PELVIC FLOOR HEALTH 1

[00:00:01]okay all right so for our uh this webinar series I have created one PPD and um let let's start I'm sharing the PPT with all of you visible visible yeah yes yes okay all right so when we talk about the pelvic floor muscle the first and very beautiful thing over here is that we all are physiotherapist and we understand the body anatomy we know the bones we have understanding of muscles we know how this coordination is going on into the body how the movements take place and uh now this is the only one part pelvic Flo Rehabilitation and pelvic Flo understanding which is not which was not a part of our cabus and that's why we are learning it together today uh why it was not a part of cabus unfortunately the muscle which we are talking about is lying at a very private areas somewhere and people are not very comfortable when we talk about the private areas and intimate areas even you will be surprised that the nerve which Supply this area the name of the nerve is tendal nerve and tendal word came from a Greek word that is a shame shameful area Okay so the nerve which supplies the shameful area is a pudendal nerve so unfortunately this type of U things are there into our medical field as well and we are missing understanding of this very important muscle when we talk about the pelvic floor so it means pelvic floor muscle a muscle which is forming the floor of the pelvis so that is the pelvic floor muscle all of us we are sitting right now in the chair of when you whenever we are like you know male or female who whoever we are that the downward part the part between our uh like below the abdomen the part between the both thighs uh the area around the perenial that is the uh area where pelvic muscle is present so you can assume that assume that we have a glass and the glass is like a cylinder okay it's like a cylinder so the cylender is having upper top it has a bottom it has anterior layer it has posterior layer it has side layers so our whole pelvic region is like a cylinder and anteriorly we are having all these abdominal muscles laterally also we have this obliques posterior we also have the posture back muscles superficially we are having the diaphragm abdominal diaphragm ra same way downward we are having the pelvic floor so the movement which is taking place into the whole area pelvic floor is very very integrated part so you cannot complete the whole core without involving the pelvic Flor in it so the core strengthening like uh one girl from all of us is she's a Pilates instructor and when we understand the Pilates and this kind of uh like exercise programs we generate this kind of training for our our people people so this core strengthening and core training is important part and when the core training is important part pelvic floor is also very very important that is not complete cor is training is not complete without involving pelvic floor in it so now when we talk about the pelvic floor if you just say that uh what is the diagram what is the definition so you might found different definition but just a simple understanding pelvic floor is a floor of the pelvis simp simple okay so as a female and male when we saw that we have a pelvic bone so we know that we have this pelvic bone two bones are coming together and they're forming anterior and posteriorly they're joining together posteriorly we are having SI joint two SI joint so sacrum is joining with the ilum so two SI joints are there posteriorly and anteriorly you can see that all this pubic bone are joined together with the pubic symphisis anteriorly so the bone is giving a good attachment ment and the bone is joined with this connective tissues anterior and posterior joints are also formed now this whole bone is uh somewhere we don't have anything down so if I just show you this this particular model of mine let me pin myself okay if I'll show you this particular model to you all this the pelvic bone so you can say this is a bone and we understand that and we read about this and this in our you know first year itself first year session anat session itself so you can see that these are the two pubic bone which is coming together and attached with the pubic symphisis anteriorly posteriorly we are having this the sacrum attachment with the helium and two SI joint is formed now when we saw when we see that this is the cavity which is formed inside okay so this is a pelvic cavity and into this pelvic cavity depending upon male or female we have a different organ situated if I say that this is a female pelvis so in female pelvis we have three organs are lying one is a bladder second is a uterus and the third is a rectum and uterus is making us more unique we can become mother and every month process is also there starting from the puberty all the time up to the menopause uh so that like know we can become mother so baby can get develop inside so this these are the three organs present in a female pelvis uh now the first is bladder uh which is just behind the pubic symphasis then on the top of the bladder we are having uterus so this is a uterus and then posteriorly we are having this rectum and after this rectum the sacrum is present so this way anterior to posterior these organs are situated into the pelvic cavity of a female and you can also see that these three organs they have canals what the organs are doing they are collecting they have some functioning so we can see that this is the first organ the bladder and bladder is present in both male and female bladder the function of the bladder is like you know expansion collection of the urine and it does expansion so collection of urine as well as the voiding process it is also going to help in to void it when we want to urinate so it collect the urine from the Urus and Urus are attached with the renal system it's a part of renal system with the kidney so kidney they do this their filtration then through the ureters the urine keeps coming downwards and we have these two ureters coming and joining at the posterior part of the bladder so this is anterior aax this is the posterior wall and posterior wall you can see this two ureters attachments are there and through this they are opening inside that down this poer wall and this filling is going on so it will keep filling keep filling and this bladder is going to expand it will collect the urine depending upon is the bladder of a female or a male male bladder size is bigger because we understand the male body is different than the female body so they have more bigger organs as compared to female organ so it they have a more bigger into size it means the collection or that expansion capacity or collection of the urine will be also somewhere into more amount so when we talk about how much urine can be collected normally in a female bladder so we can say 450 ml to 550 ML but when we say that how much there can be in m in male so it can be extra 100 you can see so it can be extra 100 it it means 550 to 650 ml urine can be collect inside the bladder of a male so this is how the bladder is collecting storing till the time because we cannot just we don't have that kind of things like you know other animals are having Urus coming and they're dribbling no we have our brain is involved in that coordination process the nerves are involved and we we uh we can you know control our urine and this controlling is very very important so the bladder is having the nervous control by the brain so nervous system is also present now you can see is also involved now you can see that it is expanding and now who is expanding the whole bladder is expanding so now how many layers are present into the bladder more detail understanding of the bladder we are going to have in our upcoming sessions so but this the you can see the first is the bladder and bladder if it is storing we also need something some some type of canal or tube through which we can pass the urine so same way the tube which is attached with the bladder or the the tube of the bladder we are calling it as a urra or ureal tube so when it is a tube so you can understand tube is like a tunnel it's like a canal and the canal is uh it can be various into size if it is a female so it it can be 4 cm long and if it is a male so we they have a more longer urethra so it can be 17 to 18 cm long because the whole proc this whole mutus is going to pass through the penile structure so we have a difference uh between the female urethra and the male urethra but urethra is a canal through which the fluids are exiting from the body they are going going outside okay and now the canal or the tube it it will definitely have have two openings one opening which is going to attach with the organ itself so this is the internal uh meters you can say or internal opening oral internal opening we can see okay and now external meters externally we can see the canal is having two ends one and attached with the organ other end exiting outside into the perenium we can see visually we can see that okay so we will also show you into uh the slides so this was a small introduction about the bladder cactin and urethra helping into uh uh removal or this voiding process now this is also having different layers different n Supply because this is a smooth organ like our heart other organs are there in in the body so you cannot control what is going on with the organ so the process will be continuous we don't have any control CNS system is going to control okay so that is a made up with the involuntary okay now you can see that this whole part is going to pass through the pelvic floor so if I uh if I'm showing you this this is a pelvic cavity which is made by the pelvic Flor muscle so you can see that starting from the pubic symphisis all the way back up to the sacrum from here to here every where one group of muscles are lying so you can now compare these two structures without muscles and with muscle why we want uh we don't have any bones here because this part is exit we need to have exit passages for exit passages we need something which can relax and contract as per the demand we don't want hard bone there because we need to remove something out of the body it can be removal of the urine feces feces can be TI sometimes constipated stool bigger stool or the baby exit for the baby when baby is coming outside so these all are very very important uh structures just give me a minute I think someone is uh waiting in the room okay no one is in the waiting room so just calling me just give me a minute I'm sorry all right so you can understand you can this comparison between this and this now this is one muscle which is visible here telic floor but there are different part of the pelvic floor we are going to understand later on but here you can see that the this pelvic floor cavity which is formed by completely now this pelvic bone side to side wall like this room you have a wall and then this room where you sitting right now you have a floor also and who are you you are a pelvic organ you are sitting on the floor so the same way we can put this bladder and it we can make it sit on the pelvic floor look it is sitting on the pelvic floor so this is the first organ most anterior organ it means if you palpate your pivic symphisis just behind the pubic symphisis this organ is lying so organ is lying into the pelvic cavity when the bladder is empty if you