at tip of coccyx/anal sphincter

Question 71

female internal genital organs

Answer 71

ovaries uterine tubes uterus vagina

Question 72

male internal genital organs

Answer 72

epidymides/epidymis ductus deferens/vas deferens seminal glands ejaculatory ducts prostate bulbourethral glands

Question 73

what is benign prostatic hypertrophy

Answer 73

prostate continues to grow and BPH will affect virtually all males over 80 common after mid life obstructions may occur; increases risk for UTI; can be relieved endoscopically TURP (transurethral resection of the prostate) may be used in episodes of prostate cancer or in severe obstruction cases of BPH (risk of urinary incontinence and loss of sexual function)

Question 74

reasons for urinary referrals in pelvic health

Answer 74

stress urge mixed incontinence retention

Question 75

reasons for bowel referrals in pelvic health

Answer 75

constipation fecal incontinence

Question 76

reasons for pelvic pain referrals in pelvic health

Answer 76

pain at rest dyspareunia pain with activity (vulvodynia, vaginismus) pelvic organ prolapse coccydynia

Question 77

what hx questions to ask in a pelvic floor eval

Answer 77

OBGYN hx bladder/bowel hx/S&S pain symptoms sexual activity tobacco falls/trauma abuse meds sx imaging

Question 78

objective measures for pelvic floor

Answer 78

pelvic floor distress intentory PFDI modules (pain, urinary, bowel, prolapse) Oswestry disability index LEFS/lower extremity functional scale is an option with concomitant LE impairment depression inventories

Question 79

different portions of the pelvic floor exam

Answer 79

sensory - light touch -sharp/dull (if necessary) reflexes -anal wink - cremaster reflex (males) external - perineal body mobility testing (ROM of pelvic floor) internal - strength test via laycock's perfect scale - prolapse testing coordination

Question 80

PF mm interventions

Answer 80

uptrain with respiratory coordination downtrain with respiratory coordination coordination training strategy training/return to activity exercise with PFM coordination/timing modalities - biofeedback -Estim -rehabilitative US imaging tools - dilators - therapeutic wands encourage general mobility/activity

Question 81

how to structure goals with PF therapy and examples

Answer 81

should be pt specific and reflectve of objective measures gathered i.e. - decrease incontinence pad use - pain reduction - fiber/water intake - SUI goals - change in PFDI, oswestry, etc