THE LAND DOWN UNDER
Presented by: Karla Giramonti MS FNP With support from Carin Cappadocia, PT, DPT DISCLOSURE
In the past 12 months, I have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in my presentation.
This presentation will not include discussion of pharmaceuticals or devices that have not been approved by the FDA or if you will be discussing unapproved or “off-label” uses of pharmaceuticals or devices. WHAT IS THE PELVIC FLOOR?
“All visceral, neurovascular, and myofascial structures contained in the bony pelvis from pubis to coccyx and between lateral ischial walls” – APTA SOWH FUNCTION OF THE PELVIC FLOOR MUSCLES
1. Support
2. Sphincteric
3. Sexual
4. Trunk and Pelvic Stabilization
5. Lymphatic PELVIC GIRDLE aka BONEY LANDMARKS
http://classconnection.s3.amazonaws.com/551/flashcards/1673551/png/sc reen_shot_2014-03-07_at_40412_pm-1449E5C571029BC2ABD.png FIRST LAYER PELVIC FLOOR MUSCLES
• Ischiocavernosus (S2,3,4) • Superficial Transverse Perineal • O: Ischial tuberosity and ramus Muscle (S2,3,4) • I: Inferolateral apponeurosis over • O: Ischial Tuberosity cura of clitoris/penis • I: Central perineal tendon/Perineal • A: Erection (clitoral, penile) Body • Bulbocavernosus/Bulbospongios • A: Pelvic Floor Stability us (S2,3,4) • External Anal Sphincter • O: Central perineal tendon, • O: Perineal Body (F) Palpable under • I: Partial coccyx and surrounds anal labia canal (M) Midline Scrotum • A: Voluntary opening of anal orifice • I: Fascia over the (F) Corpus cavernosum of the clitoris (M) Shaft of Penis • A: (F) Vaginal Sphincter and clitoral erection (M) Penile Erection SECOND LAYER PELVIC FLOOR MUSCLES
• Sphincter Urethra (S2-4) • Compressor Urethrae (S2, 3, 4) • O: Inferior pubic arch and wraps • O:B Ischiopubic ramus around the urethra • I: Joins to opposite side and • A: Urethral constriction and relaxation passes anterior to urethra and vaginal wall • Urethrovaginal Sphincter • A: Compresses urethra and vagina • O: Vaginal wall • I: Superior surface of urethra • Deep Transverse Perineal (S 2,3,4) • A: Compresses urethra and assists in • O: Inferior Rami of ischium continence • I: Deep transverse perineum of opposite side (through perineum) • A: Stabilize pelvic floor THIRD LAYER PELVIC FLOOR MUSCLES
Levator Ani • Puborectalis (S2,3,4) • Iliococcygeus (S3,4) • O: Posterior pubis and fascia of • O: Archus Tendineus Levator Ani obturator internus (ATLA) • I: Anococcygeal ligament, • I: Anococcygeal body and coccyx around rectum and anal canal • A: Visceral and lateral coccyx • A: Voluntary sphincter of anal support canal • Coccygeus [Ischiococcygeus] • Pubococcygeus ( S3,4,5) (S4,5) • O: Posterior pubis and fascia of • O: Ischial Spine and obturator Internus Sacrospinous ligament • I: Anococcygeal ligament • I: Lower sacrum and coccyx • A: Pelvic visceral support • A: Visceral support, Coccyx mobility (flex), stability of SI joint ACCESSORY MUSCLES
• Piriformis (L5,S1,2) • O: Sacral border, through greater sciatic foramen • I: Superior border of the greater trochanter of the femur • A: Lateral hip rotation • Obturator Internus (L5,S1,2) • O: Internal aspect of pelvic foramen • I: Medial greater trochanter of femur, proximal to trochanteric fossa • A: Lateral hip rotation
http://web.uni-plovdiv.bg/stu1104541018/docs/res/anatomy_atlas_- _Patrick_W._Tank/6%20-%20The%20Pelvis%20and%20Perineum.htm PELVIC FLOOR MUSCLE FIBERS
• 70% Slow Twitch (Type I) • Maintain tonicity and support of pelvic organs.
