MSK LQ Week 7: Pelvic hypertonic disorders and special groups

What is hypertonic pelvic floor muscle dysfunction?

A condition where the pelvic floor muscles are overactive, guarding, short, and tight, typically presenting with pelvic pain.

What are common disorders associated with hypertonic pelvic floor dysfunction?

Generalized pelvic pain, myofascial pain syndrome, interstitial cystitis, pelvic pain limiting sexual function, endometriosis, PCOS, dysmenorrhea, constipation, UTIs, incomplete bladder emptying, prostatitis, and coccydynia.

pelvic pain type

diffuse

Pelvic pain can refer

distally into the feet, lumbar spine, hips, glutes and perineum

Typical Patients of pelvic pain

-Multiple providers

-Stress/anxiety/embarrassment d/t pain

-It's in your head

-Significant impact on quality of life

Pelvic Pain categories

-Supportive

-Hypertonus

-Incoordination

-visceral

Chronic

supportive pelvic floor dysfunction

Hypermobility issues

pelvic hypermobility issues

Pelvic floor tries to stabilize and become overactive when there is a lack of support to the pelvis, lumbar or hip regions or an injury to the support structures like a labral tear or diastasis

hypertonus pelvic floor dysfunctions

-Pelvic tension (generalized)

-Myalgia/pelvic floor muscle spasms (including vaginismus)

-Dyspareunia

-Vulvodynia

-Coccydynia

-Constipation

What is vaginismus?

Involuntary contraction of the outer third of the pelvic floor muscles in response to attempted vaginal penetration.

What is dyspareunia?

Painful intercourse that can occur before, during, or after sex, felt in the vagina, pelvic, or abdominal region.

What is vulvodynia?

Pain from the tissues of the vulva, which includes the outer and inner labias, introits, vestibule, urethral opening, and clitoris.

What is coccydynia?

Pain from the coccyx, often occurring after childbirth due to tailbone dislocation.

Incoordination pelvic dysfunction

Muscle dissynergy: where the muscles do the opposite of what they should do

VISCERAL PELVIC PAIN

Arises from internal organs; assoc'd w/ strong contractions of Visceral muscles

What is chronic pelvic pain?

Pelvic pain lasting longer than 6 months.

What is endometriosis?

A condition where cells that normally grow inside the uterus grow outside of it, causing pain and scar tissue.

endometriosis causes

sloughing effect of cells outside of the uterus creating scar tissue and plaques in areas creating systemic pain

What is interstitial cystitis?

A chronic disabling disease characterized by bladder inflammation, often leading to urinary frequency and pelvic pain.

causes of interstitial cystitis

unknown bu tpossible bacterial infection, irritants, neurogenic hypersensitivity

Hunner's ulcer

superficial erosion of the bladder mucosa in interstital cystitis

What is pudendal neuralgia?

Pain caused by irritation or injury to the pudendal nerve, often associated with cycling.

pudendal nerve innervates

External genitalia (directly)

Indirectly (through two branches): perineum, and external urethral and external anal sphincters (fecal continence)

Lichen Sclerosis

Painful white patches of skin in the gential areas resulting in scarring and overactive pelvic floor muscles from the pain

CAUSES OF LICHEN SCLEROSIS

Insidious but could be autoimmune or hormone related

presentation of lichen sclerosis

intense itching, some patients may complain of burning, vulvar pain or dyspareunia (painful intercourse)

thin, wrinkled white skin with cigarette paper appearance

What is prostatitis?

Inflammation and infection of the prostate in males, leading to urinary issues and pelvic pain.

prostatitis presentation

difficulty emptying bladder, urinary frequency, constipation, difficulty getting an erection, inability to ejaculate

overactive pelvic floor aka

levator ani syndrome, levator spasm, pelvic floor tension myalgia, hypertonic pelvic floor

What are some common symptoms of overactive pelvic floor?

Acute or chronic pain, pelvic floor muscle spasms, low back pain, heaviness in the pelvic area, constipation, and dyspareunia.

What is the significance of a multidisciplinary approach in evaluating pelvic pain?

It involves various specialists to rule out dysfunctions in multiple systems, including urologists, gynecologists, and physical therapists.

What are common medical tests for pelvic pain?

Urinalysis

MRI (with and without contrast)

Ultrasound

STD testing

Stool testing

Hormonal assays and Blood testing

CT Scan

Defecography and Gastrointestinal Testing

Cystogram and Cystoscopy

Pelvic Venography

Nerve Conduction Test

Laparaoscopy

Hysterosalpingography

What is the pelvic connection in relation to pelvic pain?

