Pelvic Health Review

Where do the urogenital triangle and anal triangles attach

• Urogenital triangle

  • Ischial tuberosity <> pubic symphysis <> ischial tuberosity

• Anal triangle

  • Ischial tuberosity <> coccyx <> ischial tuberosity

List the 3 layers of pelvic floor muscles

• 1st layer: Urogenital diaphragm

  • Most superficial layer

  • Comprised of slow and fast muscle fibers

• 2nd layer: Perineal membrane

  • Middle layer

  • Comprised of mostly slow muscle fibers

• 3rd layer: Pelvic diaphragm

  • Deepest layer

  • Levator ani muscles (puboanalis / puborectalis) - rectal continence

  • Comprised of mostly slow muscle fibers and some fast muscle fibers

List pelvic floor innervations

• S2-S4 (pudendal nerve)

• S4-S5 (sacral plexus)

List the 5 S’s of pelvic floor function

• Support

• Sphincter

• Sexual

• Stability

• Sump pump

Describe the relationship between pelvic floor muscles and bladder function

• Reciprocal relationship

  • Detrusor muscle

List the 3 primary CNS areas and how correlate to bladder function

• Cerebral cortex

  • Right time and place to void

• Sacral micturition center

  • Coordinate with sphincters for voiding

• Pontine micturition center

  • Efferent and afferent

  • Contraction and knowing when to void

Describe the primary nervous system areas responsible for defecation

• Cerebral cortex

  • When appropriate and relax to allow

• Sacral defecation center

  • Colon contractions and internal / sphincter afferent part tells us when stool is present

• Gastrocolic reflexes

  • Moves food through stomach and intestines

Describe the prevalence of urinary incontinence

• 1 in 4 women over the age of 18 experience episodes of UI

• 25 million Americans (75% women)

• 2x more common in women

List the requirements of urinary continence

• Intact CNS/PNS

• Development of key neurological areas which control micturition

• Ability of the bladder to expand and contract

• Sensory awareness to know the bladder is full

• Mobility to get to the bathroom

• Dexterity to remove clothing

List and describe the 4 Bradley’s loops of micturition

• Loop 1

  • Frontal lobe → cortex → brainstem

  • Voluntary control of micturition (suppress micturition reflex)

  • Provides desire or awareness of voiding

• Loop 2

  • Pons → sacral micturition center

  • Maintains duration of detrusor contraction

  • Provides the ability to empty

• Loop 3

  • Sacral micturition center → S2-S4

  • Coordinates detrusor contraction with sphincter relaxation

  • Provides inhibited sphincter relaxation

• Loop 4

  • Cerebral → sacral

  • Keeps sphincters closed during bladder filling

Describe the phases of bladder filling and micturition

• Bladder fills

  • Detrusor muscle relaxes

  • Urethral sphincter contracts

  • Pelvic floor contracts

• First sensation to void

  • Bladder half full

  • Urination voluntarily inhibited until appropriate time

• Normal desire to void

  • Closer to completely full

• Micutirition

  • Detrusor muscle contracts

  • Pelvic floor relaxes

List and describe 3 types of incontinence

• Overflow

  • Urethral blockage

  • Bladder unable to empty properly

• Stress

  • Relaxed pelvic floor

  • Increased abdominal pressure

  • From effort or physical exertion

• Urge

  • Bladder oversensitivity from infection

  • Neurologic disorders

Describe medical manage of UI

• Pharmacology

  • Anticholinergics, beta-3 adrenergic agonists, botox, estrogen, tricyclic antidepressants, SNRI

• SUI

  • Surgery, urethral bulking

• OAB

  • Neuromodulation, botox

When does pelvic organ prolapse occur

When the muscles and ligaments supporting the pelvic organs weaken

List types of prolapse

• Anterior prolapse

  • Cystocele (bladder)

• Posterior prolapse

  • Rectocele (rectum)

• Uterine prolapse

• Small bowel prolapse

  • Enterocele (small intestines)

