Pelvic Floor Dysfunction – Causes, Symptoms, Treatment

Pelvic Floor Dysfunction (PFD) refers to a broad constellation of symptoms and anatomic changes related to abnormal function of the pelvic floor musculature. The disordered function corresponds to either increase activity (hypertonicity) or diminished activity (hypotonicity) or inappropriate coordination of the pelvic floor muscles. Alterations regarding the support of pelvic organs are included in the discussion of PFD and are known as Pelvic Organ Prolapse (POP). The clinical aspects of PFD can be urologic, gynecologic, or colorectal and are often interrelated. Another way to compartmentalize the concerns are anterior- urethra/bladder, middle- vagina/uterus and posterior- anus/rectum.

Pelvic floor dysfunction may include any of a group of clinical conditions that includes urinary incontinence, fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction, and several chronic pain syndromes, including vulvodynia in women and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men. The three most common and definable conditions encountered clinically are urinary incontinence, anal incontinence, and pelvic organ prolapse.

Types

When the muscles tighten, or spasm, people may have trouble urinating or passing stool. When they weaken, the organs within the pelvis may drop and press down on the rectum and bladder.

The table below outlines several common types of pelvic floor dysfunction.

Anatomy

The pelvic floor is a combination of multiple muscles with ligamentous attachments creating a dome-shaped diaphragm across the boney pelvic outlet. This complex of muscles spans from the pubis (anterior) to the sacrum/coccyx (posterior) and bilateral to the ischial tuberosities. The bulk of the pelvic musculature is the levator ani, composed of the puborectalis, pubococcygeus, and iliococcygeus. The puborectalis wraps as a sling around the anorectal junction accentuating the anorectal angle during contraction and is a primary contributor to fecal continence. Elevation and support of the pelvic organs are associated with the pubococcygeus and the iliococcygeus.[rx] The pubococcygeus is the most medial component which separates, fashioning the levator hiatus with openings for the urethra, vagina (females), and anus. The bulbospongiosus and ischiocavernosus muscles are the primary contributors to the superficial portion of the anterior pelvic floor. The more superficial musculature of the posterior pelvic floor constitutes the external anal sphincter. The transverse perineal muscles cross the mid-portion of the superficial aspect of the pelvic floor and coalesce with the bulbospongiosus muscles and external anal sphincter as the perineal body.

The nerve supply to the pelvic floor structures is primarily from sacral nerves S3 and S4 as the pudendal nerve. The predominant blood supply is derived from parietal branches of the internal iliac artery. The muscles of the pelvic floor have three functions:

• Support of the pelvic organs- bladder, urethra, prostate (males), vagina and uterus (females), anus, and rectum, along with the general support of the intra-abdominal contents.
• Contribute to the continence of urine and feces.
• Contribute to the sexual functions of arousal and orgasm[rx]

Conditions

A wide variety of conditions are attributed to PFD due to hypertonicity, hypotonicity, loss of pelvic support, or mixed concerns.

• Urologic

  • Difficult urination: hesitancy, delay in the urinary stream.
  • Cystocele: bulging or herniation of the bladder into the vagina (anterior).
  • Urethrocele(urethral prolapse): bulging of the urethra into the vagina (anterior)
  • Urinary incontinence: involuntary leakage of urine.

• Gynecologic

  • Dyspareunia: pain with or following sexual intercourse.
  • Uterine prolapse: herniation of the uterus via the vagina beyond the introitus.
  • Vaginal prolapse: herniation of the vaginal apex beyond the introitus.
  • Enterocele: bulging or herniation of the intestines into the vagina (apical/posterior).
  • Rectocele: bulging or herniation of the rectum into the vagina (posterior).

• Colorectal

  • Constipation: paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation (dyssynergic defecation).[rx]
  • Fecal incontinence: involuntary leakage of stool (not related to sphincter disruption).
  • Rectal prolapse: intussusception of the rectum beyond the anal verge (Procedentia) or proximal to the anus (Occult).

