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 The PF consists of three muscle layers:
 Superficial perineal layer: innervated by the pudendal nerve
 Bulbocavernosus...
2 types of muscle fibres
Type I slow twitch fibers
Type II fast twitch fibres
70% PFM are slow twitch fibres
The PFM ...
 In females, supports and gives tone to
the vaginal wall
 Supports pelvic organs against gravity
 Increase intra abdomi...
Allow for opening of the pelvic floor to
accommodate excretory functions and
parturition
Reinforce urethral closure duri...
 Diaphragmatic-
 The abdominal wall, respiratory
and pelvic diaphragms create a
functional cylinder
 This cylinder is c...
 As the abdominal muscles
respiratory and pelvic
diaphragms contract
The intra-abdominal pressure
increases
The entire ab...
 Anatomic impairment
Birth injuries
Neurological dysfunction
 Psychological impairement
Motivation
Sexual abuse
 Pt assessment should include
 Presenting symptoms in order of importance
 Relevant obstetric , medical , gynecological...
 Rectal function-defecation pattern
 Objective assessment
 Digital per vaginal examination
 Digital per anal muscle as...
PERFECT
 P-power
 E-endurance
 R –resting tone
 F- fast contraction
 Ect- each contraction time
 C- coordination
 O...
 1.vaginal examination by the physiotherapist
 2. self-examination by the patient
 3. hand on perineum by the physiothe...
 8.stop and start midstream
 9. using the Neen Healthcare ‘Educator’
 10. using a cone in the vagina and applying
tract...
Peritron
Peritron is a hand-held clinical Perineometer intended for
assessing the strength of pelvic floor (PF) muscles an...
 Grades
 1/5- unable to slow the stream of urine
 2/5- can slow the stream of urine but cannot stop
it
 3/5- can stop ...
 Jumping jack test
 Pad test
 EMG
 Urodynamic assessment
 Pelvic floor dynamometer
 Pregnancy
 Within 6 weeks of vaginal or cesarean delivery
and pelvic surgery
 Atrophic vaginitis
 Active pelvic infec...
Endurance impairment
Mobility impairment
Posture impairment
Coordination impairment
Supportive dysfunction
Hypertonic dysfunction
In coordination dysfunction
Visceral dysfunction
 Results from loss of strength and integrity of
contractile and non contractile tissues.
 This dysfunction is weakness a...
 Boat- pelvic organs
 Water- pelvic floor muscles
 ropes –ligaments that support pelvic organ
 Problem is with the wat...
 Anatomic impairment of PFM and nerves in
the area
 Vaginal delivery
 Muscle atrophy due to central and peripheral
nerv...
 Impaired performance and endurance of PFM
 Increased PFM length
 Increased connective tissue length and
muscle atrophy...
 Related to pain and spasm
 Medical diagnosis associated with hypertonia
dysfunction, include levator ani syndrome,
pelv...
 Lumbo pelvic joint mobility impairments or
pathology.
 Injuries, such as fall onto the coccyx or pubic
ramus.
 Hip mus...
 Altered tone of the PFM, associated muscle of
hip, buttock and trunk.
 Mobility impairment of scar and connective
tissu...
 Divided into neurological and non neurological
 Detrusor sphincter dyssynergia is a type of
incoordination resulting fr...
 Discuse and decrease awareness of PFM.
 Pain in the pelvic or abdominal area may
disrupt recruitment pattern.
 PFM wea...
 Pseudo- PFM dysfunction dysfunction.
 It is an abnormlity in mobility or motility of
the abdominopelvic visceral tissue...
 Endometriosis
 pelvic inflammatory disease.
 Dysmenorrhea
 Surgical scars
 Irritable bowel syndrome
 Interstitial c...
 Weakness of the abdominal muscles, especially the
oblique and transverse layers may occur in
response to pain in the abd...