just urinated your bladder is into the pelvic cavity but the moment it is going to expand it is going to expand into the the size is going to increase and your bladder will come up because it will fill up like a balloon expand like a balloon and it can like involve the pelvic cavity and as well as it can start coming up into the abdominal cavity as well so Supra pubically just this this a pubic symphasis and this on the top of the pubic symphasis if you put your pressure press that area with your fingers so that is a Supra pubic pressure If you apply and if your blood is full you might feel urinal sensation all of you if you have a defecated right now so you can palp if you feel that there's a urinal sensation or something it's like one hour before you urinating so you can right now you can touch Supra pubically and press press so mild pressure can give you sensation so it means your bladder is getting filled up and when you have more sensation if you'll press you will feel more urge as well like know you can see more bladder Sensation will be felt by the brain so Supra pubically when it is palpable it means the expansion is going on the feeling is going on and it is coming into the abdominal cavity so now this bladder is expanding it means it is movable it is not staying in a one position one place I'm I'm staying um into pelvic cavity also and I can expand into the abdominal cavity also it means we don't want any restriction around the whole organ any restriction which is causing uh uh you know this uh movement of the bladder can give a patient difficulty into expansion of the bladder because if someone is pressing on me someone is restricting me I can't expand when I can't expand I can't accumulate more urine inside when I can't accumulate means my storing capacity will minimize when the storing capacity will minimize it means the frequency of urination will be High isn't it it means instead of I'm going for six to seven times in a day I might start going for urination more frequently because I can't expand I can't get filled up within 20200 ml 300 ml because I can't be go beyond that I might have to go for weding so frequency is very very important when we talk about the blad Health we are going to discuss all this one by one in our upcoming uh session but frequency matters and you can see that if I I'm going to put that onto this just behind the pubic symphasis and which muscle is this this is the part of the pelvic flow deeper layer uh pelvic diaphragm or lator ni more deeper layer if I'm putting it so lator ni I is going to come in a direct connection contact with the bladder or the organ organs are sitting onto the levator ni so very very important support liit Ani is providing to the organ if this muscle liit Ani is weak because of something whatever factors if this is weak they cannot hold the organ in a right position and might be organ can start sing downwards this is what happens into prolapse cases the levat an muscles start getting weaker it don't have the tone and strength we will discuss about that in our upcoming sessions now this is resting into the Le ni I and if I if I'll show you the canal the ureal canal is passing through this opening so this particular opening which is present you can see there are two openings present the open other name of the opening is ayus so this is a euro genital hius because urinal system is coming passing through that genital system is also passing through that if we see that male is having penis so penis is passing through this particular heus that's why the name of this heus is penis is a part where sexual functioning is also going on and reproductive system like sperm is also coming outside and urine is also coming outside so urinal system as well as genital system so urogenital opening we can say urogenital heus we can say okay so this is a urogenital opening in female the urethra is passing and then below the urethra we have a different part for the genital that is a uh this is what is our utrus is and uterus is having a vaginal canal and that is also passing through the sameus just beneath the look beneath the urethra so this is how Euro genital system is passing through this urogenital hus I hope it is clear to all of you the first opening urogenital and if this opening is coming who are they they are Flor muscle so around the opening these muscles are wrapped so they are passing and as well as this these are the different layers of pelvic Flor which I'll show you so you can see that look this is how the organ are passing in a female body so this is a female organ uh Velva and you can see externally we have lebia Majora labia minora once you open the labia majora labia minora inside you can see vest vular area and into vestibular area you can see two openings downward is a vaginal opening and the upper is a ureal opening so ureal opening you can say urethra is passing here it is exit Point end point this part now look this whole urethra is passing through the pelvic floor first is a Lor anile then the second layer and the third layer bulbo we will discuss one by one after another so what is the role of this muscle so the muscle is going to help into maintaining micturation process micturation process somewhere is taken care by the brain but uh controlling because we are human being and we are trained in that way since our childhood we can control our urinal system if I'm sitting into the webinar and if I don't want to miss something and U like you know I want to hold my urine so I can hold my urine I can just send the signal to the brain through through the from the brain through the nerves to the muscles that hold so muscles which is present here they are going to contract so whenever you want to hold something muscles will contract the moment you will feel no I want to void so brain will send a signal to the uh if if I'm ready for urination I'll go to the urinal I'll go I'll sit on the commode and I'll I'll just remove my pen sit on the commode and I'll send a signal to my my system relax because I want to pass at that time muscles will relax so they are like a a controlling uh rubber band around the urethra you tighten the rubber band contraction will be there you relax the rub band relaxation urination will be there so the muscle is every muscle of the body they contract they can hold and they can relax squeeze relax this is a moment and the coordination depending upon what brain wants so this is very very important part okay so the muscles are playing so these are the muscles beautifully arranged and how these muscles are helping into that functioning I will disc we will discuss if these muscles which is all around the urethra so you can understand the muscle like levator ni which is directly attached with this platter if that don't have tone so the toning is missing so means muscles cannot hold the organ in a right place so because of the less lack laxity weakness so what will happen if you have a loose rubber band lose rubber band the descending of the organ will start as per the gravity because gravity will keep pulling the organs downwards so the organs can start descending downwards and this is what we we can see into the prolapse cases the organs descent downward okay and laxity cases if the lator an eyes legs organs descent can happen and the second is if the muscles second layer of the muscles are weak the rubber band like you know sping trick roll close close close if that is weak so what these or these muscles are doing one muscle they are passing levator and I but the second layer is holding it from 360° holding so holding means squeezing squeezing means sric action closing if that sric action is muscle don't have tone it it will fail to contract it will fail to react this create this SP trick action if you cannot hold when you have to hold I want to hold right now but I can't hold because the muscles are weak so what will happen leakage the leakage will start coming outside so urinal leakage can come into this picture so this is a sric action or we can in other way sphri disp function or urine leakage because muscles are weak and this muscles when the muscles are weak they can be worse when patient is into the activities like if I'm doing some if for example I'm cuffing in any case where intraabdominal pressure will increase and suddenly the pressure will risen up in the abdominal area the pressure will fall onto the pelvic region pelvic organs and it will descending downward pressure will be there and if your muscles are not strong enough so urine will come outside because what is present into the bladder what the bladder is holding urine but if the pressure is there the pressure will not be taken care by it will not be supported by the muscles because they are weak the tone is not good so the leakage can come so this is what we are seeing is a stress incontinence this is the type stress incontinence due to some internal stress over the pelvic organ stress is coming from the intraabdominal pressure activities so so whenever those activities are putting stress onto the pelvic region pelvic organs cannot maintain that stress and leakage is going on this is a stress incontinence okay so stress incontinence means simply pelvic floor muscle weakness so now what is the rehab in that case we have to strengthen the muscles okay simple the all if you can strengthen the biceps same protocol we have to apply onto strengthening of the muscles which is all around the urethra so specific muscles are there around the urethra urogenital muscles so muscles around the urethra we have to strengthen or muscles which is supporting the levator an so lator an strengthening so that is very very important and same way uh if the muscles are for example they are weak so leakage can happen and if the muscles are tight spasm is there other case what can happen with the muscle it can be weak or they can be tight muscle if the muscles are tight so you can assume that levator and I the floor on which the organ is sitting the floor where you are sitting right now if the floor is down it will be tight so what will happen with you as the organ there will be ascending pressure because muscles are tight so you will Ascend towards the pelvic up upside so this is what we say pelvic congestion so too much of congestion into the pelvic or the organs are congested Ed because pelvic FL muscles are tight they are applying ascending pressure so in this case always pressure will be into the abdomen upward pressure in this way you can understand even the pressure will fall over the diaphragm abdominal diaphragm upside we we have this Dome shaped muscle but you can see the pressure is ascending so even diaphragm will be ascending it is going to even affect your chest complete chest shape as well because of the pressure you might feel the pressure the the shape know anterior posterior diameter of the chest or lateral diameter of the chest there might be the change into this and even breathing will be also difficult affected so we know that there's a complete up to down facial connection is there isn't it if you have a tightness into the downward fascia there will be definitely tightness into all the upset so patient will have this congestion into the body okay and different different posture we will also discuss more detailed about this in our assessment part I will explain you so the congestion