MSC IV Exam 1

- Closure/support of urethral opening

- Closure/support of the vaginal opening

- Maintain clitoral erection

- Maintain penile erection

- Assists in emptying of the urethra

What is the function of the 1st and 2nd layers of the perineals?

Supportive, Sphincteric, Sexual

What are the 3 functions of the pelvic floor?

Support of the pelvis, support of the organs, helps to fix the trunk with UE movements, assists with IAP management

What are the functions of the pelvic diaphragm?

Coccygeus

Which muscle?

-Runs laterally from ischial spine to anococcygeal ligament of the coccyx

-Runs parallel with the sacrospinous ligament

-Flexes the coccyx

-Helps to support the sacrococcygeal joint

laterally

anococcygeal

sacrospinous

flexes

sacrococcygeal

Coccygeus

-Runs (medially/laterally) from ischial spine to _____ ligament of the coccyx

-Runs parallel with the _____ ligament

-(Flexes/extends) the coccyx

-Helps to support the _____ joint

Obturator Internus

Which muscle?

-Originates from the medial side of the obturator foramen and obturator fascia

-Exits the pelvic cavity through the lesser sciatic foramen

-Attaches onto the greater trochanter

-Medial surface of the obturator fascia thickens into acuate tendon of the levator ani (ATLA)

(ATLA provides point of attachment for all three muscles of the levator ani)

medial

lesser sciatic foramen

greater

medial

Obturator Internus

-Originates from the (medial/lateral) side of the obturator foramen and obturator fascia

-Exits the pelvic cavity through the _____ _____ _____

-Attaches onto the (greater/lesser) trochanter

-(Medial/lateral) surface of the obturator fascia thickens into acuate tendon of the _____ _____

ATLA (arcuate tendon of the levator ani)

What provides the point of attachment for all 3 muscles of the levator ani?

ilium, ischium, pubis

What bones form the pelvic girdle?

Sacroiliac joints, symphysis pubis

What joint articulations are in the pelvic girdle?

Sacral promontory

Pubic Symphysis

Iliopectineal line

Pelvic Inlet & Outlet Borders

Superior view

Posterior border:_____

Anterior border:_____

Lateral border:_____

Pubic arch

Ischial tuberosity and sacrotuberous ligament

Tip of coccyx

Pelvic Inlet & Outlet Borders

Inferior View

Anterior border:_____

Lateral border:_____

Posterior border:______

increases

intra-abdominal pressure

organs

Functions of the Pelvic Floor

Supportive

- Resting tone which (increases/decreases) based on demand and _____ _____.

- Provides a muscular shelf for the pelvic _____.

urethra, vagina, rectum

both

Functions of the Pelvic Floor

Sphincteric

- Pelvic floor muscles encircle the _____, _____, and _____.

- Assist with (involuntary/voluntary/both) control

canals

proprioception

orgasmic

Functions of the Pelvic Floor

Sexual

- Provide tone to the _____.

- Provide a foundation for _____.

- _____ function.

Perineals and Levator ani

What muscles make up the 3 layers of pelvic musculature?

Perineals

What muscles make up the first and second layers of pelvic musculature?

Perineal membrane

What is the interior fascia of the urogenital diaphragm?

1st layer (most superficial)

Which layer of the anterior urogenital diaphragm contains

-Superficial transverse perineal

-Bulbocavernosus (male - bulbospongiosus)

-Ischiocavernosus

2nd layer (deep)

Which layer of the anterior urogenital diaphragm contains

-Sphincter urethrae

-Compressor urethane

-Deep transverse perineal

Levator ani

What makes up the third layer of the pelvic musculature?

Puborectalis

Pubococcygeus

Iliococcygeus

(medial/central to lateral)

What muscles make up the levator ani?

Puborectalis

Which muscle of the levator ani forms a "sling" around the rectum and helps maintain continence?

30%

70%

The muscle fiber makeup is _____% fast twitch, _____% slow twitch (postural role and endurance)

Coccygeus

Obturator Internus

Piriformis

What are the supporting muscles of the pelvic girdle?

Piriformis

Which muscle?