• General

  • Pelvic pain: chronic pain lasting more than three to six months, unrelated to other defined conditions.
  • Levator spasm: another term for chronic pelvic pain related to the levator ani musculature.
  • Proctalgia fugax: fleeting spastic pain related to the levator ani musculature.
  • Perineal descent- bulging of the perineum below the boney pelvic outlet.

Causes of Pelvic Floor Dysfunction

The causes of pelvic floor dysfunction are not well understood.

• No specific inciting event or factor has been generally identified as an etiology of PFD, but multiple factors have been discussed. Hypertonicity symptoms associated with voiding and defecation difficulties might be related to learning poor evacuation techniques. Habitual efforts to avoid urination or bowel movements might be lifestyle attributing factors.[rx][rx] Dyssynergic defecation may begin in childhood.[rx] Surgical or obstetric trauma may lead to muscular pain with hypertonicity of the pelvic floor.[rx][rx]
• Sexual abuse has been associated with chronic pelvic pain.[rx] Posture, gait and skeletal asymmetry may contribute to pelvic muscular pain.[rx][rx] Degenerative neuromuscular disease, spinal nerve injury, lower back injury, or surgery may contribute to pelvic floor dysfunction.
• Dyspareunia from atrophic vaginitis or vulvodynia may contribute to reinforced muscle contraction resulting in pelvic pain.[rx] Irritable bowel syndrome, endometriosis, interstitial cystitis are some visceral syndromes that might contribute to PFD pain.[rx] Again, symptoms of PFD are often interrelated between urologic, gynecologic, and colorectal concerns. “Cross-talk’ via normal regulation to the bowel, bladder, and sexual function may explain the interaction of pelvic pain syndromes.[rx][rx]
• Muscle relaxants, narcotics, alpha-blocking agents, calcium-channel blockers, and methyldopa can increase smooth and skeletal muscle relaxation, possibly contributing to incontinence. Antihistamines and anticholinergics may have additive effects leading to urinary hesitancy and retention.[rx] Additional factors contributing to PFD include advancing age, obesity, childbearing, and hysterectomy.[rx]

Symptoms of Pelvic Floor Dysfunction

Symptoms of nonrelaxing pelvic floor dysfunction are associated with

• Avoiding dysfunction,
• Anorectal dysfunction,
• Sexual dysfunction, and pain. S
• Symptoms tend to develop slowly and insidiously; for some patients, they may begin in childhood (eg, defecatory disorders).
• Difficulty evacuating stool or straining with bowel movements, a sense of incomplete evacuation, bloating, and constipation are bowel symptoms characteristic of non relaxing pelvic floor dysfunction.
• Urinary symptoms include frequency, hesitancy, urgency, dysuria, bladder pain, and sometimes urge incontinence. Insertional or deep dyspareunia, a pelvic ache after intercourse, low back pain radiating to the thighs or groin, and pelvic pain unrelated to intercourse are also common.
• It is important to inquire about the range of symptoms that may suggest nonrelaxing or hypertonic pelvic floor dysfunction in women who present with bowel, bladder, or sexual concerns.
• urinary issues, such as the urge to urinate or painful urination
• constipation or bowel strains
• lower back pain
• pain in the pelvic region, genitals, or rectum
• discomfort during sexual intercourse for women
• pressure in the pelvic region or rectum
• muscle spasms in the pelvis

What does pelvic floor dysfunction feel like?

Several symptoms may be a sign that you have pelvic floor dysfunction. If you have any of these symptoms, you should tell your healthcare provider:

• Frequently needing to use the bathroom. You may also feel like you need to ‘force it out’ to go, or you might stop and start many times.
• Constipation, or a straining pain during your bowel movements. It’s thought that up to half of people suffering long-term constipation also have pelvic floor dysfunction.
• Straining or pushing really hard to pass a bowel movement, or having to change positions on the toilet or use your hand to help eliminate stool.
• Leaking stool or urine (incontinence).
• Painful urination.
• Feeling pain in your lower back with no other cause.
• Feeling ongoing pain in your pelvic region, genitals or rectum — with or without a bowel movement.