Pelvic pain may result from musculoskeletal dysfunction, where support mechanisms of the pelvic area are compromised.

Defecography

visualizing of how well bowel moves through GI system

sits marker testing

to see how quickly something passes through gI system

Pelvic Venography

Imaging of the flow of pelvic arteries and veins

Laparaoscopy

Looking into abdomen and pelvis through scope

Hysterosalpingography

x-ray imaging of the uterus and fallopian tubes after injection of contrast material

What are the common psychological impacts of pelvic pain?

Stress, anxiety, and embarrassment due to pain, often leading to misconceptions that it is 'in your head'.

What is the role of antidepressants in pelvic pain management?

They may be prescribed to manage pain and associated psychological symptoms.

What is the typical patient experience for those with pelvic pain?

They often see multiple providers (7-9) before receiving a proper diagnosis, with many tests returning negative results.

What are the anatomical structures involved in pelvic support?

The bony pelvis, pubocervical fascia, ligaments, and pelvic floor musculature.

What is the significance of pelvic floor muscle spasms?

They can lead to pain in the coccyx, piriformis muscle, gluteal muscles, and posterior thigh.

What is the importance of treating pelvic pain symptoms?

Treating symptoms is essential, especially when diagnostic tests return negative findings.

What is the typical age range for individuals affected by interstitial cystitis?

Predominantly affects women aged 30-50.

Which muscle is responsible for extension and rotation of the vertebral column?

Multifidus

What is the referral pattern for the Multifidus muscle?

Thoracolumbar region, abdomen, medial to the ASIS, SI joint, buttock, coccyx.

What actions does the Piriformis muscle primarily perform?

-primarily external rotation of the hip

-may abduct the hip when the hip is in 90 degrees of flexion

-stabilizes the hip and may place a strong oblique force on the sacrum

What are the referred pain patterns for the Piriformis muscle?

Lowback

Lateral to the sacrum

Posterolateral aspect of the hip

Pain in the buttock, coccyx, posterior thigh, leg and foot

Inguinal region

Dyspareunia

Pain on defecation

What is the function of the Quadratus Lumborum?

Stabilizer of the lumbar spine; in an upright position controls side bending to opposite side, lateral flexion of thoracolumbar spine, bilaterally extends the spine

What is the referral pattern for the Quadratus Lumborum?

Crest of the ilium, lower abdomen, outer aspect of the groin, greater trochanter, outer aspect of thigh, SI joint.

What action does the Iliopsoas muscle perform?

Hip flexion.

What is the referral pattern for the Iliopsoas muscle?

Low back, anterior thigh, lateral to the rectus abdominis, sacrum, proximal medial buttock, groin.

What is the primary action of the Rectus Abdominus?

Support of abdominal viscera and forward flexion of the spine, maintenance of normal lordotic curve

What are the referred pain patterns for the Rectus Abdominus?

Thoracolumbar region

Side or middle abdomen

Low back

SI joint

Can result in Spasm in urinary sphincter

What is the action of the External Obliques?

Flexion of the vertebral column, spinal rotation, and lateral flexion, assists in maintenance of lordotic curve

What is the referral pattern for the External Obliques?

Along inguinal ligament

Abdomen

Groin and genitalia

Hip adductors

May simulate pain from pelvic organs

External obliques May be overactive in postpartum d/t

diastasis of the rectus abdominus

Obturator Internus action

External rotation of hip; assists in abduction of hip

OI pain referral pattern

-Posterior to the greater trochanter

-Upper portion of posterior thigh

-Genitalia

-May feel Pain and fullness in rectum

-Sign: feels like sitting on a golfball

What is the role of the Pubococcygeus and Iliococcygeus muscles?

Support the pelvic diaphragm and oppose increases in intraabdominal pressure.

What are the referral patterns for the Pubococcygeus and Iliococcygeus?

Low back

Posteriorthigh

Hip

Sacrum

Coccyx

Rectum

Deep Pelvic floor

Vagina

Buttock

Suprapubic

lower abdomen

dyspareunia

What is the function of the Coccygeus muscle?

Pulls the coccyx forward and stabilizes the SI joint.

What are the referral patterns for the Coccygeus muscle?

Hip, low back, sacrum, coccyx, pelvic floor, vagina, posterior thigh.

What does the Bulbospongiosis/Bulbocavernosis muscle do?

Constricts the opening of the vagina and contributes to erection.

