Vaginal Assessment of the Pelvic Floor[1]

1/23/20

Vaginal Assessment of the pelvic floor complex. Kate Walsh Specialist Physiotherapist -Pelvic Health Chelsea and Westminster Hospital Saturday 25th January 2020

Scope of practice

Consent to treatment Professional Use of chaperone Issues Confidentiality

Infection prevention/control

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Scope of practice Standard 3: Work within the limits of your knowledge and skills Keep within your scope of practice

3.1 You must keep within your scope of practice by only practising in the areas you have appropriate knowledge, skills and experience for.

3.2 You must refer a service user to another practitioner if the care, treatment or other services they need are beyond your scope of practice. Standards of conduct, performance and ethics

HCPC (2016)

Consent to treatment

“You must make sure that you have consent from service users or other appropriate authority before you provide care, treatment or other services”.

• Standard 1.4 of the Standards of conduct, performance and ethics, HCPC (2016)

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Consent: key points

“valid” • The patient must be competent to take that particular decision • Informed • Not acting under duress Consent maybe withdrawn at any time Signature – this does not prove consent valid • Assessment of capacity • Our conclusions • Our thought processes • Relevant risk

Consent: key points contd.

The patient understands why the assessment/treatment has to be done • Relevant risks • Benefits • Alternatives

Photography/ video of patients • Written consent

3 1/23/20

Use of Chaperone

Risk assessment • Lone-working • Male therapists treating female patients • Close technique in a state of undress • Failure to communicate techniques with adequate explanation to patients

• Chartered Society of Physiotherapy (2013)

Confidentiality

“Chartered Physiotherapists shall ensure the confidentiality and security of information acquired in a professional capacity”

• Rule 3, Rules of Professional Conduct, CSP (2002)

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Infection prevention/control

• Establish and maintain a safe practice environment • Equipment • Therapist • Patient • Communication

Anatomy and mapping of the female pelvis and pelvic floor complex

EXTERNAL

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Aims

• Review and consolidate anatomy of the external pelvis, joints, ligaments and muscles

• Understanding association between pelvic floor complex and lumbo- pelvic region

• Enhance palpation skills of external pelvis and female pelvic floor complex

• Consolidate knowledge in relation to the post-natal client

The lumbo- pelvic hip complex

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Stability/ function

• Optimum function requires stability and mobility

• Static stability

• Dynamic stability

• Control (Diane Lee)

• Using optimum strategies to achieve function

• Brain/ CNS “controller”

Form/Force closure

• Form Closure Architecture of joints maintain integrity of system (shape, orientation etc.)

• Force Closure Extra forces needed to maintain integrity of system under load (compressive forces generated by muscles, fascia, ligaments)

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Integrated Model of Function (Lee 2004)

Framework for organizing the knowledge gained through assessment and guiding treatment planning

Form Closure Force closure

Integrated Model of FUNCTION Function Motor Control Emotions/awa (neural reness patterning)

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Pelvic Mobility

3 planes of movement • Ant/post (sagittal) • Lateral tilt (coronal) • Axial rotation (transverse)

Intra-pelvic mobility • Sacroiliac joint • Pubic symphysis

SACRUM

Sacroiliac Joint • Synovial joint with L-shaped articular surface • Articular surfaces have complimentary ridges and depressions • Joint capsule outer fibrous/inner synovial layer NUTATION • Forward flexion sacrum on ilium • With posterior rotation ileum -> sacrum close packed position (stable) COUNTERNUTATION • Extension of sacrum on ilium • With anterior rotation ileum on sacrum -> loose packed (unstable)

• Reciprocal movement at lumbo-sacral and sacrococcygeal junctions

9 1/23/20

Common postures

• Slumped sitting

Posterior pelvic tilt

Counternutation

Compression top of pubic symphysis

Gap/widening inferiorly pubic symphysis and ischial tuberosities (pain in “sitting bones”/long dorsal ligt.)

Lumbar flexion

Common postures contd.

• Supine Counternutation

• Sitting to standing Slight nutation

• Forward flexion/extension Complete nutation

10 1/23/20

Common postures contd.