system because muscles are tight they can create a congestion or this is what we are saying is a pelvic congestion or uh it can cause pelvic pain syndrome as well so chronic pelvic pain syndrome can be one condition so why the chronic pelvic pain syndrome is there the one one reason can be the tightness into the pelvic L muscle okay now what other things can happen if the muscles around the whole Ure the sric muscles which is creating the looping around if they are tight so what they will do they will not relax if they will not relax so patient cannot pass urine or difficulty in passing the urination so this is what we are calling it as avoiding dysfunction patient has a difficulty in passing the urine so might be slowly spending lot of time into Ur for into the washroom bathroom if I have to pass urine I'll go to the bathroom within 1 minute I'll come outside or within maximum 2 minutes I'll come outside but if the patient is there inside the washroom person is there and five minutes 10 minutes is using in passing the urine it means the urine is not coming and the flow is not good okay flow should be good within 30 second your whole urinal bladder should be empty but if it is not emptying it means there's some obstruction into either the canal or it can be the tightness of the pelvic floor and this condition we are we are talking we are saying as a voiding dysfunction patient is having voiding difficulty so the tightness into the pelvic floor can be the cause of can be one of the cause of voiding difficulty when you are not able to empty your whole bladder when you cannot empty your bladder so what will happen because the canal the tube is tight because of the pelvic or muscle there's a tightness on the tube if you cannot void so what will happen into the bladder too much of collection of the urine too much of collection because you cannot void it so instead of 350 ml 450 ml there might be 550 ML 650 ml 750 too much of urinal flow going urinal uh fing is going on and this condition we are seeing is a overflow bladder is getting over overfilling is going on into the bladder so and this overflow bladder too much of bigger bladder always if overflow is going on stretch receptors which is a part of the bladder they will keep stretching and they will keep sending signal to the brain urine is there urine is there and if the urine is there what the blood will do go to urinal and if I I'll keep going on to the washroom so frequency will be every 50 minute 30 minute 15 minutes I'll keep visiting to the washroom and but I can't void so that can be another cause overflow because of the tightness of the P Flor so in this case what we have to do what will be what should be the rehab strengthening or relaxing so keegle exercise is a part of strengthening protocol keegle squeeze for 10 second but in this case when muscles are already tight so we will should we go for strengthening the answer is no we will not go for reverse gigle reverse reverse yes we have to go for reverse gigle relaxing me whatever way you can relax the area stretching exercises vibrator use relaxing protocols manual muscle release techniques everything we are going to use in these cases okay just to release the tension from the canal from these muscles okay so this is how the whole urethra the muscles around the urethra are behaving they can control and they can help into voiding if they are very loose they can't control if if they are very tight they cannot let it void so the bladder is very very important part and which is Crossing from the pelvic floor so pelvic floor Rehabilitation and understanding that which muscles are present here is very very crucial and now this muscles in a male body and female body there's a difference we will also discuss about that in upcoming session after this organ the next organ which is present just on the top of in a female body we're talking about a female body so on the top of this is a u you this uterus is present okay on top of the blad so uh look you this is a bladder upper part posterior wall and let me put it like this so now the uterus is present on the top of bladder it is not behind the bladder okay so there is uterus present behind the bladder no wrong answer who is behind the bladder vagina is behind the bladder you can see vaginal Canal so this is our a female uterus this is the female uterus and uterus is having three part one is upper part uh the tubes are attached here fopen tubes so we have fundus then we have body and the downward neck is the esmus and now here we have a cervix cervix of the uterus now in I have another model I'll open for you to make you more understand about this so you can see this is is the whole uterus and it has two Fallopian tubes which is going on the both side right and left Fallopian tubes and then we have this this is a body and upper part is a fundus and then we have ismus lower part and this is a cervix cervix and once you insert your finger inside the vagina we can palpate the cervix so we can palpate the cervix part of the utrus cervix is the neck of the uterus like this okay so now cervix is attached with the vagina so again this is a canal and this canal vaginal is a canal it's a where this uterus is opened in this canal like UT the blad was having urethra our uterus is is attached with the vaginal Canal they are not one organ they are different organ but they they are join joining with each other at the top so utrus is somewhere exiting into the um vagina so it means we can assume in this way that the room where you are sitting we have a door and from the door is there so this door through which the something is coming out into the vagina vagina is again a passage okay there are two different organs so now same vagina when we talk about the vagina so assume vagina as a tube and the whole tube for example 6 to 7 cm long okay so that particular normal length of the vagina so this whole assume that it is assume it is 100% so this 6 to 7 cm is 100% of the vaginal length out of this 100% of the vaginal length uh and you can say that vagina is having it's like a cylinder anterior part posterior part two lateral balls so your room where you're sitting right now anterior posterior and two lateral sides same way as a cylinder vagina is there round into this cylinder on the from the top Superior side cervix is coming and downward outside you can see into vva of a female this peral this vestibular area of a female over here opening vaginal opening is visible to vagana is again two parts one is attached with the cervix upper inside and outside is uh you can visible into the vva of a female vestibular area of a female clear so this whole tube is again having this type of one is external opening and one is internal opening okay internal opening is where it is not just inside it is where it is attached with the cervix up up more deep so internal opening and external opening so the thing which is visible if as a female if you we open our ourself and we'll see in a mirror the structure which is visible outside is not vagina that is the part of vagina which part external opening it is not the whole vagina because whole vagina is inside you cannot can you see the vagina the answer is no we can't see vagina we can only see that uh opening extraordinary but if you have a speculum and you are opening it like a gyx they are doing the examination by using the this their operators then they can see you know that some part of the vagina in inside they cannot see the whole vagina okay to we can palpate the vagina with our finger by inserting the finger we can't see the vagina so external part which is visible into the vestibular area of a female is not vagina it is a vaginal external opening or vaginal metas you can also say or vaginal orif is another way uh name so there are three names vaginal opening vaginal external opening vaginal orifice or vaginal external meters okay so these are the three names now you can say that this whole length assume that is 100% so where is the pelvic FL exactly uh let me put it through the pelvic floor so if I'm putting it into the pelvic floor so it is coming out from the Lor ni so this is how it is going out and after extending from the Lor and I more deeper layer it is going to pass pass through these middle layers of the vaganel and it is going to come outside uh by Crossing The Superficial layer also and this is the uh vaginal opening external vaginal opening so now the whole length of the vagina is it covered by the pelvic floor the answer is no it is the only lower part 10% lower 10 to 20% is only covered by the pelvic floor so out of 100% last 20% is covered by the pelvic floor so means door is covered this room is having a door and the door the whole vagina and the door is a pelvic floor muscle so same way if you want to now how the pelvic floor pelvic floor can affect it if the levator an i through which it is passing if the levator I don't have tone so what will happen it will start sing downward as per gravity it will come out downwards so prolapse vaginal prolapse or things from the vagina can start coming outside and what else um it might start coming out by crossing the middle layer and outer layer externally here so too much of laxity looseness prolapse okay so this can can happen and there's no tone and even uh if these muscles are what what the what the vagina is doing like you know it is a very important part which is playing during the sexual activity is during our sexual functioning we have arousal we have desire arousal then you can say penetration and that orgasm so the the four fourth stage when we talk about orgasm for orgasm what we want as a female we want some squeezing effect inside the vagina so this squeezing effect like if whatever tool like for example we are having a penis so we want grabbing of the penis so if your vagina is weak you cannot grab so is it a vagina weak or a pelvic floor pelvic floor vagina cannot grab who's doing the grabbing contraction pelvic floor if pelvic floor are weak they can they cannot grab the penis when they cannot grab the penis female cannot feel the sexual sensation and this is what we are saying is a orgasmic dysfunction she don't have a feeling inside sexual feeling is not there she can't feel sex and this is very common after having child birth frequent child birth with the vagina when there's a damage to the tone of the vagina and the area of the that particular whole vaginal area uh when the baby's coming outside because that much of opening is going on of the pelvic floor so pelvic floor might lose its strength and U so now the gra grabbing capacity or the contraction capacity can affect when it is affecting so the grabbing will not be happen when it is not happening she might not don't feel uh sex that's why 70 to 75% of mother who deliver through the vagina frequently they might don't like having sex they don't like sex actually why because then if I don't uh I there's no taste in a food will I have the food because the first his brain wants to have some stimulus but the stimulus is not going to the brain so brain is not liking it when the brain is not liking it f will start avoiding it so this is the very very important part the pelvic for muscles are playing one is they're helping into maintaining the tone the tone of the pelvic Flor can help in maintaining the organ in a place so organ descend will