Pelvic Health: Anatomy, Function, and Changes

Pelvic Health Basics

• The term to describe the number of times a woman has been pregnant is Gravida.
• NVD stands for Normal Vaginal Delivery.
• Pelvic floor muscles (PFM) support pelvic organs, assist with urinary and faecal continence, and contribute to sexual function.
• Bulbospongiosus is not part of the levator ani group.
• The main function of the round ligament is to attach the uterus to the mons pubis.

Pelvic Anatomy and Physiology

• The true pelvis is shallower in females compared to males.
• The primary function of the broad ligament covers and supports the uterus, fallopian tubes, and ovaries.
• The iliococcygeus muscle contributes to the elevation of the recto-anal junction.
• The pelvic inlet separates the true pelvis from the false pelvis.

Pregnancy and Postpartum Changes

• Relaxin is responsible for relaxing ligaments and joints during pregnancy.
• Increased joint mobility due to hormonal changes is a common cause of pelvic girdle pain (PGP) during pregnancy.
• The Gynaecoid pelvic shape is most favorable for vaginal delivery.

Pelvic Floor Dysfunction and Prolapse

• LUSCS stands for Lower Uterine Segment Caesarean Section.

• Diastasis rectus abdominis (DRAM) is defined as a separation of the rectus abdominis along the linea alba.

• Regular swimming is not a risk factor for pelvic organ prolapse (POP).

• Obstetric Anal Sphincter Injury (OASI) includes third- and fourth-degree perineal tears.

• The primary role of the perineal body provides attachment for pelvic floor muscles.

• Overload is the pelvic floor muscle training (PFMT) principle that focuses on progressively increasing intensity to improve muscle strength.

• Pelvic floor muscles contain a mix of slow and fast-twitch fibers.

Male Pelvic Health and Prostate Conditions

• The prostate gland is located between the bladder and the pelvic floor muscles, anterior to the rectum.
• Radical prostatectomy (RP) is a surgical treatment for prostate cancer.
• Stress urinary incontinence (SUI) is the most common type of urinary incontinence following radical prostatectomy.
• The external urethral sphincter is the most important muscle for urinary continence post-prostatectomy.
• Erectile dysfunction (ED) post-RP can be improved by pelvic floor muscle training, vacuum erection devices, and medications like Viagra.

Bladder and Bowel Health

• The normal bladder capacity for an adult is 300-600 mL.
• The pelvic nerve controls bladder contraction during micturition.
• The detrusor muscle contracts during urination.
• Acetylcholine is the main neurotransmitter responsible for bladder contraction.
• The internal anal sphincter is controlled by the parasympathetic nervous system.
• The recommended daily fibre intake for adult females is 25g.
• A Bristol Stool Chart score of 1 or 2 indicates constipation.
• The primary function of the puborectalis muscle is faecal continence.
• The purpose of a bladder diary is to assess fluid intake and urinary output.
• Damage to the pudendal nerve, weak external anal sphincter, and obstetric trauma are common causes of faecal incontinence.

Pelvic Floor Assessment and Training

• Digital vaginal or rectal examination is considered the gold standard for evaluating pelvic floor muscle function.
• The Modified Oxford Scale (MOS) measures the strength of the PFM.
• The correct Modified Oxford Scale (MOS) score for a strong contraction is 5.
• "The Knack" refers to a quick squeeze before sneezing or coughing in pelvic floor muscle training.
• PFM training is first-line treatment for stress urinary incontinence, urge urinary incontinence, and pelvic organ prolapse.
• The recommended number of PFM contractions per day for optimal training is 20-30.
• PFM training should start lying down for a beginner with weak pelvic floor muscles.
• Biofeedback is most useful for patients who cannot identify their pelvic floor muscles.

Pelvic Organ Prolapse (POP)

• Type I (slow-twitch) muscle fibres make up most of the pelvic floor.
• PFM training is not only useful for postpartum women.
• Pelvic organ prolapse (POP) is most commonly associated with previous vaginal delivery, obesity, and aging.
• Cystocele is the most common type of POP.
• A vaginal pessary is the best non-surgical treatment for POP.
• A Stage III prolapse means the organ is slightly beyond the vaginal opening.
• The primary purpose of a vaginal pessary is to support prolapsed pelvic organs.