• Standing Neutral pelvis Slight nutation

• Standing - kyphotic/lordotic • Pelvis - anterior tilt • Complete nutation

Pelvic Ligaments

Key ligaments • Anterior sacroiliac ligament • Iliolumbar ligament • Sacrococcygeal ligament (flex/extn in response to pelvic floor contraction/ relaxation ) • Sacrospinous ligament (resists nutation)

• www.anatomy.tv

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Pelvic Ligaments

Key ligaments • Posterior sacro-iliac ligament • Posterior sacrococcygeal ligament • Long dorsal ligament (resists counternutation) • Sacrotuberous ligament (resists nutation) • Surperficial posterior sacrococcygeal ligament

www.anatomy.tv

Symphysis Pubis

• Non synovial joint • Reinforced by ligaments Superior (fibres from abdominals and adductors) INFERIOR ARCUATE (stability) Anterior Posterior • Inguinal ligament • Nerve supply – pudendal and genitofemoral (L1,2) • Vulnerable to shear • Gray’s anatomy for students

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Abdomino-Pelvic Cannister

• 85 joints • specific tasks -> optimum strategies (specific co-contraction) • Paul Hodges (2007) association of pelvic floor / diaphragm and transversus abdominis • Core stability • Anticipatory feedforward activity of pelvic floor in response to Upper limb activity (knack) • Synergy

Abdomino-Pelvic Cannister contd.

• Pelvic floor key role in dynamic stability (3d) • Co-activation of trans abs with pelvic floor during lifting -> Increased intra-abdominal pressure Increased tension thoraco-lumbar fascia Increased tension anterior abdominal fascia and linea alba • Deep muscles LPHC prepare the body for loads via mechanisms that increase intra-abdominal pressure. • CNS - controller

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Summary key factors in successful load transfer via the LPHC.

• Mobility maintained keeping intended path of movement • Respiration supported • Continence maintained • Ability to control expected/unexpected perturbations (internal/external)

Studies :-

Pool Goudzwaard et al (2004) • Increase SIJ stiffness when pelvic floor contract as group • NOT with individual stimulation of muscles (ileococcygeus)

Pel et al (2008) • Stimulation of trans ab. And pelvic floor -> significant decrease in shear forces through SIJ • Gluteus medius , minimus and piriformis increase compression between innominate and sacrum but do not influence shear.

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Global Muscle Slings

• Posterior Sling – latissimus dorsi, gluteus maximus, thoracolumbar fascia

• Anterior Sling- external oblique, contra-lateral internal oblique, contralateral adductors, anterior abdominal fascia

• Longitudinal Sling – erector spinae, thoraco-lumbar fascia, sacrotuberous ligament, biceps femoris, peroneii

• Lateral Sling – gluteus medius, gluteus minimus, thoracolumbar fascia, contralateral adductors

PRACTICAL: External Palpation

Bony landmarks •Anterior superior iliac spines (ASIS) •Symphysis pubis •Posterior superior iliac spines (PSIS) •Inferior lateral angles of sacrum (ILA) •Sacral sulci •Femoral head •Ischial tuberosities

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Practical : external palpation Contd.

Ligaments • Arcuate • Long dorsal • Sacrotuberous • Sacrospinous • Ilio-lumbar

Practical: external palpation contd.

Muscles • Transversus abdominis • Rectus abdominis • Diaphragm • Adductors • Gluteals • External Oblique

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Mapping: the Pelvic Floor and Perineum

INTERNAL

Orientation of the Pelvis

• 3 dimensional

• Depth/width/height

• ASIS and symphysis pubis perpendicular to floor

• Genital hiatus parallel

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Endopelvic Fascia

• Support (and constriction of urethro-vesical neck) • Dense fibrous connective tissue • Role in supporting pelvic organs, continence and postural control • Ashton-Miller and Delancey (2009) Pubovisceral muscle stretches x3 resting length during 2nd stage

• Delancey 2005

Endopelvic Fascia

Endopelvic fascia surrounds vagina attaches to Arcus Tendineous Fascia pelvis (ATFP) laterally ATFP attaches to pubis bone ventrally and ischial spine dorsally Provides attachment points for support to anchor urethra, bladder and vagina

Levator Ani ATLA Vesical neck ATFP

Delancey, 2002

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Arcus tendinous Levator Ani (ATLA)

Arcus Tendineous Levator Ani (ATLA)