not happen so prolapse will not happen and the second is so who can prolapse through the vagina like there are many things uh bladder is there the bladder can prolapse through the vagina uterus can prolapse through the vagina rectum can prolapse through the vagina so things can different organs can prolapse through the vagina if this organ is Central opening isn't it so like if I'm the central part so someone can come from the posterior side rctum someone can from the anterior bladder someone can come from the top utrus or even the vagina can start coming outside we call it as a vaginal Vault prolapse or might be urethra can start coming out from the vagina so this is a URL prolapse or if there's a no uterus or might be intestines can start coming out from the vagina so this is a what we say is osil so there are six six types of of prolapse through the vagina so why the prolapse is going on because the opening is so so big that gravity is pulling the organs downward and whatever organ will come in connection with the gravity that organ will start pulling downwards okay so this is the prolapse so first is the tone is important around the vaginal muscles the pelvic FL muscles so prolapse should not happen and the second is I also want to have a good sexual life isn't it because throughout our as per Whos sexual health is very important so if sexual uh because for the partners for the couples this wellbeing is also very important so that even can uh if there's no tone so it is going to affect the intimacy it is going to affect the relationship or the sexual dysfunction come to picture that can be because of the weakness of the muscles around the vaginal area and uh so those muscles we'll discuss which muscles are they now assume that the other case what what can be the other case Okay in one case Vina cannot hold cannot grab weakness but the second case muscles are overtight so they're not loose they are overtight they have a tightness they have a spasm they have a shortening so whenever shortening and tightness is there so what we want what is going to happen the muscles around the opening the door through which you want to come inside the vagina if the door is tight so you cannot even penetrate the finger inside so you can't even touch so muscles are having spasm like a trapas can have spasm the calf can have a spasm same spasm can happen into the muscles around the area tightness tension and this tension when present you can't you might don't touch the moment you will touch there will be pain or it if you can't touch you might be having a difficulty into intercourse you can't penetrate inside the vagina if you can't penetrate inside the vagina you can't have sex so sexual difficult you female might be I'm married but I I'm not able to have sex because my muscles are tight and believe me 7 to 177% of the 7 to 17% cases are there in India the female who can't have penetration inside the vagina because of the muscles tight tension and tightness around the vagin muscles are tight now if you can't penetrate I can't have sex the first thing it's a part of sexual fun dysfunction and name of this uh condition is a vaginismus vaginal muscle spasm or muscles around the vagina are spasm so which muscles part of the pelvic floor which is surrounding the vagina those muscles are tied we will discuss about that so vaginismus which is 7 to 17% uh prevalence are there into India and uh depending upon this North to South so North is more cases 16 to 70% and most like starting from the south 7% and travel towards the north 177% uh it can be the environment and whatever it can be you know the cold situations muscles whenever we have a more cold outside it's like muscles having this kind of tension all the time isn't it because of the Freezy environment Freez environment so that can always affect now if the muscles are tight the first you can't have sex so first will be the pain second you can't have sex no penetration no no sex and the third if no sex and no penetration so means what penetration penis can't go inside if the penis can't go inside so the simple thing is that uh fertility will not happen isn't it because process of fertilization is a spum should be there inside the vagina so but if this vag if the penis can't go inside the vagina how this spum will be ejacula inside that uh UT inside this um uh vaginal Canal because here exactly this is a part through which the sperm is going to travel towards the uterus so we need ejaculation of the sperm for fertility if the ejaculation is not present because penetration is not present if penetration is not possible so for infertility female cannot get pregnant in these cases what doctors are doing they are collecting the sperm and they are injecting inside so the injecting I can become mother through this injection uh but I can't have sex so without having sex I'm getting pregnant so yeah you can make me mother but still my my womenhood is not complete because I'm not able to have enjoy my sexual intimate life isn't it so that is a big problem so this vaginismus is the muscles around the bagana which they are when they are tight so when the muscles are completely tight and you can't go so that is a vaginismus but when the muscles are partially tight means you can penetrate but once you are trying to penetrate it's paining it is not a smooth penetration it's a painful penetration painful insertion this condition we are seeing dispareunia painful sex 30 to 40% of female they are suffering from painful sex so if I'm having like you know this is very simple myth we are saying that sex is a painful activity sometimes during the sex pain will be there but no sex is a pleasurable activity brain should not feel pain if the brain is feeling pain bladder can't brain will not feel pleasure if the brain will not feel pleasure female will not enjoy the sex and she will not go for it she will not participate into it again it is a sexual dysfunction because sex is giving her pain that's why she will avoid it so partially yeah okay penetration is going on ejaculation is also going on of the sperm she might get pregnant the muscles are not fully relaxed there is always some tension and uh it might be penetration pain it can be the thirsting pain so means pain is not for example pain is under the penetration or pain can be after the penetration when they are having the sex so this condition we are saying is a dispareunia painful sex so guys there's a different between vaginismus and desperia vaginismus means no penetration you can't go you can't enter into this room okay and uh disparia means you can enter into this room but you are giving pain so difficulty into entering so this is a disparia and both the situations are not good both need rehab both need what keigle or reverse gigle reverse gigle we need to relax those muscles which is surrounding that particular org clear everyone that vaginal area also the last part so this is a bladder this is uterus with the vagina and most posteriorly we are having the rectum so rectum is a part of uh is a part which is attached with the colog and then it is attached with the intestines so we can see as for the digestive system food is traveling all the way through when it is transported from small intestine that it is going to move into the large intestine still the absorption of water and nutrient is going on into the large intestine and then the rest the peristalsis movement is going on and they're going to keep moving the this food into the rectum the rectum is a last part where that excretory things are going to store okay so our feces is going to get stored into the rectum so rectum is again like a balloon and it is a big balloon it can expand okay it can expand even more so this balloon is again it is having some kind of you can say that different type of ruges are present inside keep keep moving keep moving keep and you can we can also feel that this stool is is it is having a weight is not like a liquid like bladder is having a liquid urine this is a feis it can be hard and it is having a weight so this is going to store here and now this rectum is a organ which is collecting the faces and the like bladder was having the urethra vagina was a part of which is which was attached with the uterus same way anal Canal is a canal which is attached with the rectum so there's one small Canal which is attached with it and this canal is the rectum when we say these three canals are present in a female body uh urethra then vagina and then this Anis three canals attached with the three organs out of these three organs this canal is the uh smallest Canal smallest we can see that was 4 cm vagina was 6 cm and this is 3.5 CM so 3.5 to 4 cm the length of this can be so smallest canal and we want smallest Canal because we don't want to put unnecessary load onto this canal and this particular rectum is putting is taking a shape of the sacrum so like you can see that this is a sacrum and it is present like that look it is following the same shape of a secum and now this is going to come outside uh what is externally visible anus is it anus complete anus no anal opening external annal opening is a right word so whenever you have to write down check external annal opening so that's a right now uh when it is coming out so first some levator and I part deeper muscle is going to come in connection leave and after that this is going to cross through the pelvic floor so this is a posterior hius part and through this you can see here posterior heus this rectal hus or anal heus I show you two opening isn't it urogenital and uh anal or rectal hydrus so through this let me make it go through so it is situated inside like that look opening I'm placing it situated following that uh sacral shape and now this canal is passing like this so This levator an i which is giving it a will after this it is going to cross through this these muscles so let me attach from up to down and now it is coming outside here so this is a external anal mucosa so mucosa of the anus externally we can see pinkish color like this are the this lips so say mucosa so skin is different okay so this is the mucosal and surrounding the mucosa pelvic FL muscles are present so the muscle which surround the anus is a external anal sphc muscle name of this muscle itself is a external because externally present around the anus and sping trick complete 360° squeezing it's like a rolling around wrapping around so external anal sentric muscle now throughout 3.5 CM as per the MRI studies the 3.5 CM length is completely covered by this muscle so and we want like you know some strong grabbing so like this grabbing so Canal is crossing through this external anal spectric muscle one muscle external which is completely covering the whole anus and if this muscle if it is tight too much tight spasm into this muscle so what will happen you can't defecate defecation issues might be uh patient will be always having this kind of heaviness inside and difficulty in passing the stool or stool is uh like you know breaking of the stool is going on smooth stool is not coming outside so difficulty in passing the stool okay other way constipation constipation is a big word it can be because of that gut health related to the food related to the gut health it can be related to the tight P floor muscle because the muscles are tight it's like obstruction going