Corinne Jedynak-Bell DO - American Osteopathic Association

Corinne Jedynak-Bell DO, MBA, FACOOG
OMED
October 7, 2012
San Diego, California

Overview
• What women want from their physicians?
• Evaluation and Management
• What can cause pain in the Peri and Post Menopausal
patient?
• Sexuality in Older Women
• Breaking Barriers:Taking a Sexual History
• Dyspareunia in the Older women
• The Osteopathic Approach
• Techniques of treatment
• Pelvic Diaphragm
• Symphysis Pubis
• Innominate

What women want from their physicians
• To receive personalized care
• To be taken seriously
• To receive an explanation for their condition (more so
than a cure)
• To be reassured

Evaluation and Management
• History and Physical
• Do not interrupt
• Explain what you are going to do on your exam
• Treatment
• Discuss plan of care with possible tests and medications
• Discuss osteopathic treatment

What can cause pain in the Peri and Post Menopausal
patient
Gynecologic
• Adhesions, adenomyosis, adnexal cysts, chronic endometritis,
dysmenorrhea, endometriosis, gynecologic malignancies, hormonal
changes, leiomyomata pelvic congestion syndrome, pelvic inflammatory
disease
Gastrointestinal
• Celiac disease, colitis, colon cancer, inflammatory bowel disease, irritable
bowel syndrome
Musculoskeletal
• Chronic pain syndrome, degenerative disk disease, fibromyalgia, levator
ani syndrome, myofascial pain, osteoporsis,, somatization, stress fractures
Psychiatric/neurologic
• Abdominal epilepsy, abdominal migraines, depression, nerve entrapment,
neurologic dysfunction, sleep disturbances
Urologic
• Bladder malignancy, chronic urinary tract infection, interstitial cystitis,
radiation cystitis, organ prolapse, urolithiasis

Sexuality of the older woman
• Level of sexual activity, interest, and enjoyment in
younger years determines sexual behavior with aging
• Decreased sexual activity is associated with:
‣ Poor health
‣ Social issues
‣ Partner availability
‣ Decreased libido
‣ Menopause

Breaking the Barrier: Taking a Sexual History
• Provide comfortable atmosphere
• Frame careful questions
• Ask about any previous negative sexual
experience (e.g., rape, child abuse, domestic
violence)
• Ask about current dyspareunia

Dyspareunia in Older Women
• Due to organic or psychological factors, or a
combination of the two
• Most common organic cause: atrophic
vaginitis due to estrogen deficiency
• Some other causes:
‣ Cystitis
‣ Incontinance
‣ Pelvic organ prolapse
‣ Osteoporosis
‣ Mastectomy
‣ Rheumatoid Arthritis

Pathophysiology
• The support of the pelvic floor is composed
of a network of muscles, fascia and
ligaments
• Damage to any one of these structures may
result in weakening and loss of support
• Pelvic prolapse (“pelvic relaxation”) may
lead to symptoms of pressure, fullness,
urinary and/or fecal incontinence, need for
vaginal splinting

The Osteopathic Approach
• Approaching the patient and providing treatment for
many symptoms associated with dyspareunia and
pelvic pain in conjuction with other modalities
• Addressing the WHOLE patient: Social, emotional,
psychological, physical, spiritual
• Looking at the anatomy

Autonomic Innervation
• Innervation of each viscus
• generally follows the course
of
• the arterial supply.
• Sympathetic supply:
• Prostate & Prostatic Urethra: T11-
L1
• Testis & Ovary: T10-11
• Ureter: T11-L2
• Urinary Bladder: T11-L2
• Uterus: T12-L1
• Uterine Tube: T10-L1
• Source: British Gray’s, p. 1306
British Gray’s Anatomy 38 th Ed., p.1293

Pelvic Diaphragm
• The thoracic diaphragm can be monitored for
synchrony of motion between the two –
pelvic & thoracic
• Looking forward from the posterior right
aspect
• View of the ischiorectal fossa –
• Reasonably direct access to one hemidiaphragm
of the pelvic diaphragm.
Moore, Clinically Oriented Anatomy, 4th Edition, 1999, p.400

Lymphatic Congestion
• Thoracic diaphragm function should be
evaluated and treated because it can restrict the
thoracic duct
• Pelvic diaphragm must be evaluated and treated
• Moves passively and synchronously with thoracic
diaphragm

Pelvic Diaphragm
1. Assess for spasm or asymmetry related to prior
surgery involving lower sigmoid, rectum and anal
areas
2. Funnel shaped muscle attaching to lateral walls of
the true pelvis
3. Angles inferior and medially to attach to the
urogenital diaphragm and midline structures of the
urogenital and anal triangles
4. Innervated by pudendal nerve originated from
sacral roots S2,3,4

Pelvic Dysfunction
• Pelvic diaphragm function can be influenced by
sacral and pelvic function.
• Focus upon pelvic dysfunction and its contribution to fluid
congestion, as well as sub-optimal parasympathetic function.
• Pubic & Innominate dysfunction change tensions in the urogenital
diaphragm and the levator ani.
• Thus fluid congestions may be augmented by decreased tissue
motion

Pubic & Innominate Dysfunction
• Parasympathetic changes occur with suboptimal
sacral motion and the increased tensions in the
pelvic tissues
• Sympathetic changes for the same reasons
especially around the sacral sympathetic chain and
the ganglion impar at its end.
• In summary, innominate dysfunction can influence:
• Fluid congestion
• Parasympathetics
• Sympathetics

Symphysis Pubis
• Superior and Inferior shearing mechanics seen
with pubic dysfunction
• Seen post partum
• Also seen in strenuous use of adductor muscles
of thighs or trauma

Superior Pubes
•Physician uses the
shoulder to compress from
the knee toward the
acetabulum
•Physician internally rotates
the lower extremity
•The monitoring finger can
feel the pubes descend

Inferior Pubes
•Compression is again the
first step
•Followed by external
rotation of the lower
extremity to carry an
inferior pubes superior.
•The monitoring finger
can feel the pubes
ascend.

Innominate: Rotated Anterior
•Caudad Hand: Holds knee to maintain eversion at the hip.
•Cephalad Hand: Directs force on the ASIS superior and posterior
•Patient: Gently and slowly carries the foot along the medial aspect of
the opposite leg until straight.

Innominate: Rotated Posterior
•Same technique, except
•Cephalad Hand: contacts the
ischial tuberosity and carries it
superior/posterior

Summary
1. Osteopathic treatment of the lower GI tract involves
evaluating the patient’s entire health
- Nutritional status, psychological stress
2. Somatic influences on the pelvis must be evaluated
and treated
- Short leg syndrome, lumbar & sacral strain/sprain, post-partum
considerations, innominate upslip
3. The potency of further therapy hinges on the
manipulative treatment.
- For antibiotics to be fully effective, blood flow and lymphatic
drainage must be optimized

Somatic Dysfunction
• Osteopathic manipulative treatment is directed
toward:
• Improving blood flow
• Improving lymphatic flow
• Balancing autonomic impulses to and from the bowel

References
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+ Black references are Osteopathic