Pelvic Health in Men

• Urinary incontinence is the most common post-prostatectomy issue.
• Nerve damage is the primary cause of erectile dysfunction (ED) after radical prostatectomy.
• The bulbospongiosus muscle in men controls ejaculation and maintains erection.
• Sildenafil (Viagra) is the medication most commonly prescribed for post-prostatectomy erectile dysfunction.
• Penile rehabilitation post-RP is used for maintaining penile blood flow.

Urinary and Faecal Incontinence

• Stress incontinence is characterized by leakage associated with physical exertion.
• An overactive bladder is a common cause of urge urinary incontinence (UUI).
• Pelvic floor muscle training (PFMT) is the first-line treatment for stress urinary incontinence.
• Anal sphincter dysfunction, obstetric trauma and chronic constipation are most commonly associated with faecal incontinence.
• Dietary fibre modification, pelvic floor muscle exercises and biofeedback training are most effective in managing faecal incontinence.

Sexual Function and Pelvic Health

• Testosterone is primarily responsible for libido in both men and women.
• The pubococcygeus muscle plays a key role in sexual function.
• Dyspareunia, Anorgasmia, and Vaginismus are common sexual dysfunctions in women with pelvic floor dysfunction.
• Cognitive behavioral therapy, pelvic floor physiotherapy, and vaginal dilator therapy are recommended treatments for vaginismus.
• Regular physical activity is NOT a risk factor for sexual dysfunction.

Post-Surgical Pelvic Rehabilitation

• Hysterectomy is most likely to result in pelvic organ prolapse.
• The primary role of physiotherapy after pelvic surgery is to promote tissue healing, improve pelvic floor function, and reduce postoperative complications.
• Pelvic floor muscle training (PFMT) is the most effective intervention in managing post-hysterectomy urinary incontinence.
• A patient should wait 6-8 weeks after pelvic surgery before resuming high-impact activities.

Lifestyle and Pelvic Health

• Urinary incontinence is a common complication following a radical prostatectomy.
• Chronic constipation is a lifestyle factor most strongly associated with pelvic organ prolapse.
• Increased water intake helps prevent urinary tract infections (UTIs).
• Running, Weightlifting and Jumping are not recommended for individuals with pelvic floor dysfunction.
• Kegel exercises strengthen the pelvic floor.
• Obesity increases intra-abdominal pressure, weakens pelvic floor muscles, and leads to increased strain on ligaments.
• Postmenopausal women are at most risk for pelvic floor dysfunction.
• High-impact sports increase the risk of stress urinary incontinence in female athletes.

Special Populations and Pelvic Health

• Avoiding weight-bearing exercises is the best exercise modification for pregnant women with pelvic girdle pain.
• Pelvic floor muscle training can improve continence in older adults.
• Pelvic floor muscle training is most appropriate for an elderly patient with both urinary and faecal incontinence.

Postpartum Pelvic Health

• Weak pelvic floor muscles are the most common cause of postpartum urinary incontinence.
• Kegel exercises are the most recommended postpartum exercise for early pelvic floor recovery.
• The pelvic floor typically takes 6-12 weeks to recover after vaginal delivery.
• A feeling of heaviness or bulging in the vagina is most indicative of postpartum pelvic organ prolapse.
• Strengthening pelvic floor muscles is the main goal of postpartum pelvic floor physiotherapy.

Pediatric Pelvic Health

• An overactive bladder is the most common cause of childhood urinary incontinence.
• Bladder training is most effective for treating bedwetting in children.
• Urge incontinence is the most common type of incontinence in children.
• A low-fibre diet is most commonly associated with paediatric constipation.
• Increased fibre and water intake is the recommended first-line treatment for childhood constipation.

Pelvic Health and Neurological Conditions

• Multiple sclerosis is most commonly associated with urinary incontinence.
• Urge incontinence is most common in people with Parkinson's disease.
• Catheterisation is most effective for neurogenic bladder dysfunction.
• Sphincter dysfunction is the primary cause of faecal incontinence in spinal cord injury patients.
• Anticholinergic medication is most commonly used for overactive bladder in multiple sclerosis.