Is pelvic floor dysfunction different for men and women?

There are different pelvic conditions that are unique to men and women.

Pelvic floor dysfunction in men

Every year, millions of men around the world experience pelvic floor dysfunction. Because the pelvic floor muscles work as part of the waste (excretory) and reproductive systems during urination and sex, pelvic floor dysfunction can co-exist with many other conditions affecting men, including:

• Male urinary dysfunction – This condition can involve leaking urine after peeing, running to the bathroom (incontinence), and other bladder and bowel issues.
• Erectile Dysfunction (ED) – ED is when men can’t get or maintain an erection during sex. Sometimes pelvic muscle tension or pain is the cause, but ED is a complex condition so this may not be the case.
• Prostatitis – Pelvic floor dysfunction symptoms closely resemble prostatitis, which is an infection or inflammation of the prostate (a male reproductive gland). Prostatitis can have many causes including bacteria, sexually transmitted infections or trauma to the nervous system.

Pelvic floor dysfunction in women

Pelvic floor dysfunction can interfere with a woman’s reproductive health by affecting the uterus and vagina. Women who get pelvic floor dysfunction may also have other symptoms like pain during sex.

Pelvic floor dysfunction is very different than pelvic organ prolapse. Pelvic organ prolapse happens when the muscles holding a woman’s pelvic organs (uterus, rectum and bladder) in place loosen and become too stretched out. Pelvic organ prolapse can cause the organs to protrude (stick out) of the vagina or rectum and may require women to push them back inside.

Diagnosis of Pelvic Floor Dysfunction

History and Physical

History

• General

  • Pelvic pain/pressure.

• Urologic

  • Urinary hesitancy/frequency/urgency, dysuria, bladder pain, incontinence- urge, and stress.

• Gynecologic

  • dyspareunia (during/after intercourse), sexual arousal, orgasm, bulging from the vagina.

• Colorectal

  • Difficult/straining/incomplete evacuation of stool, bloating, constipation, fecal incontinence/leaking, prolapse/protrusion from anus.
• Splinting- pressure within the vagina or on the perineum to provide support and assist with voiding or defecation.[rx]
• Voiding, defecation, pain, and dietary diaries are beneficial to assist with the evaluation.

Physical Exam

• Visual inspection, including bulging with pelvic organ prolapse.
• Pelvic floor contraction (to avoid urination), should lift the perineum.
• Cotton swab test for localizing vulvodynia.
• Speculum exam for atrophy or inflammation of the vaginal mucosa and visualization of the cervix.
• Digital palpation of pelvic floor muscles for contraction, relaxation (after attempted voluntary contraction), and pain.
• Palpation of the urogenital triangle includes ischiocavernosus, bulbospongiosus, and transverse perineal muscles and perineal body- is especially important in assessing dyspareunia.
• Bimanual exam of the pelvic organs.
• Rectal digital exam to evaluate sphincter tone and pelvic floor muscles; coccyx; exclude neoplasm; to identify sources of pain, hemorrhoids, anal fissure, or anorectal abscess.
• Anal sensation., response to touch, and pinprick.
• Examination on the toilet, inspection for prolapse with straining.