List and describe the grades of prolapse

• Stage 0

  • Least severe

  • Managed conservatively

  • Common, may not be evidence of pathology

• Stage 1

  • Managed conservatively

  • Common, may not be evidence of pathology

• Stage 2

  • Managed conservatively

  • Right around the exit hole

• Stage 3

  • Managed surgically

  • Outside of the body

• Stage 4

  • Most severe

  • Managed surgically

  • Outside of the body

List contributors to prolapse

• Childbirth

• Genetics

• Levator hiatus size and GH+PB

• Raised intra-abdominal pressure

• Abdominal wall dysfunction

• Obesity

• Smoking

• Estrogen deficiency / menopause

List S&S of pelvic organ prolapse

• Bulge or protrusion

• Poor/prolonged urinary stream

• Feeling incomplete emptying

• Stress urinary incontinence

• Urinary retention

• Post-micturition dribble

• Positional changes to start or complete emptying

• Difficulty evaluating bowels

• Needs for splinting

• LBP, worsening as day goes on

• Abnormal vaginal discharge

• Increased pain / discomfort with prolonged standing which is relieved by laying down

Describe medical management of pelvic organ prolapse

• Medications

  • Estrogen

• Surgery

  • Sutures or mesh

  • Hysterectomy

  • Vaginal closure

What is the key mechanism in defecation

Relaxation of the puboanalis / puborectalis increases anorectal angle

List S&S of constipation

HA, bad breath, decreased appetite, bloating/gas, skin eruptions, flatulence, depression

List contributors to constipation

Drugs, neurologic condition, metabolic conditions, systemic disease, scar tissue, tumors, cancer

Describe dyssynergic defecation

Contracting when they should be relaxing

List S&S of IBS

Cramping, abdominal pain, bloating, gas, diarrhea, constipation, LBP

List diagnostic criteria for IBS

• Recurrent abdominal pain on average at least 1 day/week in the last 3 months associated with 2 or more

  • Related to defecation

  • Associated with change in frequency of stool

  • Associated with a change in form / appearance of stool

List types of fecal incontinence

Passive, urge, fecal seepage/smearing, gas incontinence

List causes / contributors to fecal incontinence

• Muscle weakness / nerve damage

• Chronic constipation

• Loss of storage capacity

• Surgery

• Gut mobility disorders (IBS, anxiety, infection, diet)

• Medications

• Dementia

• Impaired sensation

• Rectal prolapse

• Comorbidities (diabetes, SCI, chrons)

Describe medical management for fecal incontinence

• Medications

• Sacral nerve stimulation

• Surgery

• Fecal microbiota transplants

• VOWST

• Rebyota

List the types of assisted delivery

• Forceps

• Vacuum extraction

Describe the grades of perineal injury

• Grade 1 = only skin

• Grade 2 = skin, fascia, perineal muscles (episiotomy)

• Grade 3 = skin, fascia, perineal muscles, anal sphincter (OASI)

• Grade 4 = skin, fascia, perineal muscles, anal sphincter, tissue lining the rectum (OASI)

What is an episiotomy

Slight cut to prevent extensive tearing, no longer recommended

Describe OASI and what it can lead to

• Obstetric anal sphincter injury

• Lead risk factor for subsequent loss of bowel control

List risk factors of OASI

• Prolonged 2nd stage of labor, induced labor

• Instrumented delivery

• Advanced material age (>35)

• Shoulder dystocia

Describe the impact of pregnancy and childbirth on the abdomen and pelvic floor

• Levator ani muscle avulsion

  • Separation of the levator ani muscles from the pubic bone

  • Risk factor

    • Spontaneous deliveries, vacuum assisted, forceps assisted, POP

  • Diagnosis

    • Palpation, imaging

  • Management

    • Repair at time of avulsion or conservative

• Diastasis rectus abdominus (DRA)

  • Separation of the rectus abdominis at the linea alba

  • Risk factors

    • Number of pregnancies, BMI, diabetes

• Pubic symphysis dysfunction

  • Discomfort and pain in the pelvic area

  • Most common in 2nd trimester

  • S&S

    • Pain, clicking in low back, hip, SIJ

    • Difficulty in movement like abd, add

    • Difficulty with walking, stairs, sit to stand, weight bearing, turning

• Genitourinary syndrome of lactation

  • High levels of prolactin inhibit estrogen and androgen secretion

  • Management

    • Lubricants, moisturizers, topical estrogen, pelvic floor PT

Describe pelvic floor hypertonus / levator ani syndrome

• Elevated pelvic floor tone and inability to relax

  • Tender to palpation, weak/painful contraction, delay in relaxation, Difficulty emptying bladder/bowel, pain with sitting, pain with intercourse