Pelvic floor
Pelvic floor
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Pelvic floor

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pelvic floor anatomy

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Pelvic floor

  1. 1.  The PF consists of three muscle layers:  Superficial perineal layer: innervated by the pudendal nerve  Bulbocavernosus  Ischiocavernosus  Superficial transverse perineal  External anal sphincter (EAS)  Deep urogenital diaphragm layer: innervated by pudendal nerve  Compressor urethera  Uretrovaginal sphincter  Deep transverse perineal  Pelvic diaphragm: innervated by sacral nerve roots S3-S5  Levator ani: pubococcygeus (pubovaginalis, puborectalis), iliococcygeus  Coccygeus/ischiococcygeus  Piriformis  Obturator internus
  2. 2. 2 types of muscle fibres Type I slow twitch fibers Type II fast twitch fibres 70% PFM are slow twitch fibres The PFM are the only transverse load bearing muscle group in the body.
  3. 3.  In females, supports and gives tone to the vaginal wall  Supports pelvic organs against gravity  Increase intra abdominal pressure  Maintain anorectal angle.  Relaxation for defecation/contraction  Prevent incontinence (urinary & fecal)
  4. 4. Allow for opening of the pelvic floor to accommodate excretory functions and parturition Reinforce urethral closure during increase of intra abdominal pressure Has an inhibitory effect on bladder activity Assist in unloading the spine Assists in pelvispinal stability Contribute to sexual arousal and performance
  5. 5.  Diaphragmatic-  The abdominal wall, respiratory and pelvic diaphragms create a functional cylinder  This cylinder is created by muscles that must contract and become rigid in order to protect the spine and pelvis during any mechanical loading  In some patients, the pelvic diaphragm does not contract. This causes weakness of this entire support mechanism
  6. 6.  As the abdominal muscles respiratory and pelvic diaphragms contract The intra-abdominal pressure increases The entire abdomen becomes more rigid, able to transmit greater mechanical loads without hurting the spine nor pelvic joints
  7. 7.  Anatomic impairment Birth injuries Neurological dysfunction  Psychological impairement Motivation Sexual abuse
  8. 8.  Pt assessment should include  Presenting symptoms in order of importance  Relevant obstetric , medical , gynecological and surgical h/o  Investigation, and previous and current treatment  Details of voiding dysfunction/ incontinence  Details from frequency / volume charts, fluid intake
  9. 9.  Rectal function-defecation pattern  Objective assessment  Digital per vaginal examination  Digital per anal muscle assessment  Effect of coughing and straining on vaginal wall and organ position  Six point scale- ( 0 for nil contraction, 1- flicker, 2- weak, 3- moderate, 4- good, 5- strong)  Position – supine or standing  One finger or two finger  Perineometer- records vaginal pressure
  10. 10. PERFECT  P-power  E-endurance  R –resting tone  F- fast contraction  Ect- each contraction time  C- coordination  Other impairments ,such as pelvic floor trigger points, decreased sensation, and scars or myofascial adhesions should be noted
  11. 11.  1.vaginal examination by the physiotherapist  2. self-examination by the patient  3. hand on perineum by the physiotherapist  4. hand on perineum by the patient  5. observation of perineum by the physiotherapist  6. observation of perineum by the patient – using a mirror  7. perineometer
  12. 12.  8.stop and start midstream  9. using the Neen Healthcare ‘Educator’  10. using a cone in the vagina and applying traction to the string while  trying to grip the cone  11. asking the partner at intercourse  12. manometric and EMG biofeedback  13. transperineal or labial ultrasound.
  13. 13. Peritron Peritron is a hand-held clinical Perineometer intended for assessing the strength of pelvic floor (PF) muscles and teaching pelvic floor exercises. In operation, air pressure in the sensor caused by a pelvic floor contraction is transferred by a tube to the Readout Unit where it is displayed in several ways . The pressure is displayed either numerically in centimetres water pressure or as a multi-range analogue bar-graph.
  14. 14.  Grades  1/5- unable to slow the stream of urine  2/5- can slow the stream of urine but cannot stop it  3/5- can stop the flow of urine slowly and with difficulty  4/5- urine stop abruptly but cannot be repeated  5/5- urine stops abruptly and stopping can be repeated.