Evaluation

Basic evaluation

• carried out by a general practitioner, gynecologist, or urologist; suffices to establish the indication for initial conservative treatment, with antibiotic treatment of urinary tract infections (if necessary), pelvic floor exercises, behavior modification, or anticholinergic medication
• history, including basic psychosomatic questions
• urinalysis to rule out infection
• determination of post-void residual volume
• micturition diary

Extended basic evaluation

• carried out by a gynecologist or urologist (with the aid of a psychiatrist and/or specialist in psychosomatic medicine, if indicated); suffices to establish the indication for a further trial of conservative treatment
• vaginal inspection (prolapse, local hormone deficiency, contractility of pelvic floor)
• perineal/intraoral ultrasonography (bladder neck mobility, bladder neck funneling, prolapse)
• clinical stress test (urine loss upon coughing while standing)
• Urinary pad test

Special tests

• carried out by a specialist (perhaps at specialized continence and pelvic floor center); necessary to establish the indication for a surgical procedure when conservative treatment has failed
• urodynamic testing
• cystoscopy
• specialized perineal/intraoral ultrasonography
• endoanal ultrasonography, if indicated
• dynamic magnetic resonance defecography, if indicated

Evaluation of patients with PFD and POP concerns are initially directed toward their presenting complaints. As noted previously, the complaints and concerns often involve multiple systems requiring multidisciplinary care. Multiple forms of evaluation are available, but none are specifically diagnostic for PFD. Various tests are incorporated to augment the physician’s clinical perception.

• Urodynamics – measures the functional aspects of the distal urinary tract to include urine storage and evacuation.
• Cystoscopy – visual inspection of the bladder and urethra.
• Anorectal Manometry – the measurement of anal canal pressures at rest and with squeezing and with attempted evacuation. Anal canal length can be measured. The neurologic function can be estimated by observing the rectoanal inhibitory reflex (RAIR) and sensation for evacuation with balloon insufflation.
• Balloon expulsion – timed evacuation of a filled 50cc balloon attached to a catheter.
• Electromyography (EMG): electrodes (needle or surface) measure external sphincter activity during contraction and relaxation.
• Endoanal ultrasonography – assess the structural integrity of the anal sphincter complex to exclude a traumatic defect contributing to fecal incontinence.
• Defecography – the patient’s rectum is filled with contrast. Images are obtained while the patient performs efforts for maintaining continence and evacuation while sitting on a special potty chair. Defecography is the “Gold Standard” for assessing pelvic floor disease.[rx] Defecography provides assessment for rectal prolapse, rectocele, enterocele, perineal descent, and documentation of the anorectal angle with contraction and evacuation. Patients with dyssynergia defecation have a good correlation between abnormal EMG and balloon expulsion tests but do not match well with radiographic dyssynergia.[rx]
• Dynamic MRI – similar to defecography as the patient evacuates lubricating jelly that has been instilled into the rectum (no ionizing radiation; often non-physiologic defecation from a supine position).
• Surface electrodes – (self-adhesive pads placed on your skin) can test your pelvic muscle control. This might be an option if you don’t want an internal exam. The electrodes are placed on the perineum (the area between the vagina and rectum in women, and between the testicles and rectum in men) or on the sacrum (the triangular bone at the base of your spine). This test is not painful.
• Anorectal manometry – (a test measuring how well the anal sphincters are working) can test pressure, muscle strength, and coordination. This test is not painful.
• A defecating program – is a test where you’re given an enema of a thick liquid that can be seen with an X-ray. Your provider will use a special video X-ray to record the movement of your muscles as you attempt to push the liquid out of the rectum. This will help to show how well you are able to pass a bowel movement or any other causes for pelvic floor dysfunction. This test is not painful.
• A uroflow test can show how well you can empty your bladder. If your flow of urine is weak or if you have to stop and start as you urinate, it can point to pelvic floor dysfunction. Your provider may order this test if you have problems while urinating. This test is not painful.

• Additional tests – are incorporated as indicated to evaluate for other sources of pelvic pain (colorectal, gynecologic, neurologic, orthopedic, and urologic).