• Runs from ischial spine to posterior surface ipsilateral superior pubic ramus • Linear thickening of obturator internus fascia • Attaches lateral to ATFP • Palpable posterior aspect of symphysis pubis lateral to urethra

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Levator Avulsion

• Traumatic dislodgement of muscle from its bony insertion

• http://Sydney.edu.au/nepean/res earch/obstretrics/pelvic-floor- assessment/Pelvic Floor assessment/Clinical levator assessment.html

Superficial pelvic floor muscles www.anatomytv.com

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Superficial Pelvic Floor

• Ischiocavernosus • Bulbocavernosus • Superficial transverse perineal muscle • Deep transverse perineal muscle

Superficial pelvic floor muscles (layer 1)

Ischiocavernosus Perineum Bulbocavernosus Superficial transverse perineal

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Urethral sphincter complex

Striated Urethral sphincter

Urethro-vaginal sphincter

Urethral sphincter complex contd.

Compressor urethra

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Deep pelvic Floor Muscles : Levator Ani

• Pubovisceral puboperinealis Pubovaginalis Puboanalis Puborectalis • Pubococcygeus • Ileococcygeus • Coccygeus

Deep pelvic floor muscles

Coccygeus

Ileococcygeus

Pubococcygeus

Puboanalis

Obturator fascia

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Urogenital Hiatus

Rectum

Cervix Vagina urethra

Levator Ani fascia

Superior fascia of the pelvic diaphragm

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Quadratus Lumborum Iliacus Piriformis

Gluteus minimus

Vertical Clock

8 4

6 12 o’clock = symphysis pubis 4 and 8 o’clock = pubococcygeus 6 o’clock – perineal body/puborectalis

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Horizontal Clock 12

10 2

12 o’clock = coccyx 10 o’clock and 2 o’clock = Ileococcygeus Base of finger over pubococcygeus

HORIZONTAL CLOCK

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Associated pelvic muscles

PIRIFORMIS OBTURATOR INTERNUS

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Superficial pelvic floor and levator attachments

Deep Pelvic Floor Muscles

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Practical : Internal Mapping

Structures • Bladder neck • Urethra • Arcus Tendineous Levator Ani (ATLA) • Ischial spine

Practical : Internal Mapping

Superficial pelvic floor muscles • Bulbocavernosus • Ischiocavernosus • Superficial and deep perineii • Observe the length of the perineal body Deep pelvic floor muscles • Pubovisceral muscle -puboperinealis -pubovaginalis -puboanalis -puborectalis

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Practical : Internal Mapping Deep Pelvic Floor muscles (contd.)

• Pubococcygeus • Ileococcygeus • Coccygeus (Ischiococcygeus)

• Obturator Internus • Piriformis • Ischial spine

Anal Sphincters

• Internal Anal Sphincter (IAS) Circular smooth muscle

• External Anal Sphincter (EAS) Deep and superficial components Striated longitudinal muscle

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• Images courtesy of St Marks Hospital

Puborectalis Puboanalis and the Anorectal Angle www.anatomy.tv

Pubococcygeus

Puborectalis

Puboanalis

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Somatic Nerve Supply to the Pelvis

Somatic Motor Nerves • Nerve to Levator Ani (S3- S5) • Pudendal nerve (S2-4)

Somatosensory Nerves • Pudendal (mixed) • Ilioinguinal (L1) • Genitofemoral (L1,2) • Posterior femoral cutaneous nerve (L2,3,4) • Obturator nerve (L2,3,4)

Nerve supply Contd.

Nerve to Levator Ani • Main somatic nerve supply for Levator Ani • S3-5 • Sacral Plexus (L4,5 S1,2,3,4) lies on posterior pelvic wall anterior to piriformis Pudendal nerve • Branches -inferior rectal nerve - perineal nerve - dorsal nerve of clitoris • Mixed nerve (motor, sensory and autonomic)

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Nerve supply contd.