• 30% Fast Twitch (Type II) • Rapid sphincter closure
2010 Herman and Wallace Rehabilitation Institute PF1 NEUROANATOMY
• Iliohypogastric Nerve
• Ilioinguinal’Genitofemoral Nerve
• Obturator Nerve
• Lateral Femoral
• Cutaneous Nerve
• Pudendal Nerve FASCIA
A fascia is a band or sheet of connective tissue, primarily NOT ENOUGH WATER! collagen, beneath the skin that attaches, stabilizes, encloses, and separates muscles and other internal organs. A LITTLE MORE ANATOMY
Pudendal Nerve
http://www.pudendalhope.info/node/13#Femal e_Pudendal_Nerve HOW DID WE GET FROM TALKING PEE TO TALKING POOP!
1997 Pediatrics 234 children with constipation 29% daytime urinary incontinence 34% nighttime incontinence 11% urinary tract infections 12 month follow-up
Successful treatment of constipation 52%
89% - Disappearance of daytime incontinence 63% - Disappearance of nighttime incontinence 100% - UTI in the absence of anatomic abnormality
(Pediatrics Vol.. 100 No. 2 August 1997) DIGESTION CONSTIPATION
• Anatomy and Pathophysiology • Colon, Rectum, Anorectal angle • Proper toileting posture and mechanics CONSTIPATION
• Reflexes • Gastrocolic Reflex • After a meal, gastrin contributes to a cascade of events which stimulates defecation • Rectoanal Inhibitory Reflex (RAIR) • Stool distends the rectum, creating Internal anal sphincter relaxation • Sampling Reflex • Brief relaxation of the internal anal sphincter sensory receptors to determine type and consistency of rectal contents • Accommodation Reflex • Allows the normal rectum to relax in order to continue to fill with stool • Parasympathetic Defecation Reflex • Stretch of the rectum stimulates afferent fibers and activates the parasympathetic nervous system CHALLENGES TO NORMAL BOWEL ELIMINATION
• Stool consistency
• Slow colonic transit
• Increased accommodation
• Decreased accomodation
Rao, 2010 Bajwa, 2009 • Large anorectal angle Nyam, 1998 Rao, 2004 Cook, 2010 Longstretch, 2006 Hsieh, 2005 • Smaller anorectal angle Read, 1992 TYPES OF CONSTIPATION
• Functional Constipation • Dyssynergic Defecation • Slow transit constipation
• Structural constipation
• Secondary constipation WHEN THE EMERGENCY ROOM CALLS!
Hydronephrosis Urinary Retention JUST FOR FUN STOP
Now that we understand everything There is know!
Let talk treatment But not by me But by the Pros! REFERENCES
Apte G, Nelson P, Brismée JM, et al. Chronic female pelvic pain-part 1: clinical pathoanatomy and examination of the pelvic region. Pain Pract. 2012;12(2):88- 110. Bajwa A, Emmanuel A. The physiology of continence and evacuation. Best Pract Res Clin Gastroenterol. 2009; 23:477—48 Ballek N, McKenna PH. Lower urinary tract dysfunction in childhood. Urol Clin N Amer.2010:37:215-228. Brannigan AE, Church JM. Structure and Function of the Large Bowel. In: Carriere B, Feldt CM Eds. The Pelvic Floor. New York: Thieme; 2006 Nyam DCNK. The current understanding of continence and defecation. Sing Med J. 1998; 39;(3) Rao S. Pathophysiology of adult fecal incontinence. Gastroenterology. 2004; 126Suppl1:s14s22. Rao SS, Valestin J, Brown CK, Zimmerman B, Shulze K. Long-term efficacy of biofeedback therapy for dysynergic defecation: Randomized controlled trial. Am J Gastroenterol online pub, 23 February 2010 Wiener JS, Scales MT, Hampton J, King LR, Surwit R, Edwards CL. Long-term efficacy of simple behavioral therapy for day time wetting in children. J Urol. 2000;164(3 Pt1):786-90. REFERENCES
Colaiacomo MC, Masselli G, Polettini E, Lanciotti S, Casciani E, Bertini L, Gualdi G. Dynamic MR imaging of the pelvic floor: a pictoral review. Radiographics 2009; 29:3 e35 Cook IJ, Brookes SJ, Dinning PG. Colonic Motor and Sensory Function and Dysfunction. In: Feldman M, Friedman LS, Brandt IJ Eds. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease: Pathophysiology/Diagmosis/Management 9th Ed. Philadelphia: Saunders Elsevier; 2010. Drake RL, Vogl W, Mitchell AWM. Gray’s Anatomy for Students. Philadelphia, Pennsylvania. Elsevier Inc;2005. Nevéus T, von Gontard A, Hoekeke P, et al. The standardization of terminology of lower urinary tract function in children and adolescents: report from the standardization committee of the international children’s continence society. J Urol.2006; 176(1):314-324.