  • Endoscopy (anoscopy, sigmoidoscopy, colonoscopy)
  • CT scan of the abdomen and pelvis
  • MRI of the pelvis to evaluate structural anatomy
  • Pelvic ultrasound to evaluate the uterus and adnexa

Treatment of Pelvic Floor Dysfunction

Therapeutic interventions for patients with pelvic floor dysfunction should be tailored to their specific needs. A multidisciplinary approach is often necessary. Patients with a history of sexual, physical, or emotional abuse should have the information relayed to the entire treatment team to facilitate modifications of therapy to accommodate the patient’s needs.[rx]

Lifestyle Modifications

• Diet: avoidance of alcohol, caffeine (cola, tea, and coffee), acidic foods/beverages, including citrus and tomatoes, concentrated sugar, artificial sweeteners, including aspartame, spicy foods, and cigarettes for urinary frequency and incontinence.[rx] These changes have overlapping benefits for anorectal symptoms, including incontinence.
• Weight loss: a 3% to 5% weight reduction can decrease urinary incontinence episodes by about 50%.[rx]
• Pelvic floor exercises (Kegel): to strengthen the pelvic floor.
• Core exercises: to strengthen the pelvic floor and support.

Medications

• Topical vaginal estrogen for overactive bladder, vaginal thinning, and dyspareunia.
• Anticholinergics (fesoterodine, tolterodine) for overactive bladder.
• Beta3 agonists (mirabegron) for overactive bladder.
• Duloxetine –  is the sole drug used in the treatment of stress incontinence. Two systematic reviews concluded that duloxetine, in a daily dose of 80 mg, does not eliminate incontinence but does lessen the frequency of episodes of both stress and urge incontinence. Because severe nausea is a frequent side effect at the beginning of treatment, this drug should be introduced with a slow escalation to the final dose [rx].

Manipulation

• Patient splinting: digital support of the posterior vagina, anterior vagina, or perineum to facilitate voiding or defecation.
• Pessary: stress urinary incontinence and POP via the vagina.

• Physical therapy

  • trigger point massage, myofascial release, strain-counterstain, joint mobilization.[rx][rx]
  • management of dyspareunia related to pelvic floor hypertonicity.[rx]
  • expert training of pelvic floor exercises.

• Biofeedback –  a neuromuscular technique for training appropriate pelvic floor contraction and relaxation. Intra-anal, intra-vaginal, or surface electrodes are incorporated with strengthening and relaxation exercises to provide patients with visual and/or auditory responses to their efforts. Biofeedback is a mainstay for managing patients with PFD. Physical therapy and biofeedback require specifically trained therapists with interest in Pelvic Floor Disorders.

  • Improve continence urine/stool.[rx]
  • Improve relaxation for evacuation- urine/stool.[rx]
  • Improve symptoms of POP.[rx]

Invasive Procedures

• Cystoscopic intravesical injection of botulinum toxin A for overactive bladder.[rx]
• Sacral nerve stimulation/modulation-urine/fecal incontinence. It is the placement of electrical stimulation that leads to one of the S3 foramina for the management of urinary and fecal incontinence.[rx][rx][rx][rx][rx][rx] As an alternative, non-surgical posterior tibial nerve stimulation (stimulates the sacral nerves via the tibial nerve) has recently been approved in the United States for urologic conditions.[rx]
• Pain management with trigger point injections or acupuncture.[rx]

Surgery

Surgical procedures are indicated for anatomic prolapse concerns that do not have satisfactory symptom relief with non-operative measures.

• Urinary incontinence: mid-urethral sling.
• Cystocele: colposuspension (anterior repair).
• Uterine prolapse: hysterectomy and uterosacral suspension.
• Vaginal prolapse: sacrocolpopexy.
• Enterocele: repair of the rectovaginal fascia and obliteration of the cul-de-sac.
• Rectocele: posterior colporrhaphy or transrectal repair.
• Rectal prolapse: rectopexy (posterior or anterior) or perineal resection (Altemeier).

