Revitalize Physical Therapy Blog - Page 31 of 55

In honor of Endometriosis Awareness Month, I have decided to discuss and share an incredible TEDx talk given by Shannon Cohn at the University of Mississippi, entitled “The Most Common Disease You’ve Never Heard Of” (link to video). First, I will provide a bit of background information.

Endometrosis is a condition in which endometrium, tissue that typically grows inside of the uterus, grows outside of the uterus. Endometrial tissue can grow on the ovaries, fallopian tubes, and surrounding tissue. The main symptoms are pelvic pain (especially during menstruation) and infertility. Other symptoms may include nausea, bloating, fatigue, migraines, organ dysfunction, internal bleeding and/or scarring. On average, the disease takes ten years to diagnose over the course of seeing eight different doctors. It effects 10% of reproductive aged girls and women.

In her talk, Cohn discusses how endometriosis is arguably the most common devastating problem that most people have never heard of. She herself describes her personal struggle with years of menstrual pain, so much so to the point that at times she could barely stand straight during her period. Thirteen years and seventeen doctors later, she finally received an accurate diagnosis and heard the word “endometriosis” for the first time.

Once properly diagnosed, Cohn underwent an extensive surgery that required a week long hospitalization stay. She explains that there are two types of endometriosis surgeries, excision surgery (during which the endometrial growths are removed) and ablation surgery (during which growths are burned at the surface, a less effective procedure than excision). Many women with endometriosis require multiple surgeries over the course of their lives.

Cohn discusses that the medications described for women with endometriosis (ex. anti-inflammatories, birth control, or hormone drugs) are merely band aids that treat symptoms as opposed to cures. In addition, they can cause a wide variety of unpleasant side effects.

Cohn’s explores an obvious question- if endometriosis plagues so many women, why isn’t there better treatment available? Cohn posits that it is likely due to a number of factors, including lack of awareness (both within the medical and lay communities), gender bias, fragmented care, what she refers to as “the perfect awful storm.” The fact that menstruation is a taboo further complicates proper diagnosis and treatment. Sure, no one wants to discuss their menstrual cramps, at times even with physicians, however debilitating painful cramps may be indicative of a condition that requires attention. Cohn encourages women to discuss the topic with appropriate personnel to raise awareness and enable those who are suffering in silence to obtain the help they deserve. Her message has inspired me to write this blog and to share her TEDx talk. I encourage you to continue the conversation and promote further awareness.

Blog after blog, we discuss the pelvic floor and the musculoskeletal system contained within this region of the body. In case any of you have wondered, “Hmm…what exactly does she mean when she talks about the pelvic floor?…” today is your lucky day! Because today, dear reader, we will discuss some of basic anatomy and physiology of the area we refer to as the pelvic floor.

The pelvic floor is a truly incredible system. Several noteworthy anatomical landmarks include:

Hip bone- comprised of a left and right ilium, ischium, and pubic bone
Pubic symphysis- this cartilaginous joint is located at the junction of the left and right superior rami of the pubic bones. The bladder is located behind it and the clitoris and external genitalia are located below it. This joint acts like a cushion and serves as a shock absorber during walking. It also allows for pelvic expansion during labor and delivery. The pubic symphysis has a small degree of superior/inferior mobility (movement up or down) as well as the ability to separate slightly, as required during pregnancy to accommodate for the growing fetus. The space in between the two pubic bones is usually 4-5 mm, however this can increase 2-3 mm during pregnancy. Diastasis of the symphysis pubis, also known as pubic symphysis separation, is a dysfunctional excessive widening of the pubic symphysis joint during pregnancy or after delivery.
Sacrum- This bone looks like an upside down triangle and it rests at the base of the spine. It consists of five smaller sacral bones (or vertebrae) which fuse between the ages of 18 and 30. It connects to the fifth lumbar vertebrae which sits above it, the coccyx which sits below it, and the left and right ilium bones of the hip. Several important muscles which allow for movement of the legs, including the gluteus maximus, iliacus, and piriformis, originate from the sacrum and are attached to this bone.
Coccyx- This bone, colloquially referred to as the tailbone, is a small, often overlooked anatomical landmark that sits below the lumbar spine and sacrum. Despite its tiny size, it is extremely clinically significant. Think of it as the Grand Central Station of your pelvic floor, so to speak. The coccyx serves as the attachment site of the gluteus maximus and levator ani muscles (which include the coccygeus, iliococcygeus, and pubococcygeus muscles) and ligaments (including the anterior, posterior, and lateral sacrococcygeal, sacrotuberous, and sacrospinous ligaments). Injury to the coccyx can affect the aforementioned muscles and/or ligaments. Conversely, injury to the muscles and/or ligaments can affect coccyx alignment. Symptoms of coccyx dysfunction include coccyx pain (referred to as coccydynia), pain with defecation, pain with intercourse, pain with prolonged sitting, pain with transitional movements (such as sit to stand), coccyx pain, low back pain, and even neck pain
Ischial tuberosities- these prominent bumps (or protuberances) are located on the left and right ischium bones, and they are commonly referred to as the sitz bones. Most people bear weight onto the ischial tuberosities while sitting. The hamstrings muscles and sacrotuberous ligaments attach to the ischial tuberosities.

Four layers of muscular tissue (aka diaphragms) exist within the pelvic floor:

Superficial perineal space, the area overlying the pelvic outlet, which includes the genitalia, urogenital triangle, anal triangle, perineal body
Urogenital diaphragm- contains deep transverse perineal muscle and sphincter urethrae (contributes to voluntary control of voiding)
Pelvic diaphragm (aka levator ani muscles)- this is the deepest layer of striated muscle. The two primary functions of this layer of muscles is to elevate the pelvic floor and to resist intra-abdominal pressure. It consists of four muscles (one on each side), the pubococcygeus, the puborectalis (controls descent of feces, creates anorectal junction/angulation), the iliococcygeus, and the coccygeus.
Smooth muscle diaphragm- this contains the internal urethral sphincter and the external urethral sphincter

In addition, there are three openings within the pelvic floor. From front to back, the three openings are:

The urethra, which connects to the bladder and is involved with elimination of urine.
The vagina, which connects to the uterus and is the opening through which the fetus is delivered at the end of pregnancy.
The anus, which connects to the rectum and is involved with elimination of stool.

The area located between the vagina and the anus is referred to the perineal body.

Hopefully, this little anatomy lesson has given you a better frame of reference for any discussion about women’s health. Understanding one’s body and how it functions will hopefully lead to a greater appreciation of the daily miracles that occur as well as lead to quicker diagnosis and treatment of dysfunction.