What is Pelvic Floor Dysfunction?
The pelvic floor consists of a group of muscles and ligaments in the pelvic region. These work together to support the organs in the pelvis, such as the rectum, bladder, and uterus or prostate. Pelvic floor dysfunction is a condition where the muscles function abnormally and makes it more difficult to perform our daily bowel movements or urination.
The pelvic floor plays an essential role in continence, voiding, defecation, and sexual function. As such, a wide variety of conditions spanning across various disciplines can be attributed to pelvic floor dysfunction. These include urinary incontinence, faecal incontinence, sexual dysfunction, and pelvic organ prolapse. Pelvic floor dysfunction is a common condition that can affect up to 50% of childbearing women.
What are the symptoms of Pelvic Floor Dysfunction?
As pelvic floor dysfunction can affect multiple organs and systems, the symptoms can vary between individuals. The symptoms are specific to the urological, gynaecological, and colorectal systems.
Urological system
- Difficult urination: Delay in the urinary stream and slow flow
- Cystocele: Bulging of the bladder into the vagina
- Urethrocele: Bulging of the urethra into the introitus
- Urinary incontinence: Leakage of urine due to loss of bladder control or weak pelvic floor
Gynaecological system
- Uterine prolapse: Herniation or bulging of the uterus beyond the introitus
- Vaginal prolapse: Herniation or bulging of the vaginal apex beyond the introitus
- Enterocele: Herniation or bulging of the intestines into the vagina
- Rectocele: Herniation or bulging of the rectum into the vagina
- Dyspareunia: Painful sexual intercourse
Colorectal system
- Rectal prolapse: Intussusception of the rectum
- Faecal incontinence: Involuntary leakage of stools
- Constipation: Uncomfortable or infrequent bowel movements
When should I visit a doctor?
You should see a doctor if you experience any of the bothersome symptoms related to pelvic floor dysfunction, such as a change in evacuation and voiding effort. Although urinary and faecal incontinence are not life-threatening, they can worsen over time and result in more discomfort
What causes Pelvic Floor Dysfunction?
The causes of pelvic floor dysfunction are not completely understood and may be multifactorial. It is believed that pelvic floor dysfunction is associated with conditions or events that may damage the connective tissue or weaken the pelvic floor muscles. These include childbirth, traumatic injury to the pelvic region, pelvic surgery, and nerve damage. Several factors are hypothesised to contribute to pelvic floor dysfunction
- Lifestyle factors — Poor evacuation techniques and habitual efforts to delay or avoid urination or bowel movements may contribute to the symptoms related to voiding and defecation difficulties.
- Trauma — Surgical and obstetric trauma may contribute to pelvic muscular pain with hypertonicity of the pelvic floor. Sexual abuse is also a known factor associated with chronic pelvic pain.
- Nerve damage —Conditions such as spinal nerve injury and degenerative neuro muscular disease may contribute to pelvic floor dysfunction
- Other medical conditions — Conditions such as irritable bowel syndrome, interstitial cystitis, and endometriosis may contribute to pelvic floor dysfunction and pain.
- Medications — Certain medications such as muscle relaxants, narcotics, antihistamines and alpha-blocking agents may contribute to incontinence and voiding dysfunction.
What are the risk factors for Pelvic Floor Dysfunction?
Several studies revealed the risk factors for pelvic floor dysfunction, including advancing age, obesity, parity, and hysterectomy
- Age — The prevalence of pelvic floor dysfunction increases significantly with age. The pelvic floor muscles weaken with advancing age and increase the risk of pelvic organ prolapse.
- Obesity — Obesity is a known risk factor for urinary and faecal incontinence. Several studies have shown improvement in urinary continence following weight loss and bariatric surgery. The increase in intra-abdominal pressure in obese individuals causes the weakening of the pelvic floor muscles, which may lead to an increased risk of pelvic floor dysfunction.
- Parity — It refers to the number of pregnancies carried by a woman for at least 20weeks. Increasing parity is associated with pelvic organ prolapse. A third or fourth-degree anal sphincter tear increases the risk of post-partum faecal incontinence.
- Hysterectomy — Hysterectomy refers to the surgical removal of the uterus. It is associated with an increased risk of prolapse.
How is Pelvic Floor Dysfunction diagnosed?
As pelvic floor dysfunction involves multiple systems, there is no one specific test for diagnosis. The evaluation of pelvic floor dysfunction includes detailed medical history, physical exam, and various tests directed toward the presenting symptoms. Voiding, defecation, and dietary diaries can also help to assist in the evaluation and diagnosis of pelvic floor dysfunction.
