Transcript Handout 10

Pelvic Floor Anatomy
A theraband demo of Pelvic Floor Muscle, Joints and Fascia
Kathe Wallace, PT
Pelvic Resources
5901 Roosevelt Way Suite B
Seattle, WA 98105
206 527-2800
KatheWallace.com
Clinical Instructor
Division of Physical Therapy
Dept. of Rehabilitation Medicine, University of WA
Objectives
• Understand the musculoskeletal connections to the pelvic floor
which could contribute to pelvic pain, prolapse and incontinence
• Review the origins and insertions of the pelvic floor muscles using
the 3 layer model.
• Describe the changes to the pelvic floor muscles with altered pelvic
girdle joint alignment in patients presenting for clinical evaluation
of pelvic pain and/or pelvic floor dysfunction.
• Name key pelvic bony landmarks for pelvic floor muscle
• Describe the accessory muscles of the pelvic floor
The Role of Pelvic Floor Musculature
SUPPORT
– Assists in pelvic/spinal stability
– Assists in organ support along w/ ligaments & fascia
SPHINCTERIC
– Reinforces urethral closure during ↑ in intraabdominal pressure
– Has an inhibitory effect on bladder activity
SEXUAL
– Contributes to sexual arousal and performance
– Assists in penis and clitoral erection
– Assists in ejaculation male and female
Pelvic Floor Layers- Functional Divisions
Three muscle layers, w/ 3 nerve branches on each side
1. Superficial Perineal Muscles  Superficial
2. Deep Perineal Pouch
3. Pelvic Diaphragm  Deep
Figure 5.76 B. Pudendal nerve in women.
The Layers of the Pelvic Floor
Graphics from Reviving Your Sex Life after Childbirth; Your guide to painfree and pleasurable sex after the baby, 2014.
The 3 Layers of Pelvic Floor Muscles
• Layer 1 –Perineum, External
genitalia muscles
– Ischiocavernosus,
Bulbocavernous, Superficial
Transverse Perineal, External
anal sphincter
• Layer 2- Urogenital diaphragm
– EUS, Compressor Urethra,
Urethral Vaginal Sphincter
• Layer 3- Pelvic Diaphragm
– Levator Ani , Coccygeus
• Pelvic Wall Muscles- Piriformis,
Obturator internus
6
Accessory Muscles of the PF
Synergistic contraction of the
pelvic floor muscles with
• Hip adduction
• Abdominal muscles
• Gluteals
Bo and Stien (1994) used abdominal curl and
backward tilting of the pelvis in a supine
position
Also consider these muscles in
•
•
Substitution patterns
Myofascial restrictions creating pain or
difficulty contracting the PF ?
Adductor PF Fascial Connections
• Scarpa’s abdominal fascia
(over the ext obliques)
continues to the labia
minora and into the fascia
lata (hip region)
• The superficial perineal
fascia, Colles fascia
surrounds the ischiopubic
ramus at the adductor
origins near Layer 1 PF
muscles
Ciba Medical Slide 455 KW personal collection
Abdominal PF Fascial Connections Layer 2
• Abdominal wall Colles
fascia, (Scarpa fascia
continues into the
perineum) emerges
from the perineal
membrane
• Attaches to the deep
fascia of the posterior
urogenital diaphragm
near Layer 2 PF muscles
Figure 5.68 Borders and ceiling of the perineum. A. Boundaries of the perineum. B.
Perineal membrane.
Figure 5.35 Perineal membrane and deep perineal pouch. A. Inferior view.
B. Superolateral view. Perineal membrane and deep perineal pouch. C.
Medial view.
Layer 3 - Pelvic Diaphragm – Side Walls and Hip
Connections Levator Ani - ATLA
• Internal view of
Obturator internus
ATLA - Fascial
attachment for LA
muscles
• ATLA - Fascial
attachment for
Levator Ani muscles
11
Why is the Pelvic Floor
Overactive or Underactive?
Is it the criminal or the victim?
Causes of PFD Hartmann and Sarton (2014)
• Injury to the Pelvic Floor Muscles
• Inflammatory Pain Disorders Involving Pelvic Viscera
• Faulty Cumulative Behaviors of the Pelvic Floor
Muscles
• Postural and structural dysfunction
• Faulty joint or movement biomechanics
What can happen to the Pelvic Floor
Deformation = Strain
The force may be:
• Compression force, applied by
pushing; e.g. IAP
• Tensile force, occurring because of
pulling; e.g. Scars
• Torsion, which is applied by
twisting or joint position changes
e.g. SI joint dysfunction
Shaffer, R., Moalli, P., Physiology of the Pelvic
Muscles, Vagina, and Anorectum in
Urogynecolgoy and Reconstructive Surgery, (2015)
Chapter 5, 68-80.
Contribution of Pelvic Floor Muscles
to Stability of the Pelvic Ring (Pel 2008)
• PF contributes to
lowering of the vertical
Sacroiliac joint (SIJ)
shear forces, increasing
SIJ compression and
hence increasing SIJ
stability
PF Muscles Alter Pelvic and Hip Alignment
Bendova 2007
• 14 female subjects MRIfunctional stimulation to
unilateral pelvic floor
• The femoral head,
innominate and coccyx
showed the greatest
displacement with PF
muscle stimulation
Attachment Sites for the Pelvic Floor Muscles
• Bone
– Coccyx
– Pubes
– Ischial Tuberosities
– Ischial Spines
– Ischiopubic Rami
• Key Fascial Attachments
– Perineal Body
– Clitoris
– ATLA
Muscle, Joint, Fascia Relationships Demo
Theraband demo adapted from -Franklin, E. (2002). Pelvic Power: Mind / Body Exercises for
Strength, Flexibility, Posture, and Balance for Men and Women. Hightstown, NY, Elysian
Editions Princeton Book Company
Simulations with the bones and muscles