Pelvic Floor Dysfunction

What is Pelvic Floor Dysfunction?

Pelvic floor dysfunction (PFD) is a term that refers to a set of symptoms and physical changes related to problems with the pelvic floor muscles. The pelvic floor muscles are in your lower abdomen, holding and supporting your bladder, uterus (for women), prostate (for men), and rectum like a sling. When these muscles don’t function properly, they may be too active (hypertonicity) or too inactive (hypotonicity), or their coordination may be off. Changes to the support of pelvic organs, a condition known as Pelvic Organ Prolapse (POP), are also related to PFD. PFD’s effects can be related to bladder (urologic), reproductive organs (gynecologic), or rectum (colorectal), and these issues often affect each other. We can break down the problems into three areas: the front (urethra/bladder), the middle (vagina/uterus), and the back (anus/rectum).

The pelvic floor resembles a dome-shaped muscle diaphragm, with several muscles attached by ligaments spreading across the base of the pelvis. The main pelvic musculature is the levator ani muscle group, which consists of the puborectalis, pubococcygeus, and iliococcygeus muscles. These muscles help support the pelvic organs and maintain, for instance, fecal continence – the ability to control bowel movements.

The nerves mostly controlling the pelvic floor are the S3 and S4 sacral nerves, known as the pudendal nerve. The main blood supply comes from the internal iliac artery. The pelvic floor muscles have three main roles: supporting the pelvic organs, assisting with control of urine and feces, and contributing to sexual functions.

Various conditions might occur due to PFD – when the muscles are too active or inactive, there’s a loss of pelvic support, or a combination of these problems. Some of these conditions include:

Urinary issues like cystocele (bladder bulging into the vagina), urethrocele (urethra bulging into the vagina), urinary incontinence (unintentional urine leakage), and difficulty in urination. Reproductive system issues like dyspareunia (pain during or after sex), uterine and vaginal prolapse (herniation of the uterus or the vagina), and enterocele (intestines bulging into the vagina). Rectal issues like constipation due to muscle incoordination during defecation, fecal incontinence (unintentional leakage of stool), and rectal prolapse (rectum pushing out through the anus). Other general problems include chronic pelvic pain, muscle spasms, brief spasmodic pain in the pelvis, and perineal descent (bulging of the perineum below the pelvic outlet).

What Causes Pelvic Floor Dysfunction?

Pelvic floor dysfunction is a condition that isn’t fully understood yet. There isn’t one particular event or factor that has been commonly identified as the cause, but many aspects have been discussed. Things such as difficulty in urinating or passing stool due to too much muscle tension could be caused by learning incorrect elimination techniques. Regular attempts to avoid going to the bathroom might be due to lifestyle habits.

Dyssynergic defecation, a condition where muscles used for bowel movements don’t work together, can start in childhood. Trauma from surgery or childbirth may result in muscle pain with increased tension in the pelvic floor.

Chronic pelvic pain is sometimes linked with sexual abuse. Posture, walking patterns, and a non-symmetrical skeleton can contribute to muscular pain in the pelvis. Degenerative neuromuscular disease, injury to the spinal nerve, lower back injury, or previous surgeries can also be factors for pelvic floor dysfunction. Pain during sexual intercourse from atrophic vaginitis (thinning, drying and inflammation of the vaginal walls) or vulvodynia (chronic pain in the area around the opening of the vagina) might cause the muscles to contract more, leading to pelvic pain.

Conditions like irritable bowel syndrome, endometriosis, or interstitial cystitis that involve the internal organs might contribute to the pain associated with pelvic floor dysfunction. The symptoms often overlap between urologic (relating to the urinary system), gynecologic (relating to the female reproductive system), and colorectal (relating to the lower digestive system) concerns. The interaction of pelvic pain could be due to ‘Cross-talk’ where normal communication between the bowel, bladder, and sexual function is disrupted.

Medications like muscle relaxants, narcotics, alpha-blocking agents, calcium-channel blockers, and methyldopa can cause smooth and skeletal muscle relaxation, potentially leading to leakage of urine (incontinence). Antihistamines and anticholinergics might increase these effects resulting in difficulty urinating and urinary retention. Other factors that contribute to pelvic floor dysfunction include getting older, obesity, giving birth, and having a hysterectomy (surgery to remove the uterus).

Risk Factors and Frequency for Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) is a complex medical condition that affects many people and can manifest in several ways. Understanding the exact number of cases can be challenging because the symptoms and conditions of PFD cover a wide range of issues. However, we do have some statistics that throw light on the prevalence of this problem.

