PELVIC FLOOR DYSFUNCTION

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com

Pelvic floor dysfunction is the inability to correctly relax and coordinate your pelvic floor muscles to have a bowel movement. Symptoms include constipation, straining to defecate, having urine or stool leakage and experiencing a frequent need to pee. Initial treatments include biofeedback, pelvic floor physical therapy and medications.

INTRODUCTION-

Pelvic floor dysfunction is a common condition where you’re unable to correctly relax and coordinate the muscles in your pelvic floor to urinate or to have a bowel movement. If you’re a woman, you may also feel pain during sex, and if you’re a man you may have problems having or keeping an erection (erectile dysfunction or ED). Your pelvic floor is a group of muscles found in the floor (the base) of your pelvis (the bottom of your torso).

If you think of the pelvis as being the home to organs like the bladder, uterus (or prostate in men) and rectum, the pelvic floor muscles are the home’s foundation. These muscles act as the support structure keeping everything in place within your body. Your pelvic floor muscles add support to several of your organs by wrapping around your pelvic bone. Some of these muscles add more stability by forming a sling around the rectum.

The pelvic organs include:

• The bladder (the pouch holding your urine).
• The uterus and vagina (in women).
• The prostate (in men).
• The rectum (the area at the end of the large intestine where your body stores solid waste).

Normally, you’re able to go to the bathroom with no problem because your body tightens and relaxes its pelvic floor muscles. This is just like any other muscular action, like tightening your biceps when you lift a heavy box or clenching your fist.

But if you have pelvic floor dysfunction, your body keeps tightening these muscles instead of relaxing them like it should. This tension means you may have:

• Trouble evacuating (releasing) a bowel movement.
• An incomplete bowel movement.
• Urine or stool that leaks.

As many as 50 percent of people with chronic constipation have pelvic floor dysfunction (PFD) — impaired relaxation and coordination of pelvic floor and abdominal muscles during evacuation. Straining, hard or thin stools, and a feeling of incomplete elimination are common signs and symptoms. But because slow transit constipation and functional constipation can overlap with PFD, some patients may also present with other signs and symptoms, such as a long time between bowel movements and abdominal pain.

When mechanical, anatomic, and disease- and diet-related causes of constipation have been ruled out, clinical suspicion should be raised to the possibility that PFD is causing or contributing to constipation. A focused history and digital examination are key components in diagnosing PFD. The diagnosis can be confirmed by anorectal manometry with balloon expulsion and, in some cases, traditional proctography or dynamic magnetic resonance imaging defecography to visualize pathologic pelvic floor motion, sphincter anatomy and greater detail of surrounding structures.

To help patients restore normal bowel function, Mayo Clinic staff use a multidisciplinary approach that can include:

• Constipation education classes led by a dietitian and a nurse educator
• Intensive pelvic floor retraining exercises
• Biofeedback training
• Behavior modification

Patients may meet individually with a dedicated nurse educator who provides a focused session on bowel management techniques. Central to the process is a daily regimen that combines an evening dose of fiber supplement with a morning routine of mild physical activity; a hot, preferably caffeinated beverage; and, possibly, a fiber cereal followed by another cup of a hot beverage — all within 45 minutes of waking. This routine augments early morning high-amplitude peristaltic contractions by incorporating multiple colon stimulators.

The regimen, useful for many types of constipation, is fine-tuned for PFD. Some patients do not need fiber; others may need to supplement with occasional laxatives. The program can change over time as patients make advancements.

Biofeedback to retrain pelvic floor muscles

Once patients with pelvic floor constipation have these basic tools, they can begin retraining the pelvic floor muscles with biofeedback. Based on the principle of operant conditioning, biofeedback provides auditory and visual feedback to help retrain the pelvic floor and relax the anal sphincter. Biofeedback training is the treatment of choice for medically refractory pelvic floor constipation, with some studies showing improvement in more than 70 percent of patients. Patients also learn to identify internal sensations associated with relaxation and long-term skills and exercises for use at home.

Although many centers are familiar with retraining techniques to improve pelvic floor dysfunction, few have the multidisciplinary expertise to teach patients with constipation how to appropriately coordinate abdominal and pelvic floor muscles during defecation, and how to use bowel management techniques, along with behavior modification, to relieve symptoms. Because pelvic floor dysfunction can be associated with psychological, sexual or physical abuse and other life stressors, psychological counseling is often included in the evaluation process.