-Origin: pelvic surface of the sacrum, passes through the greater sciatic foramen

-Insertion: superior border of the greater trochanter of the femur

greater

greater

Piriformis

Origin: pelvic surface of the sacrum, passes through the (greater/lesser) sciatic foramen

Insertion: superior border of the (greater/lesser) trochanter of the femur

Pudendal nerve

What nerve provides primary innervation to urogenital and pelvic diaphragm?

Pudendal nerve

Which nerve?

-Originates from ventral rami of sacral nerves S2, S3, S4

-Exits the pelvis through the greater sciatic foramen

-Enters back into the pelvis through the lesser sciatic foramen

-After re-entry, accompanies the pudendal artery and vein through the pudendal canal (Alcock's canal)

Pudendal nerve

What nerve originates from the ventral rami of sacral nerves S2-4?

S2-S4

Pudendal nerve originates from ventral rami of what sacral nerves?

Pudendal nerve

What nerve exits the pelvis through the greater sciatic foramen?

greater

The pudendal nerve exits the pelvis through the (greater/lesser) sciatic foramen

lesser

The pudendal nerve enters back into the pelvis through the (greater/lesser) sciatic foramen

Pudendal artery and vein

What accompanies the pudendal nerve after it re-enters the pelvis?

Pudendal canal (Alcock's canal)

The pudendal nerve, artery and vein travel together through what?

obturator fascia

medial

Pudendal (Alcock's) canal is formed by the _____ _____ and runs along the (medial/lateral) aspect of the ischial ramus

Inferior rectal nerve

perineal nerve

dorsal nerve of the clitoris (female) or penis (male)

The pudendal nerve splits into what branches?

Pudendal nerve

What nerve innervates all muscles of th perineum and pelvic floor, including the external anal sphincter through the inferior rectal branch?

Innervates all muscles of the perineum and pelvic floor, including the external anal sphincter through the inferior rectal branch

What is the motor function of the pudendal nerve?

External anal sphincter

Inferior

The pudendal nerve innervates all muscles of the perineum and pelvic floor, including the _____ _____ _____ through the (superior/inferior) rectal branch

Pudendal

_____ nerve supplies sensation to the external genitalia of both sexes and the skin around the anus, anal canal, and perineum through its branches.

Inferior rectal nerve

Which nerve supplies sensory to the perianal skin and lower third of the anal canal?

Perineal nerve

Which nerve supplies sensory to the skin of the perineum, labia minor & major or posterior scrotum?

Dorsal nerve of the penis/clitoris

What nerve supplies sensory to the skin of the penis/clitoris?

Iliohypogastric

Ilioinguinal

Genitofemoral

Lateral femoral cutaneous nerve

What are the 4 main nerves from the lumbar plexus?

- Intra-abdominal pressure regulation

- Length tension relationship of the pelvic floor

- Changing breath can change pelvic floor activation

What is important about the biomechanical connection between the pelvic floor and the diaphragm?

Increased bladder pressure, SUI, POP

What does poorly managed intra-abdominal pressure contribute to?

Improving efficacy and timing of breaths

What may help regulate symptoms of pelvic floor dysfunction during aggravating activities and movements?

True

True/False: Abdominal wall contracts with cue for PFM contraction, and activation matches the effort of the contraction

increased

Urethral closing pressure (increased/decreased) with an abdominal drawing in maneuver and a correct PFM contraction.

greater

In response to perturbation, incontinent women have (GREATER/LESSER) PFM, RA, and EO activation than continent controls (length tension curve)

false (will change)

True/False: Different types and degrees of abdominal activation will NOT change pelvic floor activation?

- help laterally rotate femur with hip extension and and femur with hip flexion

- steady femoral head in acetabulum

What is the role of the obturator internus?

they are physically connected so what happens at one can impact the other, therefore, the pelvic floor may act different in different positions of hip rotation

What is important about the biomechanical relationship between the levator ani and the obturator internus?

hips

Strengthening the ___ can help provide pelvic diaphragm with greater support

Impaired hip strength and altered motor control of these primary hip muscles may explain why woman with SUI display greater moments to counteract forces placed on the body during gait

What is the relationship between hip strength and stress urinary incontinence (SUI)?