on if obstruction of the passage stool can't come outside so that can be uh and for that we have a different test we will discuss about that so muscles can create obstruction tight tightness and tension and you can't deficate and gas like sensation blotting and that kind of things will be into the history and into the assessment so that can be one thing and this condition we are seeing is a anismus muscles around the anus are spasmodic when the anismus is there you can't go inside the anus we don't have to go inside the anus because we never travel inside the an we don't insert a necessary fingers or anything vagina is a part where insertion is required that penis is required to go so the for the reproductive uh you know this health for this fertilization process but anus is a area which has a habit of passing the thing we don't insert generally inside the an but still uh if the muscles are tight you can't even pass something out of through that Canal so anus can be the condition and uh another thing is if these muscles around that area are weak weak lose so what will happen you can't hold stool leakage of stool so uh stool uh incontinence FAL incontinence can be the issue okay FAL incontinence so in case of when the muscles are loose we have to strengthen the muscles and when the muscles are tight we have to relax the muscles how we get how we will get that what is going on depending the symptoms patient will tell you that I can't touch I have pain I can't penetrate I can't void when the pain comes difficulty comes penetration difficulty defecation difficulty voiding difficulty it means somewhere muscles are tight something is tied okay and when they cannot hold leakage is going on they some is coming outside uh what is what can come outside even the bins can come outside they can hang outside and this is what we call it as a piles and hemorrhoids what are the piles and hemorrhoid inflamed veins through the anus through the anus veins are hanging outside uh so there there's a degree of the Hemorrhoid grade 1 2 3 4 we will discuss about that so when this protusion of the vein is there hemorrhoids you can understand if something is going on around your anus some veins are hanging so that kind of person will even will will face the difficulty into sitting the moment they will sit down the vein is going to irritate isn't it they're touching so it will it might be inflammation pain and you know depending upon the severity of that grade of the piles and the Hamid that the same thing so this is what you can understand when the veins are falling outside so when when the Hemorrhoid and pile so is it HR and piles is the is a dysfunction of weak pelvic floor or tight pelvic floor is a dysfunction of weak pelvic floor when muscles are not strong enough to hold when they can't hold they don't have tone then the veins are falling outside otherwise they could have generated the good tone and upward ascending pressure but muscles are they fail to apply that pressure they don't have that tone so piles and hemorrhoid is a type of the dysfunction which is caused when the mus are weak so so far I and the other thing is a constipation or difficulty in passing the stool or if you are applying too much of pressure during passing the stool pressure pressure pressure try you hard you pressing the stool outside with the pressure so you might create a damage to the mucosa of the whole anus organ this is the organ so assume that you have a room and through the room you are pushing something very hard so the because of the push the wall of the anus can start getting tone isn't there might be tearing into the skin anal skin anal mucosa this tearing we are seeing it as a fishes Fishers what is Fisher tearing inside the Skin So when the stool was very hard dry and they're putting and applying lot of pressure and muscles are were not relaxed passage was not relaxed and you're applying a lot of pressure and you you are defecating the you are doing the defecation with the pressure so uh that can create a tearing into the skin when the tearing is there into the skin you can understand tearing assume that you have a tearing into hair your lips so you you will always have a difficulty in opening and closing or always there will be some kind of pain all the time present so this is what we are saying is a fishes there's another thing which is a fistula we will discuss it afterwards so there are three things which can happen around the enus because of the muscle T tension tension is one is anismus uh one can be dispareunia we can say when you are inserting something inside the Anis and it is difficult and painful and uh the third can be the fissures that tearing into the skin uh yeah constipation you can con we will not say constipation but in that case might be that stool is there because the muscles are tight and if the muscles are weak falling out what can fall out we can start falling out hemorrhoid anus can fall out so this a prolapse of the anus so anal mucosa is falling out which is very common in children you can see that so this anal prolapse it can be the vein prolapse hemorrhoid it can be the rectum is falling outside rectum whole rectum is coming like a socks you know socks Inside Out socks rectum is falling outside uh which is not very common but the cases you might see in your uh I have seen three or four cases in my my uh life so far this um rectal pryse but rectal pryse through the Anis I'm talking about rectal pryse through the vagina I've seen many cases but rectal PRS to the Anis are rare then uh it can be tightness okay TI means you can't defecate you can't pass sto leakage so these are the condition around that anal area anismus constipation it can be voiding defecation difficulty or it can be that Fishers it can be fistula it can be piles and hemorrhoids it can be a stool leage okay the all are the conditions part of pelvic flow dysfunctions around the anal region so you can understand the muscles are wrapped around the canals so everywhere bladder urethra muscles vagina muscles anal muscles so muscles are important part and if the muscles are not good functional functional means good coordination contract contract relax relax they should be good good coordinated muscles but if the coordination there something is not good so this is a pical dysfunction and we can turn the pelv dysfunction According to which area is going on bowel dysfunction all area around the bow stool faes bladder dysfunction issue with the bladder Health sexual dysfunction issue with the sexual health so these are the pelvic flow dysfunctions are subdivided into three parts blood dysfunction sexual dysfunction and uh bow dysfunction and the fourth is a pelvic dysfunction means all the organs inside the pelvic region and the diaphragm and the ligament and the connective tissue somewhere is affecting so the whole pelvic health so pelvic uh pelvic dysfunction so it can be the pelvic flow dysfunction we can say bladder dysfunction we can say bow dysfunction we can say sexual dysfunction we can say or pelvic Health dysfunction we can say it is according to your understanding how you want to term it okay I hope that you have a some understanding that how important the muscles are good function muscles will should have a good tone and should have a good relaxation but if the muscle fail to create a tone they don't have tone we can term it as a hypo tone less tone no tone or less tone hypot tone so hypotonous pelvic flow dysfunction when the tone is less when the tone is high so hypertonus hyper tone tone is hyper so hypertonus SP for dysfunction so in a broad term we can say there can be two type of dysfunction hypotonus or hypotonus hypertonus means muscles are tight not relaxed and hypotonus muscle don't have tone they are over relaxed so in hypertonus relaxation protocol in high ponus strengthening protocol clear clear everyone yes ma any question so far any question anyone mam yes yes please ification is so painful it means it's tight pelvic massage right yes yes it is someone else something you want to ask um ma'am sometime it's like after micturation uh we feel like uh just to stress little more and some amount of urine comes out h so what is that yeah it means that either your posture was not not good and correct when you were defecating because we need a straight like you know this angle 18 angle either that something is diff something is the angle is not good so might be the position of Def def urination is not good or might be your organ is hanging backward there is some kind of kinking so we'll discuss about that when we will discuss about the prolapse uh there's a part of that that part particular okay yes means either the position is not good or the organ is having some kind of kinking or the muscles are tight or the ligaments are tight something is not letting the organ relaxed okay so that can be the issue okay all right so we can have a glass you can uh we can have a one or two minute break then we'll discuss the external vva because we had a mild understanding of pelvic cavity and organ situated then we'll discuss about the prostrate so this was the female pelvic organ after that we will discuss about the male pelvic organ all right so let's have a five minutes of take care okay now let's discuss about the male pelvic organs so um now the same pelvic cavity you can see this is a rectum with anal Canal same thing female is also having and we can place um bladder here so the uh on the anterior part so there are two Hiers and from these two heights two organs are passing so one is a penile penal penis is going on and through that urethra and then we have n two openings and two organs inside bladder just behind the bladder rectum so we do have vagina and we don't have that system that's a part of female so these two are present in a male pelvic uh cavity okay but another thing is the bladder and uh the urethra is bit different urethra is bit different as compared to female pis let me show you the male model so this is the a model for male pelvic cavity now this is uh bladder of male so same thing is going on you can you can do the comparison bladder bladder bladder same female and male and this is a urethra which is passing straight in female body but male urethra is not straight that is crossing through prostrate very important gland which is encircling the you uh that uh Ur urethra of a male so as soon as urethra leaves the bladder it is attached and is going down down that it is going to now enter into this almond shape organ now let me open it like this so bladder Ure has started and it is going to cross through this prostrate so prostrate is a part of the reproductive system like female is having reproductive system with uterus and vagina their reproductive system is different so uh we they have uh two testes and the testes they are doing the production of uh the sperm so they are having this kind of you can say the factory which is 24 hours going on so they will keep producing uh sperm and that sperm will keep traveling through the ducts we have two ducts attached from that testes to that um seminal vesicle so this is a seminal vesicle which is present just behind that bladder so this is bladder downward we have prostrate and posteriorly we are having the seminal vesicle and now we have duct which is attached the tube big tube which is attached from this