CAUSES-

While exact causes are still being researched, doctors can link pelvic floor dysfunction to conditions or events that weaken the pelvic muscles or tear connective tissue:

• childbirth
• traumatic injury to the pelvic region
• obesity
• pelvic surgery
• nerve damage

The full causes of pelvic floor dysfunction are still unknown. But a few of the known factors include:

• Traumatic injuries to the pelvic area (like a car accident).
• Pregnancy.
• Overusing the pelvic muscles (like going to the bathroom too often or pushing too hard), eventually leading to poor muscle coordination.
• Pelvic surgery.
• Being overweight.
• Advancing age.

Does pregnancy cause pelvic floor dysfunction?

Pregnancy is a common cause of pelvic floor dysfunction. Often women get experience pelvic floor dysfunction after they give birth. Your pelvic floor muscles and tissues can become strained during pregnancy, especially if your labor was long or difficult.

Is pelvic floor dysfunction hereditary?

Pelvic floor dysfunction can run in your family. This is called a hereditary condition. Researchers are looking into a potential genetic cause of pelvic floor dysfunction.

SIGN AND SYMPTOM-

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com

There are a few well-known signs and symptoms that people experience when they have a problem with their pelvic floor muscles. The following list of signs and symptoms are common for people with weak pelvic floor muscles. Urinary dysfunction, erectile dysfunction, premature ejaculation, painful ejaculation, and chronic pelvic pain are some conditions that can be linked with weak pelvic floor muscles.

Men

• Constipation or bowel strains
• Ongoing pain in your pelvic region, genitals or rectum.
• A prolapse – may feel as though there is a bulge/ pressure in the rectum or a feeling of needing to use your bowels without actually needing to go.
• Accidentally leaking urine when you exercise, laugh, cough or sneeze.
• Feelings of urgency in needing to the bathroom, or not making it there in time.
• Frequent need to urinate.
• Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.
• The feeling of needing to have several bowel movements during a short period of time.
• Accidentally passing wind.
• Pain in your lower back that cannot be explained by other causes.
• Pain in the testicles, penis (referred pain from the pelvic floor) or pelvis during intercourse.
• Erectile dysfunction.
• Painful ejaculation.
• Premature ejaculation.

Erectile function requires contraction of the pelvic floor muscles to block blood from leaving the penis. When the muscles are weak the outflow of blood from the penis is not stopped resulting in erectile dysfunction. Through learning voluntary control of the pelvic floor muscles this can help prevent premature ejaculation by learning how to relax and contract the muscles. Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscles can cause leaking and dribbling.

Women

• Pain or numbness during intercourse.
• Ongoing pain in your pelvic region, genitals or rectum.
• A prolapse – may be felt as a bulge in the vagina (feeling or seeing a bulge or lump in or coming out of your vagina) or a feeling of heaviness, discomfort, pulling, dragging or dropping sensation.
• Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence).
• Feelings of urgency in needing to the bathroom, or not making it there in time.
• Frequent need to urinate.
• Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.
• The feeling of needing to have several bowel movements during a short period of time.
• Constipation or bowel strains.
• Accidentally passing wind.
• Pain in your lower back that cannot be explained by other causes.

Prolapse is a common condition that can occur due to weak pelvic floor muscles in women. This occurs due to the womb, bladder, bowel or top of the vagina moving out of their normal positions and pushing into the vagina. This can cause pain and discomfort but can be improved with pelvic floor exercises and lifestyle changes . Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscles can cause leaking and dribbling.

Diagnosis

It’s important not to self-diagnose your symptoms because they may indicate more serious conditions.

To make a diagnosis, your doctor will review your medical history and observe your symptoms. After the initial consultation, your doctor will perform a physical evaluation to check for muscle spasms or knots. They will also check for muscle weakness.

To check for pelvic muscle control and pelvic muscle contractions, your doctor may perform an internal exam by placing a perineometer — a small, sensing device — into your rectum or vagina.

A less invasive option involves placing electrodes on your perineum, the area between the scrotum and anus or vagina and anus, to determine if you can contract and relax pelvic muscles.

Risk Factors

The chances of developing pelvic floor dysfunction among men and women have increased over the past few years. According to Berghmans et al. (2015) this trend is likely to continue. The incidence of pelvic floor problems is predicted to increase by 35% between 2010-2030.