• By the time women reach 80 years old, approximately 11% of them will have undergone surgery for urinary incontinence or pelvic organ prolapse.
• About 40% of women of a reproductive age experience sexual dysfunction, a common issue related to PFD.
• Up to 50% of women who have given birth can be affected by PFD.
• Population-based surveys show a lifetime prevalence of 17% to 19% for sexual pain disorders.
• Women with PFD are often likely to report decreased sexual arousal, less frequent orgasms, and increased pain during intercourse.
• Among women of childbearing age, PFD and pelvic organ prolapse (POP) are relatively common, with 65.8% of women over 40 years reporting at least one occurrence of sexual dysfunction.
• The chance of a woman requiring surgery for stress urinary incontinence in her lifetime is 20.5%.
• While PFD is often associated with women, it’s reported that 16% of men have been identified with PFD.
• The prevalence of POP is on the rise, particularly because the world’s population is getting older.
• In the United States, between 10% and 20% of individuals deal with defecation disorders, leading to 1.2 million visits to the doctor every year. In Olmsted County, Minnesota, the rate is 16 cases per 100,000 people per year.
• When patients present with constipation, 40% may actually have a condition called dyssynergic defecation.
• Patients can experience multiple symptoms at the same time, as evidenced by a study showing that 82% of people with defecatory disorders also have multiple urinary symptoms.

Signs and Symptoms of Pelvic Floor Dysfunction

Medical history for patients with particular symptoms includes the following:

• General signs such as pelvic pain or pressure
• Urologic issues like urinary hesitancy, increased frequency of urination, bladder pain, and incontinence
• Gynecological symptoms like pain during or after intercourse, bulging from the vagina
• Colorectal difficulties like trouble passing stool, constipation, and fecal incontinence
• Applying pressure within the vagina or on the perineum to assist with urination or defecation, known as splinting

Keeping a record of urination, bowel movements, pain, and diet can help doctors to evaluate the condition.

The physical examination may include the following:

• Visual inspection of pelvic organ prolapse, including any noticeable bulging
• Checking for a pelvic floor contraction when trying to prevent urination
• Use of a cotton swab to help identify vulvodynia, a condition causing pain in the vulva area
• Speculum exam to check for inflammation or atrophy of the vaginal lining and to inspect the cervix
• Using fingers to feel the pelvic floor muscles to check for contractibility, relaxation ability, and any pain present
• Checking the muscles in the lower pelvic area, this may also include the perineal body, this is especially crucial when assessing pain during intercourse
• Examining the pelvic organs by feeling them with both hands
• Rectal examination to assess muscle tone and to check for any tumors or sources of pain such as hemorrhoids, anal fissure, or an abscess around the rectum
• Sensitivity test on the anus to check the response to touch and sharp sensation

An additional procedure may involve examination on the toilet or checking for any prolapse when straining.

Testing for Pelvic Floor Dysfunction

When a patient has concerns about Pelvic Floor Dysfunction (PFD) or Pelvic Organ Prolapse (POP), doctors focus on understanding and addressing their specific complaints. Since these health issues can affect different organs within the body, patients often need care from several medical experts. There are many ways to evaluate these conditions, but there is no single diagnostic test for PFD.

Different tests can help doctors better understand what is happening in the body. Here is some information about those tests:

Urodynamics is a test that measures the functioning of the lower part of your urinary system. This includes how well your body stores and releases urine.

Cystoscopy allows doctors to inspect your bladder and urethra by using a device with a camera on the end. The urethra is the tube that urine passes through as it leaves your body.

Anorectal Manometry measures pressures in your anal canal when it’s resting, when you squeeze, and when you try to evacuate, or empty it. It can show how long your anal canal is and provide information about its nerve function. This test includes a balloon insufflation to monitor your body’s reaction to it. Balloon expulsion is another test in which you will be asked to expel a balloon filled with water that is attached to a tube.

Electromyography (EMG) uses electrodes to measure the activity in your external sphincter, the muscle controlling the release of waste from your body, during contraction and relaxation.

Endoanal ultrasonography is an ultrasound of the anal sphincter complex, the muscle structure that controls bowel movements. It helps to identify any potential physical damage that might be causing loss of bowel control.

Defecography involves filling your rectum with a special contrast substance, so that your doctor can take images while you try to retain and expel the material while sitting on a specially designed chair. This test is considered the “Gold Standard” for assessing pelvic floor disease because it helps in identifying issues like rectal prolapse, rectocele, enterocele, perineal descent, and it provides useful information about the anorectal angle when you try to contract and evacuate.