  • No gold standard for determining tone

• Common in 4-6th decades

Describe vulvar pain syndrome

• 18-25y/o

• Vulvar vestibulitis or dermatoses

• S&S

  • Chronic pain with burning/stinging sensation

  • Difficulty sitting or wearing clothing secondary to Sx

  • Often associated with inflammatory conditions

    • Yeast infection, STIs

    • Maybe worsened with soaps, powders

Describe interstitial cystitis / painful bladder syndrome, risk factors, S&S, management

• Comorbidities

  • IBS, vulvodynia, chronic fatigue, TMJ

• Sx

  • Suprapubic pain or pressure which worsens with bladder filling and temporary emptying of bladder

  • Increased frequency of urination, nighttime voids

  • Increased urgency

  • Associated with chronic constipation, food sensitivities, depression, dyspareunia

• Management

  • Rx

    • Pain meds

  • Bladder instillation

    • Rx to bladder via catheter

  • Bladder stretching

    • Hydrodistension

  • Surgery 

Describe dyspareunia

• Painful vaginal penetration

• One of the most common sx/problems in GYN

• Multifactorial

  • Painful scarring

  • Pelvic floor dysfunction

  • Vulvar pain syndrome

  • History of pelvic trauma

Describe endometriosis, S&S, risk factors, and management

• Presence of active cells/tissue similar to uterine tissue occurring outside of endometrium

• Potential genetic and race involvement

  • Asian > white > black

• Sx

  • Gradually increasing acute premenstrual pain

  • Pain in pelvic, sacral region of the spine, radiating into back, during intercourse, with defection/urination

  • Dysmenorrhea/irregular menstruation

  • Painful ovulation

  • Chronic fatigue

• Risk factors

  • First period before 11 y/o

  • Shorter than 27 d cycles

  • Low BMI

  • No pregnancies/births

  • 25-29 y/o

  • Daily consumption of alcohol at least 10g/d

  • Smoking 

• Management

  • Pharma

    • NSAID, hormonal contraceptives, Selective progesterone receptor modulators

    • Aromatase inhibitors

    • GnRH antagonist- implications for bone loss

  • Surgery

    • Laparoscopy to remove lesion

  • Radical procedure

    • Hysterectomy 

Describe coccygodynia, risk factors, S&S, management

• Pain in the tailbone

• 5x women>men

• 40 y/o

• Risk factors

  • Childbirth, falls, obesity

• Sx

  • Localized coccyx pain

  • Worse with prolonged sitting, leaning back, prolonged standing, STS

  • Pain with intercourse

  • Bowel dysfunction

• Management

  • Conservative treatment first line

  • Injections

  • Surgery

    • Coccygectomy

      • Poor outcomes and not generally recommended 

Describe testicular pain (orchialgia)

• >3 months intermittent/constant pain

• Causes

  • Structural disorders, LB strain, pelvic floor dysfunction, osteitis pubis

• Management

  • Multi-disciplinary

  • Conservative first line

  • No official guideline

  • Pharma

    • NSAID, antibiotic, tricyclic antidepressants

  • Spermatic cord block

  • Surgery if cord block is successful 

Describe appropriate screening questions and tools

• Screening questions

• Self-report questionnaires

• General MSK screen

• Abdominal wall screen

• Breathing assessment

Differentiate Valsalva, breath holding, and bearing down

• Valsalva

  • Expiratory pressure exerted on close or partially closed glottis

  • Increase BP, then HR

  • Increase in trunk stiffness and intra-thoracic and intra-abdominal pressure

• Breath holding

  • Holding breath independent of valsalva or bearing down, but correlated in both

• Bearing down

  • Applying downward pressure into pelvis and abdomen, defecation or 2nd stage of childbirth

Describe ”normal” bladder and bowel function

• Bladder capacity is 2 cups

• Voiding every 2-4 hours

• No nighttime voiding

• No pushing or straining to empty

• Able to control urge

Describe bladder changes with aging

• Reduced capacity, elasticity, compliance

• Increased incidence of uninhibited contractions

• Decreased flow rate

• Diminished urethral pressure

• Increase post-void residual volume

• Diminished thirst = dehydration = recurrent UTI

Describe behavioral/lifestyle changes for management of urinary dysfunctions

• Scheduled voiding

• Proper toileting position

• Urge suppression

• Dietary changes

• Weight loss

• Bladder habits

Describe the procedure for abdominal massage

1. Down left side

2. Across top, down left side

3. Up right side, across top, down left side