What are the referral patterns for the Bulbospongiosis/Bulbocavernosis?

Painful intercourse, vagina, perineum, adjacent urogenital structures.

Ischiocavernosis action

To maintain erection of the clitoris

Ischiocavernosis pain referral

Perineum

Adjacent urogenital structures

Pelvic pain subjective questions

-what makes it...better, worse, the same

-questions regarding systems function of bowel, bladder, and sexual health

-Previous medical management

-Previous surgeries

pelvic pain gets worse with

-sitting

-full bladders/bowels

-sexual activity

pelvic pain improves with

-bowel or bladder emptying

-laying or resting

Pelvic pain affects on gait

-Decreased step length bilaterally

-Bilateral hip ER during gait

-Antalgic gait pattern

What is the impact of pelvic pain on posture?

-May lead to forward flexed posture and posterior pelvic tilt.

-sacral sitting

-stiff thoracic spine and hips

pelvic pain posture affects on glutes

wasting of glutes d/t overactive Pelvic floor

Pelvic pain affects on balance

-Decreased balance d/t decreased ADLs and activity

-WIde BOS

LE and trunk MMTs with pelvic pain

-Weak and inhibited glutes, quads and hamstrings

-Poor core stability and strength

What is the significance of hydration for pelvic health?

Hydration supports bowel and bladder function and reduces irritation.

rhythmic movement through the pelvis is helpful for those with

abdominal pelvic pain

Dehydration may lead to more

frequent restroom use d/t more acidic urine irritating the bladder

Avoid bladder irritants

-Things that are highly acidic, caffeine, diuretics

-Caffeine, carbonation, alcohol, high sugar foods, tomato based products, fruit based products

What is the purpose of timed voiding?

To train the bladder for effective emptying and reduce frequency and nocturia.

urge suppression

used to gain control of the bladder to prevent leakage and delay voiding

-if there is an urge to void, stop what youre doing, sit down or stand quietly

-quickly squeeze pelvic floor muscles several times w/out resting between squeezes

-breathe in and out while contracting pelvic floor muscles

-try to suppress urge to void and wait until urge passes

-walk to bathroom at normal pace

Urge should only occur at

60-80% fullness of bladder

What is a reverse kegel?

A technique to teach patients to relax the pelvic floor.

What is the role of diaphragmatic breathing in pelvic health?

It helps relax the pelvic floor during inhalation.

squatty potty Mechanism

Brings knees above the hips to relax the puborectalis and increases the anorectal angle to decrease stress on the pelvic floor

double voiding

remaining at the toilet after initial voiding to allow time for additional urine volume to be excreted

Healthy Behaviors for POP Prevention

Neutral pelvic posture

Neutral Intra-abdominal pressure

Avoid Valsalva

Bowel Health

Strong support system (core/PF)

Coordinated support system during functional tasks

How To Down Train Pelvic Floor

reverse kegels

Diaphragmatic breathing

Positions that put PF on slack

Improving mobility of accessory musculature

Coordination

Kinesthetic awareness

biofeedback

Progressive relaxation strategies

as diaphragm rises up

so does pelvic floor

What is osteoporosis?

A disorder characterized by porous, brittle bones due to loss of calcium, sometimes resulting in pain, decreased height and skeletal deformities:

What are common risk factors for osteoporosis?

Menopause

Aging

Heredity

Ethnicity

Inactivity

Tobacco

HIV infections

Stroke

Cancer treatments

Organ transplants

Alcohol abuse

Chronic renal failure

Corticosteroid use

Poor nutrition

Low body weight (FAT)

DM

MS

Pregnancy and lactation

in OP

-Bone resorption > bone formation

-Osteoclast activity >osteoblast activity

Areas most susceptible for osteoporosis

Vertebral bodies in the thoracic spine

Hip

Distal forearm

What is the relationship between pelvic pain and functional mobility?

Pelvic pain can lead to decreased activity and atypical gait patterns.

What is the importance of education in pelvic pain management?

Education can improve confidence and reduce pain through informed changes.

What is the significance of pelvic floor assessment?

To evaluate muscle function and identify trigger points for treatment.

What are the benefits of manual therapies in pelvic health?

They can resolve trigger points and improve muscle mobility.

What are common consequences of decreased mobility in older adults?

Decreased ADL function, increased health care and societal costs, pain, trunk weakness, spinal deformity, functional limitations, disability, and impaired psychological function.

Estrogen changes postpartum may lead to

semimenopausal state postpartum resulting in decreased bone mineral density