Dynamic MRI is similar to defecography, but instead of a contrast material, a lubricating jelly is used inside the rectum and the patient is typically lying down. It also does not involve ionizing radiation.

There might be the need for other tests depending on your symptoms, so that other potential causes of pelvic pain like gynecological, neurological, orthopedic, urologic and colorectal issues can be ruled out. These tests may include an endoscopy, a CT scan of the abdomen and pelvis, an MRI of the pelvis, or a pelvic ultrasound.

Treatment Options for Pelvic Floor Dysfunction

It’s important to customize treatments for those with pelvic floor dysfunction based on each individual’s specific needs. Often, a team of health professionals is needed to offer care. People who have been through sexual, physical, or emotional abuse should have their whole treatment team made aware. This way, they can adjust the person’s treatment for them.

There are a few lifestyle changes that can help manage the symptoms of pelvic floor dysfunction:

• Diet: Avoiding things like alcohol, caffeine, acidic foods and drinks, high-sugar foods, artificial sweeteners, spicy foods, and cigarettes can help with urinary problems, including incontinence. These changes can also help with anorectal symptoms, such as problems controlling bowel movements.
• Weight loss: Reducing body weight by 3% to 5% can decrease incidents of incontinence (loss of control over urination) by about 50%.
• Pelvic floor exercises (Kegels): These exercises can strengthen the pelvic floor, which is a key area affected by pelvic floor dysfunction.
• Core exercises: These types of exercises focus on the core muscles, including those of the pelvic floor, to provide stronger support.

There are also some medications that can be prescribed for people with pelvic floor dysfunction:

• Topical estrogen creams for the vagina to treat overactive bladder, vaginal thinning, and pain during sex.
• Anticholinergic medications to treat an overactive bladder.
• Beta3 agonists also used for an overactive bladder.

Some patients may also undergo certain physical procedures to help manage their symptoms:

• Patient splinting: Patients can use their fingers to support parts of their vagina or perineum to help make urinating or defecation easier.
• Pessary: A device inserted into the vagina to help with urinary incontinence and pelvic organ prolapse.
• Physical therapy: Treatments can include trigger point massage, myofascial release, strain-counterstrain, joint mobilization, and also training in pelvic floor exercises
• Biofeedback: This technique helps patients learn how to contract and relax their pelvic floor muscles appropriately. It incorporates strengthening and relaxation exercises and can provide visual and/or auditory responses. Biofeedback is often used in physical therapy for patients with pelvic floor dysfunction.

There are also more invasive procedures for those with severe symptoms:

• Cystoscopic intravesical injection of botulinum toxin for overactive bladder.
• Sacral nerve stimulation/modulation: a method that involves placement of an electrical stimulation lead to one of the S3 foramina (small openings in the pelvic bone) to manage urinary and fecal incontinence. However, non-surgical tibial nerve stimulation (which stimulates the sacral nerves via a nerve in the leg) is a recently approved alternative for urinary conditions in the US.
• Pain management options include trigger point injections or acupuncture.

If symptoms persist and are significantly impacting a patient’s life, surgical intervention may be considered.

• Urinary incontinence: A mid-urethral sling procedure may be performed.
• Cystocele (prolapsed bladder): Colposuspension, also known as anterior repair, can be done.
• Uterine prolapse: A hysterectomy along with uterosacral suspension surgery may be recommended.
• Vaginal prolapse: A sacrocolpopexy can repair this condition.
• Enterocele (prolapse of the small intestines): It can be managed through repair of the rectovaginal fascia (the tissue between the rectum and vagina) and closure of the cul-de-sac (a space behind the vagina).
• Rectocele (prolapse of the rectum): This can be repaired through posterior colporrhaphy or transrectal repair.
• Rectal prolapse: Rectopexy (a procedure to repair rectal prolapse) or a perineal resection (a type of surgery on the rectum) can be performed.

It’s important, however, to thoroughly discuss the potential risks and benefits of any surgical procedure with your healthcare team before making a decision.

What else can Pelvic Floor Dysfunction be?

