Pelvic Floor
Anatomy
Coccygeus muscle
Levator ani
Examination
Signs and Symptoms
Differential Diagnosis
Associated Impairments
Tests and Measures
Interventions
Pelvic floor muscle strengthening & relaxation
Alternate Treatment/Referral
References
Coccygeus muscle
Levator ani
- Pubococcygeus: can be damaged during parturition
- Puborectalis: muscular sling envelops inferior rectum, vagina (uterus) & bladder (urethra)
- Illeococcygeus: often underdeveloped/less significant role
Examination
- Pt Hx: 1st report of sxs, aggravating/easing factors
- VAS: severity
- Bowel/Bladder
- Sexual Function
- Prolapse
- ADLs
- Obstetric/Gynecological
- Diet
- Medical Hx/Meds
Signs and Symptoms
- Muscle spasm
- Muscle Pain: dull/sharp, constant/intermittent, mild/moderate/severe
- Pain radiating to lower back, buttocks, thighs
- Pain around connective tissue and ligaments
- Pain with pelvic floor muscle contraction
- Reproductive, urinary, musculoskeletal area pain
Differential Diagnosis
- SIJ pain
- Bladder distention - urinary urgency/incontinence
- Pubic symphysis dysfunction
- LBP
- Somato-visceral referred pain
- Digestive, reproductive, urinary systems
- Neurogenic causes (nerve irritation)
- Appendicitis
- Colon cancer
- Constipation
- Crohn’s disease
- Diverticulitis
- IBS
- Fibromyalgia
- UTI
Associated Impairments
- Pelvic floor pain/dysfunction can be caused by or lead to…
- Incontinence (stress-urinary or fecal)
- Somatic pain in the lower quadrants
- Puborectalis muscle spasm
- Obstructed defecation
- Myalgia
- Vaginismus, Vulvodynia
- Pelvic organ prolapse
Tests and Measures
- Pelvic floor contraction technique
- Bladder diary/fluid volume
- Ultrasound
- Manometry
- Questionnaires
- Paper Towel Test (urinary incontinence)
- Bristol Stool Chart (fecal incontinence)
Interventions
Pelvic floor muscle strengthening & relaxation
- Kegels: Elevator metaphor contraction (slowly reach max contraction then slowly release the contraction, quick flick, sustained 10 sec contraction followed by 5 sec pause.
- Spinal stability & strengthening exercise: LTR, lunges, squats, UE PNF
- Diaphragmatic breathing: controlled expansion of abdomen on inhalation, draw in umbilicus on exhale
- Biofeedback: a specialist uses monitoring equipment that provides feedback - visual cues, sound or verbal guidance - to the patient about body functions that usually aren't under conscious control. Biofeedback can help improve pelvic floor muscle coordination and rectal and bladder sensation.
- Myofascial release (transvaginal maneuvers)
- Global massage (general)
Alternate Treatment/Referral
- Medical treatment: Various medical therapies may be helpful for pelvic floor tension myalgia, including estrogen, pain relievers, nerve pain medications, antidepressants, numbing agents or Botox injections.
- Surgery: Many different surgical procedures, including minimally invasive techniques, can be used.
- Acupuncture: This may relieve muscle pain, but more research is needed to determine whether it specifically helps with pelvic floor problems.
References
- Barbosa, A., Marini, G. I., Piculo, F., Rudge, C., Calderon, I., & Rudge, M. (2013). Prevalence of urinary incontinence and pelvic floor muscle dysfunction in primiparae two years after cesarean section: cross-sectional study. Sao Paulo Medical Journal, 131(2), 95-9.
- Giggins, O., Persson, U., & Caulfield, B. (2013). Biofeedback in rehabilitation. Journal of NeuroEngineering and Rehabilitation, 10(60), 1-11.
- Goodman, C., & Snyder, T. (2007). Differential diagnosis for physical therapists. (4 ed., pp. 3-912). St. Louis, Missouri: Saunders Elsevier.
- Kawasaki, A., & Amundsen, C. L. (2011). We need to expand the differential diagnosis for chronic pelvic pain to include pelvic myofascial pain. OBG Management, 23(10), 17-28. Retrieved from http://www.obgmanagement.com/pdf/2310/2310OBG_Update.pdf
- Memon, H., & Handa, V. (2013). Vaginal childbirth and pelvic floor disorders. Women's Health, 9(3), 265-277.
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