Autonomic nerve supply • Hypogastric nerve (L1-L2) General visceral afferents Sympathetic motor efferents

• Pelvic Splanchnic nerve (S2-S3) General visceral afferents Parasympathetic motor efferents

Dermatomes

• Pelvic pain : diagnosis and management , Howard 2000

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Nerve Supply to the perineum

a – pudendal nerve b – posterior femoral cutaneous nerve c – obturator nerve d – genitofemoral nerve

www.glowm.com

Vulva and Perineum

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Practical: Mapping

• Vulva • Labia Majora • Labia Minora • Vestibule • Harts Line • Bartholins Glands • Perineum

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ASSESSMENT OF THE PELVIC FLOOR COMPLEX

www.integration.samhsa. gov/clinical- practice/handbook- sensitive-practices4 healthcare.pdf

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Order of objective assessment

• Internal/external

• Rectal/vaginal/abdominal

• Order and specifics of assessment guided initially by subjective findings then by what you find as you assess….

• Use observational and manual assessment skills

External assessment

• Skin/superficial fascia • Abdomen • Breathing pattern • Lumbar spine movements • Hip and pelvic girdle ROM • Intra-pelvic joint movements/symmetry (SIJ, Pubic symphysis) • Pelvic girdle ligaments

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Before you start………

• Engage with the person • take your time…no hurry • Specific questions:- • Anxiety?...history? • Difficulty with previous examinations/procedures like this? • How can you make it easier for the patient… • Control…

Pelvic floor/perineum

• Observe crook lying/side lying • Scars • Prolapse visible at rest • Perineal descent at rest • Haemorrhoids • Quality of soft tissues vulva…dryness… • Obvious areas of tightness e.g adductors, gluteals, piriformis, abdominals, ribs ( flared?) • Sensory testing

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Neuro testing

Internal assessment.

Muscles (active system) (Superficial layer/ vertical clock) • Bulbocavernosus • Ischiocavernosus • Superficial transverse perineal muscle • Deep transverse perineal muscle • Perineal body (length/mobility?)

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Internal assessment contd.

(Deep layer /horizontal clock) • Puborectalis • Pubococcygeus • Ileococcygeus • Coccygeus

• Obturator Internus • Piriformis

Internal assessment contd.

• (passive system) • Urethro-vesical junction • Bladder neck • Cervix • Anterior and posterior wall support -With/without cough -Valsalva • Fascial support

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Internal examination of the pelvic floor

• Position of patient/bed height/light • Relaxed examination finger • Palpate superficial muscles , bulbo .…pincer grip (gently!)…trigger points? • Turn pad of finger upwards palpate urethra superior to pubic symphysis…tenderness/mobility/urethral sphincter activity…? • ATLA..avulsion? • Slowly sweep vaginal wall from 2 o’clock to 10 o’clock (vertical clock) - muscle bulk/symmetry? -atrophy/scars ? -soreness/pain ? -faeces in rectum?

Internal examination pelvic floor contd.

• Move deeper into the horizontal clock towards posterior pelvic floor • Score the “lift” on Modified Oxford Scale Maximum Voluntary Contraction • More anterior compartment on vertical clock ->compression action • Compare sides

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Muscle properties

• Strength • Endurance • Length • Speed of contraction and release • Stiffness- active/passive • Symmetry/synergy/co-ordination

What to assess?

• Muscle stiffness/resistance to passive stretch • Quality of contraction … brisk/sluggish • Controlled/fluctuating • Direction/specific action • Synergy – PF with diaphragm/breathing • Co-contraction of transversus abdominis • Compensatory muscle activity • Release – easy/full • Hypertonicity/shortening/asymmetry/trigger points • Imbalance – anterior>posterior

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PERFECT scoring system

• Power – performance • Endurance • Repetition • Fast (phasic) • Elevation (posterior wall lifts MVC) • Contraction (lower abs MVC) • Timing (synchronicity) Jo Laycock

Modified Oxford Scale

0- Nil 1- flicker 2-weak (increase tensions and some lift/squeeze fingers) 3- moderate (posterior wall lifts) 4 – good (elevation of posterior wall against resistance and in-drawing perineum) 5- strong (overcomes strong resistance against elevation of posterior vaginal wall)

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Documentation

• Keep it simple • Standardise your own system • Objective • Diagrams • Focus of assessment – symptoms / signs

Common post-natal pelvic floor dysfunction

What are you going to find?

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• Urinary incontinence (urge/stress/mixed) • Urinary Frequency/urgency • Pelvic organ prolapse • Pelvic pain • Sexual dysfunction/dyspareunia • Vaginal laxity • Faecal urgency/incontinence • Rectal pain • Pelvic girdle pain