seminal duct to the all the way towards the testes so what testes will do tested will produce the spum so the production is going on into the factory and that is going to transported through the duct to this seal vesicle this seminal vesicle is going to add some some fluid extra fluid to the spum because we want uh that is what we say is a um you know this ejaculate fluid so it's not always having that sperm there are what what we say that some extra co co uh some coat over that sper this fluid is creating okay so when the ejaculation is going on so ejaculation fluid inside we have spum but externally we have this fluid this fluid is going to help in maintaining the pH level of the spum we don't want spum to die throughout this transported process Transportation process and this the fluid which is going to ejaculate by secrete by this gland seminal vesicle they are going to protect the alkaline nature of the sperm sperm nature is six uh as as per pH level it is more alkaline into nature so the pH level of sperm is six and that is going to bee preserved and protected by this fluid so this is going to add extra coated fluid around that area now from that it is going to travel they're going to store here and now they're going to travel into uh can you see there there are some opening here into this uh gland so through this Prost prostate gland as soon as they will enter into the prostrate prostrate is again going to add some extra fluid you the same sperm so the sperm which is ejaculated and the fluid which is coming out during the ejaculation process during that uh when they're ejaculating so this ejaculated fluid they they contain sperm but with the sperm they have some protected other fluids are also there so that other fluids are very important to preserve the good quality of the sperm because we want quality as well as quantity quantity depending upon how much testes are doing but quality of the sperm is going to depend upon how good that fluid is secreted by this two glands because stored here and then ejaculated from here so when it is ejaculating through this prostrate so the quality of the sper should be also good okay so now these two glands are very important now this gland you can say is this has a opening and this opening is going through this opening the sperm is going to move into the urra so urethra is a one tube but this whole tube it has two opening one one opening is with the um bladder so urine is going to come down and other opening is through the prostate the sperm is going to come out so now how these two opening are going to function they are like a V okay one is attached with the bladder one is attached with the uh this seral vesicle and through the prostrate now these two opening now they're going to merge in the long tube uh urethra whole long tube so you can assume a y y you know y XY Z so y okay so this y one opening with bladder one opening with this H that so one is for urine one is for ejaculation so this two opening of the wall of this part of the canal they have a wall Volve present heart is having Volve you know four volves are present into heart now these volves are under that what the brain wants according to the need of the brain If male is if I want to urinate as a male so my only that wall will open because I want to urinate the other wall is going to be shut down that's is not going to open up the male if the male is into sexual functioning assume that he's doing masturbation or he's uh ejaculating so in that particular time urinal functioning will be shut down so one time one wall will open other will shut so that is who is going to decide brain is going to decide and who is attached nervous system is is controlling that so nerves are going to control that what is going on where what is the need Master gland brain hypothalamus that is going to decide and that according to this the wall will open and that function will the urethra is will be used for that particular functioning if that valve for example the valve are weak they can be weak as per that when the patient is person is having cardiovascular vascular issues going on so every vein and uh you can understand the arteries and the damage is going on might be the damage to the wall as well because the same passage so when they have this kind of issues going on if the valve are weak so you can say that the Retro flow so it sperm can go towards the bladder or that urine can go towards the prostrate so that kind of retr fall can also uh start so we'll discuss about that when we will discuss more about that um prostrate health so the third added Health in a male is a prostrate health so bladder health bow Health Sexual Health pelvic health and prostrate Health this is a one extra uh dysfunction which we are going to deal in a male case the prostrate has a direct effect onto the voiding assume that for example this prostate which is attached with the base starting with the base of the bladder and this is almond shaped if some issues is going to happen with the prostate and prostatitis inflammation of the prostate some infection anything when some infection any inflammation that changes so inflammation is going to happen uh the structure through which the canal is passing so what will happen the canal will start getting compressed because inflamed organ is there so if everything is inflamed around me I will get compressed if I will get compressed urine will not come out if the urine will not come out obstructed dysfunction patient cannot pass urine and voiding dysfunction is there because of the prostatitis due to inflammation of the prostate bladder is compressed and you cannot pass urine and Overflow what will happen with the bladder it will start overflowing too much of urine filling will keep going on into the bladder and too much of distended urine this distension of the urine so distended urine and uh and voiding difficulty person will always have the feeling to the brain that it is full full full urge will be there that feeling will be there but the passage is obstructed because of the prostrate so in this case uh who what is the the rehab what is the treatment treatment is decrease the inflammation so how to decrease medications doctor patient has to go to urologist urologist will give the medication which will help in subsiding the infections or might be subsiding the inflammation okay that medications and as a physio can you think something can we we decrease inflammation with some of the things yes of course we can apply icing Icing is a very good thing which is which is going to subside the uh this inflammation inflammatory changes so we'll discuss about that in our upcoming session so prostatitis is important to uh important which is going to affect the person's bladder health prostrate uh if something happen with the prostate and prostate is removed so you can understand when the prostate is removed so prostate is a one organ with which muscles are attached pelvic FL muscles are attached so it means whenever the prostate is removed some of the pelv muscles are removed so you can understand that person is going to um you might have seen that all the people around you who has done surgery with the prostate removal surgery uh prostectomy you might uh heard that they're suffering from urine leakage issue because the organ was some muscles were attached and those muscles are now wasted actually so the control syri control is weak and that can lead to the urine leakage after having a prostate and you might also observe that after prostectomy 3 months four months 5 months 6 months catheter is going on so why because internal system is still not developed what is going on how how it is going to affect the whole urethra whole we flow we will understand through the videos and we will also understand through my PP in upcoming session so this was the prostrate uh now here prostate rehab comes as a physio we need to understand that prostate can create a tension in this case we have to relax the inflammation we have to subside help in subsiding the relax prostate inflammation or if the prostate is removed and muscles damage happen so in this case there might be some stenosis we will discuss about that stenosis which can create a tension uh liit Ani muscle spasm liit Ani muscle shortening we will discuss all about that in upcoming sessions or if the muscles are wasted so leakage can also come into picture the prostate is a very important and just behind that we are having now rectum so that rectum is same as a rectum of a female so bladder prostrate and urethra is a long tube I hope you Ood about male and female pelvic organs now uh let me let let me dig more into details that was the OV uh in your mind the clarity is there that as a as a physiotherapist we have a rule isn't it we have a rule but we were not knowing it and now but this the clarity is also there that okay the muscles are tight we will relax if the muscles are weak we have to strengthen if the coordination is not there so it means it the nervous control is not there so nerve uh know as an as a uh we have to train the nerves so stimulations are also very very important nerve stimulations so mus this is what we are seeing is a neuromuscular rehab nervous rehab as well as that muscular rehab both is important into pelvic floor now let's take let me take you to the uh through the slides this uh slides are visible it is on on your screen and uh yes we know the pelvic flu is a muscular diagram diaphragm which separates pelvic cavity above to the perinal area below what does this mean uh if I say that what is this what is this external part what is this this is a peral area okay this is a peral area externally external observation I can see on external observation the perinal area and and what is inside inside is a pelvic cavity so where is the pelvic floor at the door so this is a separated door inside pelvic cavity outside perenial area Okay so pelvic R are into the middle of external and internal that when we say that external rehab so means everything without removing the cloth or without going inside externally you are doing something so that is a external rehab and when you have to insert something inside it can be your finger it can be perometer it can be dilator it can be vibrator when you are going inside so that is a invasive rehab so there are two type of treatments going Rehabilitation going on or assessment going on external or internal so external also two type whole body or uh like whole body you can just relax my whole body stretching exercises or perenial rehab external peral rehab something is going on over the perenium externally here you're doing rehab here so what is external peral rehab you're applying ice for example you're applying ice externally you're applying IR externally you're applying tense electrode you're applying if something externally you're applying uh vibrator externally you're not in this is non invasive rehab when you are invasive you are inserting inside the canals it can be inside the vagina inside the rectum so this is the trans vaginal rehab trans rectal rehab okay so in female transvaginal trans rectal both rehab is possible but in male only one rehab is possible trans rectal rehab so in female trans vaginal trans rectal assessment and transvaginal transal treatment in male trans rectal assessment and trans um rectal rehab so when we talk