EXTERNAL AND INTERNAL MANUAL THERAPY

The therapist may do manual therapy or massage both externally and internally to stabilize your pelvis before using other kinds of treatment. Manual therapy takes time and patience, and may require one to three sessions per week, depending on the technique used and your response to treatment. You may feel worse initially. However, many patients see improvement after six to eight weeks.

For internal massage, your PT may insert a finger into the vagina or rectum and massage the muscles and connective tissue directly. A frequently used technique is “Thiele stripping,” in which your therapist finds a trigger point by feeling a twitch in the muscle underneath, exercising it using a circular motion, and then putting pressure on it to help relax it, repeating the process until the muscle starts to release. Internal massage can also help release nerves. Sometimes, anesthetics can be injected into these trigger points. PTs may do this in a few states, but in most states, a doctor or nurse must administer injections.

If there is too much discomfort with internal therapy techniques, your PT may start with external techniques to help you begin to relax these muscles, including:

• Skin rolling
• Deep tissue massage, often called “myofascial release”
• Trigger-point therapy to release tight spots or “knots”
• Nerve release
• Joint mobilization

APPLICATION OF VARIOUS DEVICES AND THERAPIES TO HELP RELAX YOUR PELVIC FLOOR

PTs also use a variety of devices and therapies to help you learn to relax your pelvic floor or to treat your pelvic pain directly.

• Relaxation techniques – Your provider or physical therapist might also recommend you try relaxation techniques such as meditation, warm baths, yoga, and exercises, or acupuncture.
• Electrical stimulation – uses a small probe inserted into the vagina or rectum to stimulate your pelvic floor muscles, helping desensitize nerves and causing muscles to contract and relax. Stimulation through electrodes placed on your body may calm pain and spasms. Different kinds of electrical stimulation devices are available for home use, both for internal stimulation with a probe or for external stimulation, such as transcutaneous electrical nerve stimulation (TENS) or similar unit, to ease the pain.
• Interferential therapy – is a kind of electrical stimulation delivered from electrodes placed on the skin. The impulses “interfere” with each other at the point of pain deep in tissues and can replace and relieve the sensations of spasm. Home units are available.
• Ultrasound – uses high-frequency sound waves applied through a wand or probe on your skin to produce an internal image or to help treat pain. Real-time ultrasound can let you see your pelvic floor muscles functioning and help you learn to relax them. Therapeutic ultrasound uses sound waves to produce deep warmth that may help reduce spasm and increase blood flow or, on a nonthermal setting, may promote healing and reduce inflammation.
• Cold laser – applies low-intensity laser light to the tissue and may help with pain, inflammation, and wound healing. Some devices have FDA approval for temporary relief of minor muscle aches, joint pain and stiffness, and for relaxation of muscle spasm and increasing local blood flow.

Home exercise and therapy is also a mainstay of PFD rehabilitation. Because the goal of PFD therapy is to learn to control and, especially, relax the pelvic floor, therapists will teach you techniques for use at home to build on the therapies they do in their offices. This usually begins with general relaxation, stretching the leg and back muscles, maintaining good posture, and visualization—part of learning to sense your pelvic floor muscles and to relax them.

• https://www.ncbi.nlm.nih.gov/books/NBK563229/
• https://www.ncbi.nlm.nih.gov/books/NBK525783/
• https://www.ncbi.nlm.nih.gov/books/NBK525762/
• https://www.ncbi.nlm.nih.gov/books/NBK564429/
• https://www.ncbi.nlm.nih.gov/books/NBK542211/
• https://www.ncbi.nlm.nih.gov/books/NBK551513/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6821990/
• https://pubmed.ncbi.nlm.nih.gov/28762694/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570968/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4570968/
• https://www.ncbi.nlm.nih.gov/books/NBK231871/
• https://www.nhs.uk/conditions/pelvic-organ-prolapse/treatment/
• https://www.health.harvard.edu/womens-health/what-to-do-about-pelvic-organ-prolapse
• https://www.aafp.org/afp/2017/0801/p179.html