Increase in tone (volitional or resting) in the pelvic floor musculature

What is pelvic floor hypertonus?

voiding

defecation

length tension curve

increase

increased

increased

Characteristics of pelvic floor hypertonus include:

- Difficulty with adequate relaxation for _____, _____, gynecological exam, or penetrative intimacy

- Difficulty with force generation secondary to inadequate _____ _____ _____

- (Increase/decrease) in pelvic or abdominal pain

- (Increased/decreased) resistance to passive stretch

- (Increased/decreased) mechanical strain on neural tissue/structures

power, endurance (holding max voluntary), repetitions, fast, every contraction timed

What is the PERFECT grading system?

torque

harder

The more _____ that needs to be generated across the thorax and pelvis, the _____ the pelvic floor must work

amount of force

The length tension curve represents the _____ _____ _____ a muscle can generate while held at various lengths along its continuum

at rest

50%

100%

The pelvic floor elevator

Ground floor = PFM ___ _____

1st floor = ____% contraction

2nd floor = ______% contraction

stress

urge

mixed

functional

overflow/retention

Wha are the types of urinary dysfunction (incontinence)?

True

True/False: If UI has not resolved within 6-12 weeks of vaginal delivery, there is a greater likelihood that symptoms will persist at or beyond 1 year post-partum

Brief and involuntary loss of urine associated with an increase in intra-abdominal pressure

What is stress incontinence (SUI)?

older age, BMI > 30, pregnancy, repetitive/high-impact sports, genetics

What are some risk factors for SUI?

- address deficits in pelvic floor tone, coordination, strength, endurance, power

- IAP management with movement and functional tasks to prevent pressure loss down and out

- modifications in positioning and strategies for aggravating activities

- constipation management

What are some treatment options for SUI?

Urine leakage associated with a strong and often sudden urge to urinate

What is Urge Incontinence (UUI)?

- Bladder fills up drip by drip

- Bladder remains relaxed as it fills

- With stretching on the bladder walls, signals are sent along the spinal cord and up to the brain communicating fill level and sense of "urge"

- These signals act like alarms we can "snooze", especially at mid-levels of fill

- When we decide it's time to go, voluntary signals in the motor cortex travel to the micturition center

- Internal sphincter (involuntary) and the external sphincter/pelvic floor (voluntary) relaxes and the bladder contracts, allowing urine to exit

What is the normal bladder mechanism?

involuntary

voluntary

When allowing urine out, the internal sphincter acts (voluntary/involuntary) and the external sphincter/pelvic floor acts (voluntary/involuntary) to relax while the bladder contracts

- Bladder fills up drip by drip

- As the bladder fills, instead of walls staying relaxed, the bladder is "overactive"

- This involuntary increase in detrusor pressure can occur at any level of filling, depending on the severity

- Instead of delaying the urge, the bladder "jumps the gun", resulting in involuntary loss of urine

What is the mechanism of UUI?

- Changes in electrical coupling of the detrusor

- Hypertrophy of the walls of the detrusor

- Changes in sensitivity of neural signaling

- Low pH, high potassium concentrations can increase sensitivity of the bladder lining

- Constipation: there's only so much room down there

- Mind over matter: stress, anxiety, and fear influence the nervous system, which in turn influences the bladder

What are some contributors to bladder "overactivity"

- Bladder diary (helps to identify bladder triggers such as diet/situation, track fluid intake, voiding interval/frequency, bowel habits)

- Improve hydration while modifying/eliminating trigger foods/fluids (reducing pH, managing diuretics)

- Provide strategies for "retraining" bladder to be more relaxed and accommodating to bladder filling with less "overactivity"

What are some treatment options for UUI?

Dairy, acidic foods, coffee & tea, tomato based products, alcohol, carbonated drinks, citrus, chocolate, spicy foods

What are some common bladder irritants?

- Diaphragmatic breathing

- Quick, sub-maximal pelvic floor contractions (Bradley's loop)

- Pressure on the perineum

- Brain/body calming

- Changing position/limiting movement

What are some urge suppression strategies?

Those with components of both urge and stress urinary incontinence

What is mixed incontinence?