These statistics emphasize the importance of expanding knowledge related to the risk factors for pelvic floor dysfunction. When assessing a patient, physiotherapists should focus on a detailed subjective examination including past medical history and presenting condition/complaint, as this may reveal potential predispositions. Goal-centered conversations with the patients can provide guidance in planning treatment, and where applicable, liaising with appropriate healthcare professionals to ensure a holistic approach to care.

Men

• Prostate surgery: In general, scientific literature examining pelvic floor dysfunction among males is limited. However, prostate surgery has been identified as a potential risk factor . Specific pelvic floor disorders include urinary incontinence and erectile dysfunction, which are quite common post-operatively (up to 89% of men suffer from these conditions). Individuals who undergo this procedure may experience disturbance in pelvic floor muscles (especially urinary sphincters) and altered nerve supply to the area. In prostatectomy, the prostate (partially regulating continence) is removed, increasing the probability of incontinence. The urinary sphincter nerves may occasionally be damaged during surgery due to their proximity to the prostate. As a result, the patients might later experience poor bladder control. Cavernous nerves, which are responsible for erectile function, may also be disrupted.

Women

• Age: Females experiencing menopause are at increased risk for developing pelvic organ prolapse by 21.1%. Wu et al. (2014)assessed the relationship between age and number of pelvic floor disorders. They revealed that with each decade, the risk dramatically increased. This is most likely due to the hormonal fluctuations which change the functioning of female urogenital structures. It includes weakening of the pelvic floor, as the muscle mass tends to decrease during aging.
• Direct injury to levator ani (ex. vaginal delivery, fall on groin) and loss of tone in pelvic muscles: This involves the levator ani changing position and widening of genital hiatus, causing the pelvic structures to rely on the connective tissue for support. Over time, this alteration results in weakening or tearing of the tissue/collagen and may contribute to the occurrence of pelvic organ prolapse.
• Pregnancy and the nature of childbirth: Overstretching/damaging of the pudendal nerve during vaginal birth, prolonged labour, instrumental (forceps) delivery,episiotomy (surgical procedure to increase opening in vagina), weight and number of children (parity) have also been known to increase the pelvic floor dysfunction risk by 4-16%. These findings have been supported through biomechanical models of the pelvic floor. The researchers revealed that during the crowning of the fetal head in a vaginal birth, there is a greater risk for the avulsion of levator ani leading to a potential prolapse. Additionally, an episiotomy has been suggested to increase anal lacerations and therefore, incontinence risk. Findings within the systematic review noted parity to be a risk factor for primary pelvic organ prolapse as well.
• Genetics:Women who have a positive family history of pelvic organ prolapse, are more likely to inherit the condition. Campneau et al. (2011)showed that the risk for pelvic organ prolapse increased 1.4 times in the genetically predisposed group, after controlling for vaginal deliveries, hysterectomy, and incontinence. Additionally, some evidence suggests that in females who are experiencing urinary incontinence, the connective tissue of the pelvic floor muscles may be genetically weak. Low socioeconomic status: This factor, especially among racial minorities, may contribute to poorer access to adequate information regarding pelvic floor dysfunction. The lack of resources create a challenge in recognizing the symptoms and importance of seeking professional support in a timely manner. Hartigan and Smith (2018), presented that women of poorer socioeconomic status scored lower on the incontinence quiz than their higher socioeconomic status counterparts. Consequently, there is a strong emphasis on public education to reduce the risk of pelvic floor dysfunction. Hysterectomy (surgical removal of the uterus): This procedure often damages and weakens the pelvic muscles. Therefore, it may be a predisposing factor for pelvic organ prolapse . Lukanovic and Drazic (2010) suggest that that the incidence of postoperative complications after hysterectomy, including urinary and fecal incontinence was significantly higher in the group who undertook the surgery for vaginal prolapse compared to a control group with no diagnosis of prolapse. Being middle-aged, as an additional factor to post-hysterectomy, increases the risk to 60% for developing urinary incontinence.

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com

TREATMENT-

The goal for treating pelvic floor dysfunction is to relax the pelvic floor muscles to make bowel movements easier and to provide more control.

Kegel exercises, or similar techniques that require you to contract your muscles, will not help this condition. While surgery is an option, there are less invasive treatment options available.

A common treatment for this condition is biofeedback. This technique allows your therapist to monitor how you relax or contract your pelvic muscles through special sensors. After observing your muscle activity, your therapist will tell you how to improve your coordination.