  15. 15.  Jumping jack test  Pad test  EMG  Urodynamic assessment  Pelvic floor dynamometer
  16. 16.  Pregnancy  Within 6 weeks of vaginal or cesarean delivery and pelvic surgery  Atrophic vaginitis  Active pelvic infection  severe pelvic or vaginal pain  Childern and pre sexual adolescents  Lack of informed concent  Lack of therapist training
  17. 17. Endurance impairment Mobility impairment Posture impairment Coordination impairment
  18. 18. Supportive dysfunction Hypertonic dysfunction In coordination dysfunction Visceral dysfunction
  19. 19.  Results from loss of strength and integrity of contractile and non contractile tissues.  This dysfunction is weakness and sagging of PFM.  Common diagnosis associated with supportive dysfunction are stress incontinence, mixed incontinence and pelvic organ prolapse.
  20. 20.  Boat- pelvic organs  Water- pelvic floor muscles  ropes –ligaments that support pelvic organ  Problem is with the water or ropes or both  Result is sinking of the boat  Really the boat itself is fine
  21. 21.  Anatomic impairment of PFM and nerves in the area  Vaginal delivery  Muscle atrophy due to central and peripheral nervous system defect  Decrease awareness leads to weakness  Prolong intra abdominal pressure may result in stretching of PFM or their tendons.  obesity
  22. 22.  Impaired performance and endurance of PFM  Increased PFM length  Increased connective tissue length and muscle atrophy  Impaired abdominal muscle performance  Coordination of the PFM decreased  Pain in PFM  Mobility impairment of pelvic joint.  Symptom of incontinence
  23. 23.  Related to pain and spasm  Medical diagnosis associated with hypertonia dysfunction, include levator ani syndrome, pelvic floor tension myalgia, coccygodynia, vulvodynia , vestibulitis, vaginismus, chronic pelvic pain and dyspareunia.  Hypertonic dysfunction may result from pelvic joint dysfunctions, hip muscle imbalance, and abdomino pelvic adhesions and scars affecting the PFM function.
  24. 24.  Lumbo pelvic joint mobility impairments or pathology.  Injuries, such as fall onto the coccyx or pubic ramus.  Hip muscle imbalance with coordination, pain, altered tone, and muscle performance impairments.  Abdominal and perineal adhesions due to pelvic or abdominal surgery or inflammatory condition of abdomen, such as endometriosis.
  25. 25.  Altered tone of the PFM, associated muscle of hip, buttock and trunk.  Mobility impairment of scar and connective tissue  Mobility impairment( hypermobility, hypomobility) of pelvic joints: SI joint, pubic, lumbar, hip and sacrococcygeal.  Faulty posture  Pain in perineum  Hypersensitivity of skin and mucosa.
  26. 26.  Divided into neurological and non neurological  Detrusor sphincter dyssynergia is a type of incoordination resulting from neurological lesion in the spinal cord between brain stem and T10.the PFM and smooth internal sphincter contract during a bladder contraction so that urine is unable to be expelled.  Non-neurological incoordination dysfunction is characterized by absent or inappropriate patterns of timing and recruitment of the PFM.
  27. 27.  Discuse and decrease awareness of PFM.  Pain in the pelvic or abdominal area may disrupt recruitment pattern.  PFM weakness  Coordination impairment
  28. 28.  Pseudo- PFM dysfunction dysfunction.  It is an abnormlity in mobility or motility of the abdominopelvic visceral tissue that leads to pain and musculoskeletal impairment.  Detrusor instability
  29. 29.  Endometriosis  pelvic inflammatory disease.  Dysmenorrhea  Surgical scars  Irritable bowel syndrome  Interstitial cystitis.
  30. 30.  Weakness of the abdominal muscles, especially the oblique and transverse layers may occur in response to pain in the abdomen, causing a pendulous abdomen with poor visceral and lumbar support.  Secondary lumbo pelvic joint mobility impairment and posture impairments may result.  Altered tone or impaired muscle performance of the PFM may also occur as result of pain in the lower pelvic pain.

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