Pelvic floor dysfunction

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Pelvic floor dysfunction
SpecialtyObstetrics and gynaecology


Physical therapy

Pelvic floor dysfunction is an umbrella term for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. Although this condition predominantly affects females, up to 16 percent of males suffer as well.[1] Symptoms include pelvic pain, pressure, pain during sex, urinary incontinence (UI), incomplete emptying of feces, and visible organ protrusion.[2] Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain. Underlying causes of pelvic pain are often difficult to determine.[3] The condition affects up to 50 percent of women who have given birth.[4]

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.


Mechanistically, the causes of pelvic floor dysfunction are two-fold: widening of the pelvic floor hiatus and descent of pelvic floor below the pubococcygeal line, with specific organ prolapse graded relative to the hiatus.[2] Associations include obesity, menopause, pregnancy and childbirth.[5] Some women may be more likely to developing pelvic floor dysfunction because of an inherited deficiency in their collagen type. Some women may have congenitally weak connective tissue and fascia and are therefore at risk of stress urinary incontinence and pelvic organ prolapse.[6]

By definition, postpartum pelvic floor dysfunction only affects women who have given birth, though pregnancy rather than birth or birth method is thought to be the cause. A study of 184 first-time mothers who delivered by Caesarean section and 100 who delivered vaginally found that there was no significant difference in the prevalence of symptoms 10 months following delivery, suggesting that pregnancy is the cause of incontinence for many women irrespective of their mode of delivery. The study also suggested that the changes which occur to the properties of collagen and other connective tissues during pregnancy may affect pelvic floor function.[7]

Pelvic floor dysfunction can result after pelvic radiation,[8] as well as treatment for gynegological cancers.[9]

In addition, UI can also affect female athletes, especially those in sports that require high impact such as jumping.[10] Gymnasts report a high prevalence of UI. Other studies also showed that athletes in sports that require high spinal stability may also suffer from this condition as the muscles in the abdominal wall are activated, which causes urinary alterations during activities.[10]


Pelvic floor dysfunction can be diagnosed by history and physical exam, though it is more accurately graded by imaging. Historically, fluoroscopy with defecography and cystography were used, though modern imaging allows the usage of MRI to complement and sometimes replace fluoroscopic assessment of the disorder, allowing for less radiation exposure and increased patient comfort, though an enema is required the evening before the procedure. Instead of contrast, ultrasound gel is used during the procedure with MRI. Both methods assess the pelvic floor at rest and maximum strain using coronal and sagittal views. When grading individual organ prolapse, the rectum, bladder and uterus are individually assessed, with prolapse of the rectum referred to as a rectocele, bladder prolapse through the anterior vaginal wall a cystocele, and small bowel an enterocele.[11]

To assess the degree of dysfunction, three measurements must be taken into account. First, an anatomic landmark known as the pubococcygeal line must be determined, which is a straight line connecting the inferior margin of the pubic symphysis at the midline with the junction of the first and second coccygeal elements on a sagittal image. After this, the location of the puborectalis muscle sling is assessed, and a perpendicular line between the pubococcygeal line and muscle sling is drawn. This provides a measurement of pelvic floor descent, with descent greater than 2 cm being considered mild, and 6 cm being considered severe. Lastly, a line from the pubic symphysis to the puborectalis muscle sling is drawn, which is a measurement of the pelvic floor hiatus. Measurements of greater than 6 cm are considered mild, and greater than 10 cm severe. The degree of organ prolapse is assessed relative to the hiatus. The grading of organ prolapse relative to the hiatus is more strict, with any descent being considered abnormal, and greater than 4 cm being considered severe.[2]


There are various procedures used to address prolapse. Cystoceles are treated with a surgical procedure known as a Burch colposuspension, with the goal of suspending the prolapsed urethra so that the urethrovesical junction and proximal urethra are replaced in the pelvic cavity. Uteroceles are treated with hysterectomy and uterosacral suspension. With enteroceles, the prolapsed small bowel is elevated into the pelvis cavity and the rectovaginal fascia is reapproximated. Rectoceles, in which the anterior wall of the rectum protrudes into the posterior wall of the vagina, require posterior colporrhaphy.[6][12]

Pelvic floor dysfunction is common for many women and includes symptoms that can affect all aspects of everyday life and activities. Pelvic floor muscle (PFM) training is vital for treating different types of pelvic floor dysfunction. Two common problems are uterine prolapse and urinary incontinence both of which stem from muscle weakness. Without the ability to control PFM, pelvic floor training cannot be done successfully. Being able to control PFM is vital for a well functioning pelvic floor. Through vaginal palpation exams and the use of biofeedback the tightening, lifting, and squeezing actions of these muscles can be determined. Biofeedback can also be used to treat urinary incontinence as it records contractions of the pelvic floor muscles.[10] This technique also helps patients become aware of muscles they were unaware of before. Treatment for urinary incontinence is essential but so is prevention, and women should be encouraged to change their lifestyles; to reduce body weight, to limit the use of stimulants, to stop smoking, to limit strenuous efforts, to prevent constipation and to use physical activity[10] Survivors of gynecological cancer can also benefit from pelvic floor muscle interventions. These interventions, such as pelvic floor muscle therapy, counseling, yoga and exercise can improve sexual function and health-related quality of life for gynecological cancer survivors.[13]

In addition, abdominal muscle training has been shown to improve pelvic floor muscle function.[14] By increasing abdominal muscle strength and control, a person may have an easier time activating the pelvic floor muscles in sync with the abdominal muscles. Many physiotherapists are specially trained to address the muscles weaknesses associated with pelvic floor dysfunction and through intervention can effectively treat this.[15]

Common physical therapy interventions in male pelvic floor rehabilitation include myofascial trigger point release of both the internal and external pelvic floor and abdominal musculature, therapeutic exercises, biofeedback, and neuromodulation.[16] These interventions help improve urinary incontinence, also a common problem for many males. In severe cases, a radical prostatectomy is a treatment option. Postoperative PFM with a physiotherapist will aid in the recovery process, helping to control male urinary incontinence and improve quality of life.[17] Physical therapists have also been known to be educated about techniques that focus on aiding in resolving urinary incontinence in women, which can have a significant positive impact on the quality of life of those affected. Men and women who experience urinary incontinence profit from such techniques and see positive changes in the physical, social, and mental aspects of their lives.[18]


The condition is widespread, affecting up to 50 percent of women at some point in their lifetime.[2] About 11 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse by age 80.[19] 30 percent of those undergoing surgery will have at least two surgeries in trying to correct the problem.[citation needed]


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