Pregnancy-Related Pelvic Floor Disorders

• A high BMI is the most significant risk factor for pelvic floor dysfunction during pregnancy.
• Perineal massage is the best method for preventing perineal trauma during vaginal delivery.
• Vaginal delivery is most associated with pelvic organ prolapse.
• Placenta previa is a contraindication for vaginal delivery.
• Preventing urinary incontinence is the primary purpose of pelvic floor rehabilitation after childbirth.

Pelvic Health in Athletes

• Running is most associated with stress urinary incontinence.
• High-impact activities increase the risk of pelvic floor dysfunction in female athletes.
• Pelvic floor muscle training is most effective for managing stress urinary incontinence in athletes.
• Pelvic floor muscles are most important for preventing pelvic organ prolapse in female athletes.
• Strengthening the core and pelvic floor is the recommended strategy for preventing pelvic floor dysfunction in female athletes.

Advanced Pelvic Health Concepts

• Digital vaginal examination is the gold standard diagnostic tool for diagnosing pelvic organ prolapse.
• The Modified Oxford Scale is most commonly used to assess pelvic floor muscle function.
• An overactive pelvic floor is most associated with chronic pelvic pain.
• Biofeedback therapy is most effective for treating overactive pelvic floor muscles.
• Hysterectomy is a surgical procedure commonly used to treat severe pelvic organ prolapse.

Surgical Interventions in Pelvic Health

• A mid-urethral sling is most commonly performed for stress urinary incontinence.
• Uterine prolapse is most commonly treated with sacrocolpopexy.
• Urinary retention is a common complication of mid-urethral sling surgery.
• Posterior colporrhaphy is performed to correct rectocele.
• Providing mechanical support is the primary goal of pessary use in pelvic organ prolapse.

Post-Surgical Pelvic Floor Rehabilitation

• Pelvic floor muscle training is first-line for post-hysterectomy pelvic floor recovery.
• Scar tissue and adhesions are the most common cause of pelvic pain post-surgery.
• Opioid use increases the risk of post-surgical urinary retention.
• Strengthening core and pelvic muscles is the primary goal of physiotherapy post-sling surgery.
• Persistent pain is a contraindication for early pelvic floor exercises post-surgery.

Hormonal Influence on Pelvic Health

• Estrogen is most associated with maintaining pelvic floor integrity.
• Vaginal atrophy is most common in postmenopausal women with estrogen deficiency.
• Hormone replacement therapy (HRT) is most effective for treating vaginal atrophy.
• Increased relaxin is associated with pregnancy-related urinary incontinence.
• Urge incontinence is most associated with menopause.

Sexual Health and Pelvic Function

• The pubococcygeus muscle is the most involved in sexual function in females.
• Pelvic floor hypertonicity is most commonly associated with painful intercourse (dyspareunia.)
• Pelvic floor relaxation exercises are most effective for vaginismus.
• An overactive pelvic floor can negatively impact pelvic floor muscle function during sexual activity.
• Strengthening and relaxation is the role of pelvic floor physiotherapy in sexual dysfunction.

Pelvic Floor and Core Strengthening

• Kegels best target the pelvic floor muscles.
• The transversus abdominis is the core muscle most involved in pelvic floor activation.
• Diaphragmatic breathing is recommended during pelvic floor muscle training.
• High-impact jumping is NOT an effective strategy for strengthening the pelvic floor.
• A pelvic floor contraction should be held for 8-10 seconds for endurance training.

Special Considerations in Pelvic Health

• Overtraining is the most common cause of pelvic floor dysfunction in young athletes.
• Pelvic girdle pain is most associated with postpartum pelvic pain.
• Pelvic floor strengthening is the best way to prevent urinary incontinence during exercise.
• Obesity has the biggest impact lifestyle factor on pelvic organ prolapse.
• The 60-70 years is the age group most at risk of developing urinary incontinence.

Future Research in Pelvic Health

• Randomized controlled trials are best for studying pelvic floor dysfunction.
• Botox injections are gaining interest for overactive bladder.
• Motivation is most important for adherence to pelvic floor muscle training.
• Electromyography is being used to advance pelvic floor assessments.
• Increased fibre intake can support pelvic health.