about the assessment so external look at me I might have a tension in my body so this is a whole body external assessment and external Rehabilitation or look at my perenium perenium and do the assessment externally and do the rehab externally or internal internal inside the vagina or internal inside the anus in female or only inside the Anis and rectum a male clear okay so this is the perinal cavity is separated by the perenium with the pelvic muscle they are the door next uh MH okay uh you can take a screenshot of this slide uh we we I think you already understood some of the things bladder urethra prostrate urethra uterus vagina sphincter rectum anal Canal pelvic floor muscle micturation process pelvic floor disfunctions hypotonus hypertonus and then assessment then the treatment then the day-to-day activities which can affect it and then the posture can affect and how to uh help a person with the rehab at our clinic and Rehab at home home exercise protocol as well as rehab at our Clinic everything we are going to learn in our webinar series we know the pelvis pelvis is the area between the abdomen and the lower body and uh it includes bony pelvis with its structure all the organs which is present there the bone which is present present there the pelvic cavity which is formed by this wall and the pelvic floor muscle everything organ pelvic bone pelvic floor muscle pelvic cavity pelvic floor organs Behavior they all are the part of the pelvis and anything which is present into the pelvic the issues going on with the pelvis we as a physio can think about it and we can help and pelvic muscles internally externally and vul and perennial area externally this is what we can we have to understand now the first thing which we should be having a detail understanding is the pelvic bone we know the pelvic bone we learned that we all are thoro so I'm not going to spend a lot of time into it because we are all doing the assessment we are trained therapist but still this slide is present you can take a screenshot and you can just read it whenever you have time just over view if I have to give you the two bones are coming and they are joining with the pubic symphasis anteriorly posteriorly we are having a SI joint so you can see that SI joint is also present sacrum is present now uh the bone when we talk about the attachment so the B the four bony attachments are important to understand as a pelvic therapist one is a pubic symphasis second is that um once the pubic s fice is this one here because muscles are coming from here the pelvic muscles they start from here and abdominal muscles are insert they are doing the insertion so they some abdominal back muscle they are inserted all the way as well as the pelvic muscles they start from the pubic sasis they travel all the way back and they insert into the cockx so pubic symphasis and cockx is very important so you all please palpate your pubic symphasis right now palpated this palpation is important so please palpate your pubic symphisis so once you palpate your pubic symphisis you might see that the complete width of your pubic symphisis around four finger like like like this this much from here to here so what you can see you can palpate the tubal the tight one one bony prominence one one right side and the left side so palpate yourself right now there will be two tubercles so we call it as a superior tubercle okay and then travel your finger downward and you can feel inferior tubercle also so Superior tubercle inferior tubercle okay they both are connected with the this uh Sy pubic symphisis pubis connective tissue now this pubic Tule the length of this pubic Tu the pubic symphasis is they're long and large in male so large pubic syes elongated okay as compared to female female they are having a short wide pubic symphisis wide so our pelvis is wide as a female male pelvis is narrow their bones are elongated and long and our bones are wide because of the utrus inside that particular reproductive system change so this is a one one Gap now we can see that from here this part this whole part cuic symphasis many things are traveling who is traveling the first thing is let's talk about the bladder or this uterus so this is a uterus and uterus is hanging into the pelvic cavity we can understand that it is placed into the middle it is a middle organ so now but uterus is having four ligament one is anterior we are having two round ligament okay round lament one is coming from here one is coming from here like these two fingers they they're attached origin is from here and insertion is into this part here so they're traveling all the way this finger are coming coming coming and they're inserting here so you can see that this is important round ligament pain during the pregnancy when the uterus is expanding ligament are stretching because uterus is stretching ligaments are elong at stretch ligament they will pull from here and patient is always complaining pain around the pubic symphisis so it is very important to understand the pic sasis in female case same where as as the round ligament is going on same way when we talk about the male so male is also having some ligaments attached with the pubic symphasis now it is the ligaments which is attached which support the uterus in a female as well as if you see the this is a external part of pubic symphasis okay external now let's see the internal here in this part inside so this part here ligaments are coming ligaments which support the bladder so bladder is hanging so how the bladder is there in this part bladder is there with the help of ligament so ligament start from this part of that pubic symphisis in internal part now from here ligament will come so assume that this is that bladder so ligament will come from buic syis it will travel and circle and again insert other side so this is the like not like I am the something is there super syis I'm the I am bladder so some ligament will come and circle me or hold me so I will be on the place I will not go down up I will be on the place and this ligament we are saying as a pubo vesicular vesical ligament okay pubo there I we will discuss all these different ligaments like we have a slide so one after another we will do so ligaments are present which is coming from the internal part which is traveling from the Superior part so this ligament insertions are there into the pelvic uh this pubic symphasis so pubic symphasis are very important and the second thing is a this part pubic Sy Isis this connective tissue when we talk about the connective tissue we know that connective tissue is movable there's a movement into that and this movement is depending upon the hormones so as a female we have a relaxing hormone comes in our life when we are pregnant so during pregnancy relaxing comes it creates laxity stretching uh into this Lig laxity into this connective tissue when this because we need space to accommodate the baby so this whole area is going for expansion more big bigger Inlet will form just to accommodate the baby so when this we need a space at that particular time this two pubic bone has to move away from each other so for that we need some kind of U you know movement here this part so this pubic symphasis is under the effect of relaxing hormone when that comes it can help into widening of the inlet and that is important for accommodate the baby but this relaxing hormone is not present in male so it means their pubic symphasis is not movable as compared to female so they don't have Mobility so and they have a elongated large long so if we have a shorter assume that we have a shorter so this one short and uh wide so you can see that our angle this angle we call it as a pubic angle so pubic Arch so this angle are wider in female because pubic cavity is wiing female so this angle formed by like this is my one finger and this is my other finger so this angle is 80 to 90 90° in female okay this proportion 0 90° pubic Arch angle but this angle is shorter in M it is only 60 to 70% shorter because of elong ated um that this pubic symphasis and if pubic symphasis are elongated so you can also understand that if it is a wider wider so there's a space between both eal osity they will they will be kind of as per the 90° angle they will be separated but if this angle is narrow 60 to 70 so what will happen with the E tuberosity closer they will come closer because Arch is shorter so Pub this this tubic pal this eal tuberosity this is what we say is a Sit board they are more closer in mail as compared to female now right now you can sit down put your middle finger this two finger middle finger and place beneath your eal tuberosity and you can feel both sides by moving side to side okay side to side so this distance is might be less as compared to to male so when you ask you take a paper plain paper and make a male sit on the paper and just mark their is tuity and then make a female sit on the paper and mark the isal osity you might feel the distance is more in female as compared to male okay so that is a SE another thing which is important important part of assessment we will discuss later on why it is important part of assessment if the patient is female for example and she is having narrow angle narrow angle so angle is shorter than 90° it's for example 60 or 70° pubic AR angle is how the pubic AR angle you can measure you can just put your fingers like this and you can see yeah it is not 90° it is it is less than 90° if is less than 90° shorter so you can see that e tuberosity will be more close to each other and that can be uh what it indicates it indicates shortening into pelvic FL muscle because they're attach here and if they are shorten might be tension tight tight pelvic Flo ascending pelvic flow so that can be present in hypertonus cases so this angle is very important and palpating the angle is very important and if this angle is wide wider than 90° so what will happen wider it means too much stretched pelvic floor eity are away from each other distance is more the distance should be 10 to 12 CM not more than that in this part as a female 10 to 12 but if there's a too much of wider angle 110 degree 120° so what it indicate that stretched pelvic floor if stretched pelvic floor means what is going on look if eal tuberosity are away from each other what happens at the back look this is s joint and let me move the eal osity away from each other what happens at the back SI joint pain look stretch at the down and what is going on the pelvic Inlet is shortened look Inlet is shortened the whole SI joint will be under compression the muscles which is going to cross through this part will be tied and back pain okay so this is the correlation of eal tuberosity and the this whole pubic Arch angle and the distal tuberosity how they are as per anic they should be 80 to 90° but if it is if they are more than that means too much of laxity uh descending pressure downward pressure weak pelvic floor gravity will pull it downward and back pain okay so this and tension into all these performies ilos they will be tensed as well and U you can so SI join pain as well as that pelvic prolapse so this is the correlation we should understand the bone very important and to understand the bone assessment assessment of this Arch the angles are very important clear the third is the fourth is so means pubic symphasis Easter tuberosity