Incontinence which occurs as the result of physical mobility or dexterity challenges, not related to dysfunctions of the anatomical or neurophysiological mechanisms of bladder/bowel control

What is functional incontinence?

- Limited mobility (lack of independence in transfers, ambulation)

- Dexterity challenges (arthritis limiting ability to doff LE dressing)

- Cognitive (Dementia, Alzheimer's, or advanced Parkinson's - limiting the person's ability to recognize the need to go to the bathroom)

What are potential factors for functional incontinence?

Bladder "overflows" due to bladder not emptying completely; likely due to retention, incomplete emptying, neurogenic bladder

What is overflow/retention incontinence?

The descent of one or more of the pelvic organs (bladder, urethra, uterus, rectum, intestines) from their normal anatomical position toward or through the vaginal opening

What is pelvic organ prolapse?

Anterior prolapse

What kind of prolapse is Cystocele?

Posterior prolapse

What kind of prolapse is restocele?

Uterine prolapse

What kind of prolapse is apical?

Cystocele

Restocele

Apical

What kind of prolapse?

- Anterior

- Posterior

- Uterine

Collagen make up, pelvic shape

What are some anatomical/histological risk factors for pelvic organ prolapse?

prior pregnancy, childbirth, abdominopelvic surgery (hysterectomy), work/occupational history

What are some situational risk factors for pelvic organ prolapse?

obesity, pulmonary disease, aging, constipation

What are some physiological/biological risk factors for pelvic organ prolapse?

- Low back or low abdominal pain/ache

- Hesitancy or difficulty with exercise that requires greater load transfer or pressure management

What are some general symptoms of pelvic organ prolapse?

- Incomplete emptying of bowel or bladder

- Feeling of bulge, pressure, discomfort at the perineum

- Urinary incontinence

- Hesitancy with urine stream or position change required to initiate stream or BM

- Difficulty with vaginal penetration

- Pain with penetrative intimacy

What are some specific symptoms for pelvic organ prolapse?

- Maximizing pelvic floor coordination, strength, endurance, and power

- Improving pressure management with movement and loading tasks

(Everything from bed mobility to HIIT)

- Managing constipation and improving mechanics for emptying to decrease strain

- Symptom modification techniques for feelings of increased pressure or heaviness

What are some treatment options for pelvic organ prolapse?

The process of the linea alba widening and thinning to accommodate a growing baby

What is diastases rectus abdominus (DRA)?

Multiparity, multiple gestation, larger pregnancy weight gains, genetic predisposition to connective tissue/collagen laxity (high Beighton score)

What are some potential risk factors for DRA?

build the strength, load capacity, and strategy for tasks that require more from this area in order to return to meaningful activities and exercise

What is the goal of interventions for DRA?

higher

higher

anterior

The (higher/lower) the demand on the abdomen, lumbar spine, and pelvic girdle (load transfer, impact, torque demands, etc), the (higher/lower) the need to build tension across the (anterior/posterior) abdominal wall to manage the load and pressure.

- Painful bladder syndrome/interstitial cystitis

- IBS

- Endometriosis

What are common visceral pain disorders?

Disorder categorized by pelvic pain with lower urinary tract symptoms without other identifiable cause

What is painful bladder syndrome/intersitial cystitis?

Painful bladder syndrome/Interstitial cystitis

What visceral pain disorder?

Categorized by pelvic pain with lower urinary tract symptoms without other identifiable cause

increased

decreased

endothelium

increased

urination

sex

hypertonicity

Potential components for painful bladder syndrome/Inerstitial cystitis:

- _____ frequency/urgency of urination

- _____ functional bladder capacity

- Inflammatory or other tissue changes in the bladder _____

- _____ suprapubic/pelvic pain with bladder filling

- Pain with _____ and _____

- Pelvic floor muscle (hypotonicity/hypertonicity)

- Abdominal and pelvic pain/discomfort

- Altered bowel function

(Constipation, diarrhea, or combination of the two; changes/fluctuations in bowel motility, frequency, and overall inflammation)

- Bloating

- Symptoms often improve with defecation, at least temporarily

What are some signs/symptoms of IBS?