Other treatment options include:

• Medication. Your doctor may prescribe a muscle relaxant to help with pelvic floor dysfunction symptoms. The relaxants can prevent your muscles from contracting.
• Self-care. To reduce strain on your pelvic floor muscles, avoid pushing or straining when using the bathroom. Relaxation techniques such as yoga and stretching can also help to relax your pelvic floor muscles. Taking warm baths is another useful technique. Warm water improves blood circulation and relaxes the muscles.
• Surgery. If your pelvic floor dysfunction is the result of a rectal prolapse — a condition that causes the rectal tissue to fall into the anal opening — surgery will loosen the affected pelvic organs and cause them to relax.

Medical Management 

Pelvic floor dysfunction is a very treatable condition. Many ways exist to treat pelvic floor problems conservatively (non-surgical) and should generally be considered as the first-line option prior to more aggressive procedures such as surgery. Treatment will vary according to the nature of the condition or reason behind the dysfunction.

Pharmacological (Medication)

• Various drugs can be prescribed depending on the reason for the pelvic floor problems. Drug therapy is particularly common for urinary incontinence and will depend on the type of incontinence that your client is experiencing.
• The ageing process can lead to hormonal changes which can negatively impact the pelvic floor muscles and lead to increased laxity/stretching. Therefore, hormone replacement therapies for post-menopausal women can be used to manage or improve the symptoms.
• If your client has an over-active bladder or urge incontinence, there are medications to help relax the bladder and reduce the frequency of urination.
• Drug therapy is even more effective when used in combination with other strategies like pelvic floor exercises and lifestyle changes.

Surgical

• In some cases, when other strategies have been unsuccessful in achieving treatment goals, surgery may be the best treatment option. Depending on the specific condition, various procedures exist to address the problem.
• Incontinence and prolapse have multiple types of procedures to alter the pelvic structures or insert supports such as synthetic mesh slings, both in the goal of improving functions.
• For those who have a pelvic floor disorder, 1 in 9 will undergo surgery, however, there are risks associated with surgery as they don’t always succeed. Regarding synthetic mesh sling surgery, roughly 30% will require a second operation, and roughly 35% will need to be removed.
• Slightly less invasive options are also available, such as injections of Botox for urge incontinence or bulking agents to help reduce stress incontinence.

Physiotherapy Management

Education is the key and physiotherapists need to educate both male and female patients, on the function of the pelvic floor muscle. Assist the patient to understand the function of the pelvic floor muscle and how exercising this muscle can strengthen and reduce the risk of unwanted symptoms. This can help achieve that all important “buy in” and encourage the patient to be consistent with pelvic floor muscle training. However, explaining this can be tricky for any Physiotherapist due to the sensitivity of the subject! We have put together some tips that may be helpful to ensure a smooth, clear and lighthearted delivery!

• The Internal hammock – Try referring to the pelvic floor muscle as “ a hammock “ or a “trampoline “ which lies on the floor of the pelvis and supports organs such as the womb, bladder, bowel. This can make the function of the pelvic floor muscle easier to understand! And plus, who doesn’t want to learn about their very own internal trampoline, right?!
• Context is key! – Place emphasis on the strain that is put on the hammock or trampoline during everyday activities such as working, household duties, looking after family, exercising. Apply this to the patients’ life, by discussing their occupation, pastimes, and family situation and how the pelvic floor muscle or “trampoline “ is at risk of being overstretched as a result. This will help the patient to add context.
• Leaking waterworks?…. Time tighten up those taps! – Lack of bladder or bowel control can be a symptom of a weak pelvic floor and or a prolapse.This is an opportunity to empower the patient and show them they can still take control of their situation, through pelvic floor muscle training. Leaking, incontinence and increased urgency do not need to be tolerated! Ensure that the patient understands that there is an opportunity to tighten those taps right up! The only requirement is the right mindset and a top-notch spanner!
• Rome was not built in a day people! – It is important that physiotherapists stress that pelvic floor muscle training takes time, effort and consistency. Improvements in continence status and or stages of prolapse will not improve overnight and may take up to 3 weeks for any improvement to be felt. Be mindful of this and ensure that the patient is supported, as feelings of frustration may arise!
• If there is an issue, here is a tissue! – Physiotherapists deal with more than just muscles, we deal with emotions! It is important to be mindful of the impact that incontinence, leaking and prolapse can have on patient quality of life. Support, empathy, and compassion are an absolute necessity, to ensure the patient feels at ease. Listening to the patient and allowing them to tell you their concerns, hardships, and battles allow the patient to offload their worries and boost their feelings of self-efficacy as they begin their journey of self-management. Lending them your ear can be the greatest gift you can give.

