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Vaginal Assessment of the Pelvic Floor[1]

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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 1 Scope of practice Consent to treatment Professional Use of chaperone Issues Confidentiality Infection prevention/control 2 1 1/23/20 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) 3 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) 4 2 1/23/20 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• The patient must be competent to take that particular decision • Informed • Not acting under duress Consent maybe withdrawn at any time Signature – this does not prove consent valid • Assessment of capacity • Our conclusions • Our thought processes • Relevant risk 5 Consent: key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 6 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) 7 Confidentiality “Chartered Physiotherapists shall ensure the confidentiality and security of information acquired in a professional capacity” • Rule 3, Rules of Professional Conduct, CSP (2002) 8 4 1/23/20 Infection prevention/control • Establish and maintain a safe practice environment • Equipment • Therapist • Patient • Communication 9 Anatomy and mapping of the female pelvis and pelvic floor complex EXTERNAL 10 5 1/23/20 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 11 The lumBo- pelvic hip complex 12 6 1/23/20 StaBility/ function • Optimum function requires stability and mobility • Static stability • Dynamic stability • Control (Diane Lee) • Using optimum strategies to achieve function • Brain/ CNS “controller” 13 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) 14 7 1/23/20 Integrated Model of Function (Lee 2004) Framework for organizing the knowledge gained through assessment and guiding treatment planning 15 Form Closure Force closure Integrated Model of FUNCTION Function Motor Control Emotions/awa (neural reness patterning) 16 8 1/23/20 Pelvic MoBility 3 planes of movement • Ant/post (sagittal) • Lateral tilt (coronal) • Axial rotation (transverse) Intra-pelvic mobility • Sacroiliac joint • Pubic symphysis 17 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 18 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 19 Common postures contd. • Supine Counternutation • Sitting to standing Slight nutation • Forward flexion/extension Complete nutation 20 10 1/23/20 Common postures contd. • Standing Neutral pelvis Slight nutation • Standing - kyphotic/lordotic • Pelvis - anterior tilt • Complete nutation 21 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 22 11 1/23/20 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 23 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 24 12 1/23/20 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 25 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 26 13 1/23/20 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) 27 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. 28 14 1/23/20 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 29 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 30 30 15 1/23/20 Practical : external palpation Contd. Ligaments • Arcuate • Long dorsal • Sacrotuberous • Sacrospinous • Ilio-lumbar 31 Practical: external palpation contd. Muscles • Transversus abdominis • Rectus abdominis • Diaphragm • Adductors • Gluteals • External Oblique 32 16 1/23/20 Mapping: the Pelvic Floor and Perineum INTERNAL 33 Orientation of the Pelvis • 3 dimensional • Depth/width/height • ASIS and symphysis pubis perpendicular to floor • Genital hiatus parallel 34 17 1/23/20 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 35 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 36 18 1/23/20 Arcus tendinous Levator Ani (ATLA) 37 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 38 19 1/23/20 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 39 Superficial pelvic floor muscles www.anatomytv.com 40 20 1/23/20 Superficial Pelvic Floor • Ischiocavernosus • Bulbocavernosus • Superficial transverse perineal muscle • Deep transverse perineal muscle 41 Superficial pelvic floor muscles (layer 1) Ischiocavernosus Perineum Bulbocavernosus Superficial transverse perineal 42 21 1/23/20 Urethral sphincter complex Striated Urethral sphincter Urethro-vaginal sphincter 43 Urethral sphincter complex contd. Compressor urethra 44 22 1/23/20 Deep pelvic Floor Muscles : Levator Ani • Pubovisceral puboperinealis Pubovaginalis Puboanalis Puborectalis • Pubococcygeus • Ileococcygeus
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