Pelvic floor disorders (PFD) often cause pelvic pain, but there are many other conditions that could be the culprits. These can range from urinary and gynecological disorders to bowel and nerve problems. Some of the main conditions to consider include:

• Prostatitis and prostatodynia (inflammation or pain in the prostate)
• Urinary tract infection
• Urolithiasis (kidney stones)
• Urethral diverticula (pouch in the urinary tract)
• Bladder cancer
• Myofascial pelvic pain (pain in the connective tissue in the pelvic region)
• Interstitial cystitis (painful bladder syndrome)
• Endometriosis
• Adnexal tumors (tumors on organs adjacent to the uterus)
• Uterine fibroids
• Ovarian retention syndrome
• Pelvic congestion syndrome
• Vulvodynia (pain in the vulva)
• Gynecologic cancer
• Chronic intermittent bowel obstruction
• Chronic constipation
• Irritable bowel syndrome
• Diverticular disease (bulging pouches in the digestive tract)
• Inflammatory bowel disease
• Rectal cancer
• Pelvic abscess (infected pocket)
• Pelvic hernias
• Spinal/sacral cancer
• Neuropathy or nerve entrapments in the pelvis
• Abdominal epilepsy and migraines

Urinary incontinence might be due to excessive urine, known as overflow incontinence. Fecal incontinence, on the other hand, may occur if stool is retained, a condition known as encopresis. Lastly, it is common for hemorrhoid prolapse to be mistakenly identified as rectal prolapse.

What to expect with Pelvic Floor Dysfunction

There’s no one-size-fits-all cure for Pelvic Floor Disorder (PFD). This condition, which can cause symptoms of either muscular overactivity (hypertonicity) or underactivity (hypotonicity), may improve with changes in lifestyle, medications, and certain treatments, but total symptom relief is rare.

A common method for treating PFD is physical therapy, which can help reduce or improve symptoms in about 59% to 80% of women suffering from muscle overactivity in the pelvic floor. For example, a surgical treatment called abdominal rectopexy for rectal prolapse (a condition where the rectum turns inside out and protrudes out of the body) offers a success rate with a low recurrence of 3% to 9%. However, sadly, the success rates tend to decrease over time with the chances of the disorder returning increasing.

For women with Pelvic Organ Prolapse (POP – another condition related to PFD where the organs in the pelvis slip down from their normal position), surgical repair can not only correct the anatomical issues but also help improve sexual function and relieve pain during sex, known as dyspareunia.

Possible Complications When Diagnosed with Pelvic Floor Dysfunction

The most significant problem related to conditions of the pelvic floor dysfunction is that treatments may not work and symptoms like incontinence might continue to persist. Treatment methods like lifestyle changes and physical therapy, including biofeedback, are generally safe and don’t have substantial risks. However, if pessaries (a type of device inserted into the vagina to support structures) are not taken care of properly, there could be issues like sores (erosions), trapped devices (incarceration), or abnormal connections between parts of the body (fistulas).

Sacral nerve stimulation, a procedure to treat symptoms, is quite safe. However, minor problems may occur in some cases, such as the electrode moving out of place (12% of cases) or infection (3% of cases).

The device or lead failure or battery depletion are not unusual reasons for surgical revisions. Along with regular surgical concerns such as infection, bleeding, and general health risks, there could be damage to other nearby organs during surgery for pelvic organ prolapse. For example, while performing anterior resection for rectal prolapse, there’s a 26% chance of complications.

Common risks of treating pelvic floor dysfunction:

• All treatments may not work and symptoms might continue
• Pessaries may cause sores, trapped devices or abnormal connections if not used properly
• Sacral nerve stimulation might see electrode dislocation (12%) and infection (3%)
• Surgical revisions due device/lead failure or battery depletion
• General surgical risks (infection, bleeding, and more)
• Possible damage to nearby organs in surgery
• 26% complications during anterior resection for rectal prolapse

Preventing Pelvic Floor Dysfunction

Many people, both men and women, find it hard or uncomfortable to openly talk about problems they may be having with urination, sexual performance, and bowel movements. So, to help make it easier to get this important information from patients, a group called the Pelvic Floor Disorders Consortium (PFDC) has stepped in. This group includes a range of healthcare professionals such as colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, physiotherapists, and others who understand the wide scope of concerns surrounding Pelvic Floor Disorders (PFD).

PFDC reviewed several questionnaires that ask about symptoms, how well a patient can function, and their quality of life. They put together the “Initial Measurement of Patient-Reported Pelvic Floor Complaints Tool” or IMPACT for short. The detailed version of this tool includes 85 questions for men and between 85 to 94 questions for women. They also created a shorter version, which has 34 questions for men and 45 for women.

It’s also really important for patients to understand how the pelvic floor – a group of muscles and other tissues that form the bottom of the pelvis – works and is structured. Knowing pelvic floor exercises and relaxation techniques can be a helpful part of addressing these issues.