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Differential Diagnosis of Pelvic Floor pain in Pregnancy

Differential Diagnosis of Pelvic Floor pain in Pregnancy. Anatomy. AKA Pelvic Diaphragm Coccygeus Muscle Levator ani – pubcoccygeus, puborectalis, illeococcygeus Pubococcygeus: can be damaged during parturition

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Differential Diagnosis of Pelvic Floor pain in Pregnancy

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  1. Differential Diagnosis of Pelvic Floor pain in Pregnancy

  2. Anatomy AKA Pelvic Diaphragm • Coccygeus Muscle • Levator ani – pubcoccygeus, puborectalis, illeococcygeus • Pubococcygeus: can be damaged during parturition • Puborectalis: muscular sling envelops inferior rectum, vagina (uterus) & bladder (urethra) • Illeococcygeus: often underdeveloped/less significant role • Weight gain during pregnancy increased the subsequent risk of pelvic floor muscle dysfunction, and elective cesarean section did not prevent urinary incontinence (Barbosa et al, 2013).

  3. Subjective Questions • Pt Hx: 1st report of sxs, aggravating/easing factors • VAS: severity • Bowel/Bladder • Sexual Function • Prolapse • ADLs • Obstetric/Gynecological • Diet • Medical Hx/Meds

  4. Signs & Symptoms • Muscle spasm • Muscle Pain: dull/sharp, constant/intermittent, mild/moderate/severe • Pain radiating to lower back, buttocks, thighs • Pain around connective tissue and ligaments • Pain with pelvic floor muscle contraction • Reproductive, urinary, musculoskeletal

  5. Differential Diagnosis • SIJ pain • Bladder Distention-urinary urgency/incontinence • Pubic Symphysis dysfunction • LBP • Somato-visceral referred pain • Digestive, reproductive, urinary systems • Neurogenic causes (nerve irritation) • Appendicitis

  6. Differential Diagnosis Continued • Colon cancer • Constipation • Crohn’s Disease • Diverticulitis • IBS • Fibromyalgia • UTI

  7. Associated Impairments Pelvic Floor Pain/Dysfunction can be caused by or lead to… • Incontinence (Stress-Urinary/Fecal) • Somatic Pain in the Lower Quadrants • Puborectalis muscle spasm • Obstructed Defecation • Myalgia • Vaginismus, Vulvodynia • Pelvic Organ Prolapse

  8. Tests & Measures • Pelvic Floor contraction technique • Bladder Diary/Fluid Volume • Ultrasound • Manometry • Questionnaires • Paper Towel test (urinary incontinence) • Bristol Stool Chart (Fecal incontinence)

  9. Interventions Pelvic Floor muscle strengthening & relaxation • Kegels: Elevator metaphor contraction (slowly reach max contraction then slowly release the contraction, quick flick, sustained 10s contraction followed by 5s pause. • Spinal stability & strengthening exercise: LTR, lunges, squats, UE PNF • Diaphragmatic breathing: controlled expansion of abdomen on inhalation, draw in umbilicus on exhale

  10. Interventions Continued • Biofeedback A biofeedback specialist uses monitoring equipment that provides feedback — visual cues, sound or verbal guidance — to the patient about body functions that usually aren't under conscious control. Biofeedback can help improve pelvic floor muscle coordination and rectal and bladder sensation. • Myofascial release (transvaginal maneuvers) • Global massage (general)

  11. Alternate Treatment/Referal • Medical treatment:Various medical therapies may be helpful for pelvic floor tension myalgia, including estrogen, pain relievers, nerve pain medications, antidepressants, numbing agents or Botox injections. • Surgery:Many different surgical procedures, including minimally invasive techniques, can be used. • Acupuncture:This may relieve muscle pain, but more research is needed to determine whether it specifically helps with pelvic floor problems.

  12. References • Barbosa, A., Marini, G. I., Piculo, F., Rudge, C., Calderon, I., & Rudge, M. (2013). Prevalence of urinary incontinence and pelvic floor muscle dysfunction in primiparae two years after cesarean section: cross-sectional study. Sao Paulo Medical Journal, 131(2), 95-9. • Giggins, O., Persson, U., & Caulfield, B. (2013). Biofeedback in rehabilitation. Journal of NeuroEngineering and Rehabilitation, 10(60), 1-11. • Goodman, C., & Snyder, T. (2007). Differential diagnosis for physical therapists. (4 ed., pp. 3-912). St. Louis, Missouri: Saunders Elsevier. • Kawasaki, A., & Amundsen, C. L. (2011). We need to expand the differential diagnosis for chronic pelvic pain to include pelvic myofascial pain. OBG Management, 23(10), 17-28. Retrieved from http://www.obgmanagement.com/pdf/2310/2310OBG_Update.pdf • Memon, H., & Handa, V. (2013). Vaginal childbirth and pelvic floor disorders. Women's Health, 9(3), 265-277.

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