Pelvic Pain: Physiatric Evaluation and Management
Pelvic Anatomy, Function, and Physical examination
Jaclyn H. Bonder, MD Assistant Professor, Department of Rehabilitation Medicine Medical Director, Women’s Health Rehabilitation ANATOMY The Boney Pelvis (Pelvic Girdle)
http://www.musclereleasetherapy.com/postural-balancing-2.html ARS: What are the bony landmarks of the urogenital triangle?
• Pubic symphysis • Bilateral Ischial tuberosities • Bilateral ischial spines • Coccyx • Bilateral ischiopubic rami
Answers are in red Poll: What are the bony landmarks of the urogenital triangle? Bony Landmarks
• Urogential Triangle – Pubic symphsis/arch – Ischiopubic ramus – Ischial tuberosity
• Anal triangle – Ischial tuberosity – Sacrotuberous Ligament – Coccyx – Ischial spine Joints and Ligaments
•Pubic symphysis •Sacroiliac Joint •Sacrococcygeal joint
•Anterior & Posterior (LDL) SI Ligament
7 Pelvic Floor Muscles: Superficial
A. Superficial & Deep transverse perineal B. Bulbcavernosus/spongiosus C. Ischiocavernosus D. External Anal Sphincter (EAS) E. Perineal body
8 Pelvic Floor Muscles: Levator Ani
Puborectalis
Levator Ani Pubococcygeus
Iliococcygeus
IC PR IC PC
IC PC IC
PR
9 Pelvic Floor Muscles: Deeper Layer
Piriformis
Obturator internus
10 More Anatomy – It never ends! Nerves of the Pelvis
•Lumbosacral trunk
•Nerve to Levator Ani and Coccygeus
12 Pudendal Nerve: Anatomy Nerve Anatomy continued: Abdominopelvic nerves ARS:What are the nerves that provide sensory/cutaneous innervation to this region?
1 (correct answer) 2 3 4
A = Pudendal Pudendal Pudendal Pudendal
B = Inferior cluneal Posterior Inferior cluneal Posterior femoral femoral cutaneous n. cutanueous nerve
C = Obturator Obturator Medial cutaneous Medial n. of thigh Cutaneous n. of thigh
D = Ilioinguinal + Iliohypogastric & Iliohypogastric only Ilioinguinal + Genitofemoral Ilioinguinal Genitofemoral Physical Exam for Pelvic Pain Physical Exam
•Gait/Posture •SIJ testing •Neurologic •Pubic Symphysis •MSK •Hip •Pelvic asymmetries •L-S spine •Pelvic floor: Vaginal & Rectal
Photo: Pelvic Floor Physical Therapy, 2006
17 MSK Pelvic Floor Examination: External Vaginal •Essentially the same components as other body parts •Extension of MSK exam •External Assessment: •Inspection: labia, perineum, and introitus •Palpation: superficial genital muscles •Muscle evaluation: PFM contraction and relaxation –Lift/descent of perineal body during voluntary contraction/relaxation –Involuntary relaxation – valsalva –Involuntary contraction - cough •Assess for prolapse •Reflexes: Check anal wink •Sensory testing w/ LT and PP •Q-tip test for vulvodynia –Inner thigh, 1,4,6,7,11o’clock MSK Pelvic Floor Examination: Internal Vaginal
•Palpate the muscles –Superficial Genital muscles – DIP –LAM – PIP @ 3-5 & 7-9 o’clock –Compare L vs R •Pain •Quality of tone •Muscle bulk –Oburator Internus • Above arcus tendinous @ 3 & 9 o’clock • ER hip into examiner’s hand –Piriformis • Deep • Bring knee to opposite shoulder MSK Pelvic Floor Examination: Internal Vaginal
•Perform manual muscle testing Grading of Strength (Modified from Laycock 2001) • 0/5 - No contraction of muscles • Quality of contraction in 4 quadrants • 1/5 - Flicker or pulsation is felt, no discernible lifting or –Left, right, anterior, posterior tightening • Strong hold • 2/5 - Weak contraction, no discernible lifting or • Assess 5-10 quick flicks tightening • 3/5 - Moderate, some lifting of the posterior wall and • Compare right and left sides some tightening around the examiner's finger, • Modified Oxford Scale contraction is visible –Poor inter-rater reliability • 4/5 - Good, elevation of the vaginal wall is felt against resistance, drawing in of the perineum is felt, able to hold for 5 or more seconds •Palpate ischial spine • 5/5 - Strong resistance is felt, if 2 fingers are inserted, –Tinel’s sign: pudendal n paresthesia fingers will be approximated, able to hold for with 10- second hold MSK Pelvic Floor Examination: Rectal
External Internal •Inspection: •Sphincter exam –hemorrhoids, lesions –EAS –IAS –Resting tone and contraction •Sensory testing •Coccyx –Tenderness •Anal wink reflex –Position –Mobility •Palpate the coccyx externally •Ligaments - sacrococcygeal junction •Muscle exam: –Coccygeus, OI and LAM –Compare R and L Function of Pelvic Floor Musculature
• Kegel 1950's – – Support – Sphincteric closure – Sexual appreciation • Herman & Wallace – Above + • Stabilization • Sump Pump