Pelvic Floor Dysfunction.

Pelvic floor dysfunction is a broad term used to describe a range of symptoms that can be related to poor functioning of the pelvic floor muscles.

The pelvic floor muscles are a group of muscles inside the pelvis, which form a supportive base, or floor, for your pelvic organs – that is the bladder, rectum, and uterus (women) or prostate (men). The pelvic floor muscles have several important roles including maintaining continence, supporting the pelvic organs from below, and contributing to core control.

Well-functioning pelvic floor muscles should contract fast enough and strongly enough when needed, and also relax fully, to allow complete emptying of the bladder and bowels.

With pelvic floor dysfunction, the pelvic floor muscles may instead be weak and under-active, or conversely be over-active and unable to relax well.

Possible symptoms associated with pelvic floor dysfunction can include:

  • Stress urinary incontinence – leakage with exercise, coughing or sneezing
  • Urinary urgency – an urgent need to rush to the toilet, for fear of leaking, which may cause more frequent voiding than usual, and may or may not include urinary leakage
  • Anal incontinence – incontinence of solid, liquid or gas from the bowels
  • Difficulty fully emptying the bladder or bowels, and constipation
  • Pain or discomfort with intercourse
  • Pelvic pain, including coccyx pain
  • Pelvic organ prolapse – descent of one or more pelvic organs from their usual position in the pelvis, felt as bulging and/or heaviness in the pelvis.

What Causes Pelvic Floor Dysfunction?

Pelvic floor dysfunction is very common, with 1 in 5 Australians reporting problems with bladder and bowel control. PFD is more common amongst certain populations, for example, women who have had a baby, with 1 in 3 suffering from urinary incontinence and up to 50% developing pelvic organ prolapse later in life.

The causes of this dysfunction can be multi-faceted:

  • Trauma to the pelvic floor region from childbirth – may lead to pelvic floor muscle weakness and connective tissue damage, or conversely, reactive pelvic floor muscle over-activity and spasm. Instrumental delivery, a long labour and large baby all increase your risks of pelvic floor trauma
  • Pregnancy – hormonal changes and the weight of the pregnant uterus can weaken the pelvic floor muscles
  • Ageing – connective tissues lose their elasticity and muscles gradually weaken with age. For women, oestrogen decline after menopause can worsen many symptoms
  • Anything causing chronic strain or loading on the pelvic floor – this can include obesity, constipation, coughing and sneezing, heavy lifting and high impact exercise
  • Genetics – certain disorders, like pelvic organ prolapse, seem to run in families, and are probably related to connective tissue type and strength

Treatment Options

Treatment for this type of dysfunction will partly depend on an individual’s particular problems.

  • Lifestyle management is useful for all types of pelvic floor dysfunction, but will vary depending on symptoms and the factors contributing to them. Ensuring food and fluid intake is well balanced to aid optimal bladder and bowel function can be helpful. Modification to exercise regimes or daily activities (eg, limiting repetitive heavy lifting) may be recommended for prolapse or stress urinary incontinence, to prevent symptoms worsening. Retraining toileting position and preventing straining is also useful for many problems.
  • Pelvic floor muscle training has shown to be very effective, and is recommended as first line treatment for urinary incontinence. It is also an effective conservative management option for pelvic organ prolapse, and anal incontinence. Pelvic floor muscle training works best when correct exercise technique has been verified, and training programs are monitored and progressed regularly by a Continence and Women’s Health Physiotherapist.
  • Some problems will be aggravated by regular pelvic floor muscle training, and may instead require pelvic floor muscle down-training. This focuses more on the relaxation phase of a pelvic floor contraction, and may be recommended for those with sexual pain, and anybody with overactive pelvic floor muscles, which can include some presenting with urgency, urinary incontinence and pelvic pain.
  • Bladder training is particularly useful in managing urgency and incontinence related to urgency. This includes techniques to calm your overactive bladder, such as breathing and diversion techniques, as well as learning to gradually extend the time between toilet trips, if frequency has become a problem.
  • Support pessaries are silicone devices fitted in the vagina to help support a pelvic organ prolapse. A well-fitting pessary can be very effective in reducing prolapse symptoms, and is recommended as part of first line management for pelvic organ prolapse, along with pelvic floor muscle training and lifestyle management.
  • Soft tissue therapy on external or internal pelvic muscles can be helpful for some with pelvic floor muscle over-activity and pelvic pain to ease the muscle spasm and tension, just as massage can be useful on tight and sore muscle elsewhere in the body.
  • Electrical stimulation can be a useful treatment adjunct in several different ways. It can help achieve a correct pelvic floor muscle contraction in those with very weak muscles. External electrical stimulation can also be an effective treatment for urinary urgency and anal incontinence.
  • Surgery is usually the last resort, but may be necessary for some with advanced symptoms, or if conservative measures have failed. Common surgeries for PFD include repairs of pelvic organ prolapse, sling surgery for stress urinary incontinence, and surgery to implant a permanent electrical stimulation device for intractable urinary urgency or anal incontinence. However, it should be remembered that surgery, like all other forms of treatment, is not 100% successful, and does carry risks of complications.

Advice

  • Seek advice from a Continence and Women’s Health Physiotherapist if you are suffering from any type of pelvic floor dysfunction. They can assist with diagnosis and treatment, and ensure you are contracting and relaxing your pelvic floor muscles correctly.
  • A referral to a gynaecologist may also be useful in some cases – your GP can arrange this.
  • Maintain a healthy diet, with sufficient fruits, vegetables and wholegrains, but limited fats, sugars and heavily processed foods, and aim to drink 1.5-2 litres of fluid a day (mostly water is best). This helps to prevent obesity and constipation – both of which are risk factors for PFD.
  • Regular moderate exercise can also be helpful. Studies have shown people who exercise regularly at moderate intensity commonly have a healthier body weight, and a lower incidence of constipation and urinary incontinence.
  • Check that you are emptying your bladder and bowels normally. Emptying your bladder 4-6 times daily and your bowels 1-2 times daily, or at least every second day, is usually about right for most people. You should not need to strain to empty your bowels.
  • How you sit on the toilet can make a big difference for constipation. Place your feet on a footstool and lean forward from the hips with a straight back and relaxed tummy to aid bowel opening. Try not to hold your breath and strain.

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