Download Pelvic Pain: Physiatric Evaluation and Management

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 •Sacrotuberous ligament •Sacrospinous ligament 7

Pelvic Floor Muscles: Superficial

A. B. C. D. E.

Superficial & Deep transverse perineal Bulbcavernosus/spongiosus Ischiocavernosus External Anal Sphincter (EAS) Perineal body

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Pelvic Floor Muscles: Levator Ani Puborectalis

Levator Ani

Pubococcygeus

Iliococcygeus IC

PR

IC

PC

IC PC

IC

PR

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Pelvic Floor Muscles: Deeper Layer

Piriformis

Obturator internus

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More Anatomy – It never ends!

Nerves of the Pelvis • Lumbosacral trunk • Pudendal nerve • Nerve to Levator Ani and Coccygeus

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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 femoral cutanueous nerve

Inferior cluneal

Posterior femoral cutaneous n.

C=

Obturator

Obturator

Medial cutaneous n. of thigh

Medial Cutaneous n. of thigh

D=

Ilioinguinal + Genitofemoral

Iliohypogastric & Ilioinguinal

Iliohypogastric only

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

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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 • Quality of contraction in 4 quadrants

–Left, right, anterior, posterior • Strong hold • Assess 5-10 quick flicks • Compare right and left sides • Modified Oxford Scale

–Poor inter-rater reliability • Palpate ischial spine –Tinel’s sign: pudendal n paresthesia

Grading of Strength (Modified from Laycock 2001) • 0/5 - No contraction of muscles • 1/5 - Flicker or pulsation is felt, no discernible lifting or tightening • 2/5 - Weak contraction, no discernible lifting or tightening • 3/5 - Moderate, some lifting of the posterior wall and some tightening around the examiner's finger, contraction is visible • 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 • 5/5 - Strong resistance is felt, if 2 fingers are inserted, fingers will be approximated, able to hold for with 10second hold

MSK Pelvic Floor Examination: Rectal External

Internal

• Inspection:

• Sphincter exam

–hemorrhoids, lesions

• Sensory testing • Anal wink reflex • Palpate the coccyx externally

–EAS –IAS –Resting tone and contraction

• Coccyx –Tenderness –Position –Mobility

• 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