- Physical exam
A visual inspection of the pelvic area can help to look for any bulging associated with pelvic organ prolapse. A digital rectal exam may also be performed to evaluate the sphincter tone and pelvic floor muscles. - Urodynamic Study
A functional voiding test may be performed to better assess and diagnose voiding issues. In this study, small tubes or catheters are inserted into the bladder and rectum. Water is used to fill up the bladder slowly and you will be asked to pass urine when the bladder is full. As this test is done in real -time, the patient can better understand their condition and replicate their symptoms for us to better diagnose and manage. - Balloon expulsion test
The test involves inserting a balloon into the rectum and evacuating it. It is useful inb detecting any problems related to defecation. - Anorectal manometry
It measures the anal canal pressures at rest, with squeezing, and with evacuation. - Defecography
Images of the contrast-filled rectum are taken while the patient makes an effort tomaintain continence and evacuation. This helps in the evaluation of rectal prolapse, rectocele, enterocele, and perineal descent. - Imaging tests
Computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen and pelvis can help to evaluate the structural anatomy. Endoanal ultrasonography can also be used to assess the structural integrity of the anal sphincter complex.
What can I expect during my first consultation?
During the first consultation, detailed medical history will be taken, which includes the duration and evolution of symptoms. A physical exam will also be performed to check for any muscle spasms and muscle weakness. An internal exam that involves inserting aperineometer into the rectum or vagina may be considered to evaluate pelvic muscle control and contractions. Other imaging tests may be scheduled for further evaluation.
How is Pelvic Floor Dysfunction treated?
In many cases, pelvic floor dysfunction is a highly treatable condition. The treatment is mainly targeted at the symptoms and often involves a multidisciplinary approach.
Lifestyle modification
- Dietary habits — Avoiding or reducing intake of alcohol, caffeinated drinks, acidic food and beverages, and spicy food can help with urinary and faecal incontinence.
- Exercises — An appropriate amount of pelvic floor and core exercises can help to strengthen the pelvic floor muscles. A consultation with a pelvic floor physiotherapist will help as well when there is a need to relearn how to relax the pelvic floor muscles.
- Weight loss — Losing weight can help to reduce urinary incontinence episodes.
Medication
- Medication — Topical vagina oestrogen, anticholinergics, and beta 3 agonists can help with an overactive bladder. Other medications may be used to relax the pelvic floor muscles and the sphincters if required.
Therapy
- Physical therapy — A specialised therapy that includes exercises that can help the pelvic muscles relax and strengthen them. It may be effective to relieve some of the pelvic floor dysfunction symptoms such as pain and discomfort.
- Biofeedback — This neuromuscular technique trains pelvic floor contraction and relaxation. It involves the incorporation of surface electrodes with strengthening exercises to provide visual and auditory responses to the efforts
Invasive procedure
- Neurotoxin A injection — Intravesical injection of neurotoxin A with cystoscopy can help with overactive bladder and bladder pain syndrome. It may also help with tight sphincters.
- Sacral/tibial nerve stimulation — It is the electrical stimulation of the sacral/tibial nerves in an attempt to manage urinary and faecal incontinenc
Therapy
- Physical therapy — A specialised therapy that includes exercises that can help the pelvic muscles relax and strengthen them. It may be effective to relieve some of the pelvic floor dysfunction symptoms such as pain and discomfort.
- Biofeedback — This neuromuscular technique trains pelvic floor contraction and relaxation. It involves the incorporation of surface electrodes with strengthening exercises to provide visual and auditory responses to the efforts
Surgery
- Surgery — Surgical procedures are indicated for symptoms related to anatomic prolapse and when there is inadequate symptom relief from non-operative procedures. These procedures include hysterectomy for uterine prolapse, sacrocolpopexy for vaginal prolapse, and rectopexy for rectal prolapse
Summary
Pelvic floor dysfunction is a broad-spectrum condition that affects both men and women. It can cause significant distress and a negative impact on quality of life. As the pelvic floor musculature supports different organs in the pelvic area, the symptoms are closely associated with the urological, gynaecological, and colorectal systems. Common symptoms of pelvic floor dysfunction include urinary and faecal incontinence, constipation, and pelvic organ prolapse.
If you suffer from pelvic floor dysfunction symptoms, please consult us for a proper diagnosis and treatment. We will work with you in creating the right treatment plan with lifestyle changes, medications, therapies, and/or surgery.