okay and the last is cockx so we know the is a part last part of the sacrum which is attached with the sacrum this tail bone now this tail bone is a fused bone but pelvic floor comes from here all the way and attach with the tailbone now let me show you through this model can you see pubic symphasis pelvic Flor muscles are traveling they are going the way back and they attach with the tailbone so if pform misses are good in the tone so what will happen they will hold the tailbone if in a right concave uh Direction like this kind of small concavity but if this muscle this muscle for example is Bak if it can't hold it anterior because stone is not there so what will happen with the tailbone it can't be pulled anteriorly so tailbone will fall back so this concavity will change into convex it will be straight and this is what is the coxidia it can Co it can cause tailbone pain because straight tailbone it is not that kind of curve is not curve is missing who is giving curve to this tailbone good pelvic FL if pelvic FL has a tone it will pull it anteriorly if it is pulled anteriorly that tailbone will not be Pocky tailbone clear so pelvic Ro strength is important maintaining the this kind kind of you know curve into the cockx and this kind of cockx is not painful but if this curve is not there P muscles are weak so then we can say the tailbone pain patient is as soon as patient she or he will sit pain pain because pocking straight tailbone something which has to pull it anteriorly is missing which has to create the curve is missing muscles are weak so in in the this this can cause coxidia what is coia pain into any anything which is causing pain into the cockx there can be different different cause of that but one cause can be the weak pelv clear because it don't have that strength to so this is also very very important and so many muscles are present is attached with this and then you can see the sacrum low lower part of the Saum s we have S1 2 3 4 so S4 you can see here muscles are attached these are the pelvic FL muscles which muscles are attached we will discuss tomorrow uh in our webinar uh but look this whole when the muscles are coming from front muscles are coming from the ilum level also muscles are coming from Easter spine as well and they are going and inserting into either into the tailbone or either into the sacrum so that's how they are creating the whole bowel bowel starting from anterior to posterior the whole bowel anterior posterior lateral posterior everywhere muscles are spanned from each and every corner and they are creating the bowel shape and this is what is there into the definition bowel shaped muscle which muscles are bow shaped lator an i the deeper muscle because this is only the lator I we can see other muscles are not creating the bowel shape these are the not bowel shape but the levator an i is bow shape deeper layer so we have three layers of pelv FL superficial midle and deep deep is liit an i and lior Ani is creating the bow shape and that is closing the whole bone bony Outlet so you can say from front to back liit and side to Mid back Li and I eal spine to back L an ey and creating a bow and if this bowel is having tone srum will be good in a place back muscles will not be under the stress cockx will not be under the stress pubic syis will not be under stress because muscles are good toned but if the muscles are tight so everything will be pulled pulled together all the angles Arch will be shortened and ascending pressure will be there pelvic congestion syndrome because muscles are tight everything is pulled so it means Outlet is shorten Outlet is shorten this part is shorten Inlet is bigger in that case if shorten from down Inlet will become big this part will become big okay so means this is going on shorten Inlet big and if it is out more Outlet is Big it means Inlet is shorten so we don't want that it it should be completely you know good we don't want any malfunctioning or any one Outlet is bigger than the other Outlet so this is all taken care by the good tone of the floor muscle we don't want tightness we don't want weakness so this bone we need to understand and bone is also very important um you can say this the movement of the sacrum the male is having that elongated sacrum long sacrum large it's not a wide Saum long sacrum so it means their SI joint is not that movable as compared to female female will have more M into SI joint as compared to male so male can have a tension around that area because elongation is there tension is there no uh even connective tissues are tight elongated larger so this is a difference between male and female uh pelvic bone and and Mobility also is um somewhere affected you can see that too much of things can happen in female so this sacrum is movable S one side other side what happens is we have S1 S2 S3 S4 so for example if we have a tension male or female both if pelvic muscle is tight so what will happen with the S3 S4 downward part of the sacrum it will move anteriorly okay so what is going for flexion the lower part of the sacrum flexed anteriorly and what is going on with the upper part of the sacrum extension so posterior extension will happen if it is posterior extended so it will put unnecessarily some kind of compensative pressure on other muscles okay they will might start getting spasmodic and tensed and not relaxed and unnecessarily stretched because of this action when the muscles are are tight from here so external this uh this super Superior part of the srum will go for extension so this is a sacral extension pattern sacral extension pattern okay S1 S2 and downward part is a sec it will go into the secr fraction pattern so that can happen in hypertonus case in hypotonous case when the muscles are weak what will happen this will go for extension the part and upper part will go for flexion again is going to cause back pain now which muscles are getting affected we have to be smart enough now what to do so back pain is directly correlated with the health of the pen I hope you understood okay this movement if the muscles are tight it will pull it anteriorly so downward part will go for flexion upper part will go for extension and this is how it's going to create a tension and if muscles are loose weak this downward part will go for extension upper part will go for flection because they are fused bone they cannot separate they cannot move separately so they they have to move like this this this fused B isn't it if this is pulled this will go back if this is weak this will move anteriorly and this is how it is going to be cause pain to other or cause the pain and tension to the other back muscles now a very very important part understanding of this B okay so there's I'm going to share one this slide please take a screenshot and read uh whenever you have time just a one screen you just have to um read it and we need a good stability into this bone we don't want unnecessarily any extra space and laxity and tightness or any spasm or any pain the bone is very important first and then we have a difference between the male and female pelvis so please take a screenshot of this as well and you can read so this is only pubic Arch is important to understand Inlet is important to understand Outlet is important to understand how this pension can create a uh effect with the inlet wider Inlet will happen if the pelvic muscles are weak so wider Outlet will happen so we should how much difference is there uh into this pubic Arch so this degre of pubic Arch is very very important now the homework for all of you you have to sit on the piece of paper and then measure it where exactly how much space is there between one sit bone to other sit bone you all have to mark it on the paper and take a screenshot of the paper and send it to the group we will see the difference and next is the art what is your pubic Arch angle okay is it 60° 70° 80° 90° 100° whatever it is please write it down and send it to the uh group let's see this is our homework take a screenshot and read it and then tomorrow we are going to yeah it is also important to understand that we have two sacc um joints are there ligaments are there joint two joints are there Lig there are four gments present we will discuss about the ligament and the importance of the ligament tomorrow today we understood this pubic symphasis anteriorly and uh this there's a ligament present which is holding the bones together even posteriorly and how they are maintaining the post this whole good position this is what we are going to discuss tomorrow ligament of the pelvis and they have a significance very important because you can understand if any of ligament is tight assume this pubic ligament is tight so means this pelvic bone will be pulled anteriorly more so that is going to cause load at the back if the back ligament is tight it will separate the pubic symphisis from each other because that loading is there from the back so if this is tight this liament is tight it will pull it will give a pain here if this liament is tight it might create a tension at the back if this ligament which is holding that um Asis with pubic symphasis if this inguinal ilu ligament the green color if that is tight so you can understand if one side of the ILO ligament is tight pelvic tilting will happen one side of the pelvic tilting because that is going to pull going to shift all the pelvis in one side the for the posture the ligaments are very important and we can relax the ligament okay by our techniques and by heating protocol we can increase the movement into the ligament uh if they are tight if they are weak you can't do anything uh then they have to go for surgery but if they are tight we can definitely help uh the person to release the tension we will discuss it tomorrow this is what we discussed today uh please take a screenshot three organs first is a pubic symphisis back is a sacrum both side is a eal tuberosity and then we have three organs in a female bladder with urethra uterus with vagina rectum with anal Canal male they are having again three organs bladder and the prostrate is again organ which is attached with this long tube and it is going outside and this is a rectum with anal Canal female and male we have a extra or in male we have a penile structure so tomorrow we will understand the penile structure and we will also understand the vva of a female so perenial Health external Health what is the penis what is the scrotum what is the testes this is all we are going to discuss tomorrow this is what we are saying is a external genitals today we understood the internal organs tomorrow we will understand the external genitals of a male don't miss tomorrow's session and external genitals of the female like uh vva liia Majora libia minora uh we have a vestibule we have a clitoris this is all we are going to discuss tomorrow so I'm just because in Philippines it is 1:00 in the midnight so I don't want to stretch the session so all of you please take care and um I'll see you all tomorrow any question you can always ask in the group you can just record send it to me anything comes in your mind don't hesitate to ask because I'm also we are we are all learning together all right I hope that you you get some understanding today about the P okay thank you so much everyone and you take care of yourself okay right thank you ma'am thank you