The Correct Technique

Explaining a pelvic floor contraction is not an easy task! It is a difficult area, given the sensitivity of the subject that many patients feel uncomfortable with. Also, it is very confusing.  Medical and anatomical terminology can leave patients feeling lost or too embarrassed to ask questions. It is vital that exercising this complicated internal muscle is described in a simple but clear manner. Here are some tips that may be helpful, or if you find any nuggets of gold in this feel free to use!

The Female Contraction

• The pelvic floor muscle can be exercised in sitting standing or lying. Many patients seem to prefer sitting and feel the muscle is easier to engage in this position. Advise the patient to try out different positions to find what best suits
• In sitting, ensure both feet are placed on the floor and patient is relaxed and aware of their breathing. Encourage your patient to relax all muscles, including shoulders, abdominals, and glutes. Take a few moments to become aware of the breathing pattern.
• Ask the patient to imagine they are sitting on the toilet, having a wee. Ask them to then try and replicate the action of stopping the flow of urine mid-stream. Explain to them that this is a pelvic floor contraction involving the anterior muscles.
• Another handy example of a pelvic floor exercise is, again, ask the patient to imagine they are in a line waiting to pay for their shopping. They have been feeling bloated and the urge to pass wind has presented itself with full gusto! In order to hold that wind in it requires a contraction of the posterior pelvic floor muscles.
• Ask the patient to imagine they are sitting on the toilet. Ask them to then try and replicate the action of stopping the flow of urine mid-stream AND trying to stop themselves from passing wind at the same time. This involves a combined pelvic floor contraction of both anterior and posterior muscles.

Remember to remind your patients to never stop the flow of urine when actually going to the toilet as this may lead to difficulty in fully emptying the bladder in the long run! This is simply a visualization technique that may be helpful. Ensure to remind the patient that pelvic floor exercises can be done anytime anyplace, not only when sitting on the toilet!

EXERCISES-

The Knack Technique –   Get Involved People!

The knack technique can help to support pelvic floor health! Pressure builds up in the abdomen when lifting, exercising, coughing, sneezing laughing, lifting weights, turning to look out your rear window when driving. Basically, in pretty much everything we do! This creates a downward force or pressure on the pelvic floor muscles when can lead to our beloved internal “trampoline “ becoming stretched or laxThe knack technique involves contracting the pelvic floor muscle, before lifting, bending, sneezing, coughing, or any movement you can think of that will increase abdominal pressure. This is a supportive measure that can help maintain and support pelvic health.

The knack technique offers many benefits and can help patient’s become more involved in their pelvic health. Add context to this, go through patient activities of daily living, pastimes, family and suggest situations in which the knack technique can be useful. For example, lifting heavy shopping onto the kitchen counter, reminding the patient to contract the pelvic floor before lifting the bags, or contract the pelvic floor before lifting your 2-year-old teething toddler.

• Pelvic floor muscle training (PFMT) has been shown to be beneficial for both urinary incontinence and prolapse symptoms. A randomised control trial in adult women with pelvic floor dysfunctions suggests that using an intravaginal vibratory stimulus( IVVS) helps in improving the pelvic floor muscle strength as compared to intravaginal electrical stimulation (IVES). Findings from a review by Dumoulin et al. (2015) suggest that pelvic floor muscle training provides better outcomes compared to a control group in women with urinary incontinence. Li et al. (2016) found that those with pelvic organ prolapse undertaking pelvic floor muscle training had significantly greater improvements in subjective prolapse symptoms and objective prolapse severity compared to a control group.
• A study suggests that hypopressive exercises caused activation of the PFMs, abdominal, gluteal, and adductor muscles. 
• Pelvic floor training also seems to improve sexual function. The findings from a review by Ferreira et al. (2015) suggest that pelvic floor muscle training can improve sexual function or at least one sexual variable in women with pelvic floor dysfunction.
• Interesting findings from two RCTs also corroborate the evidence for pelvic floor muscle training. Alves et al. (2015) found that twelve group sessions of pelvic floor muscle training increased pelvic floor muscle contractility (p = 0.01) while decreasing urinary symptoms (p < 0.01) and anterior pelvic organ prolapse (p = 0.03). Hagen et al. (2014) found similar results with one to one sessions. They did note that longer-term investigations are required to strengthen the evidence.
• When prescribing a pelvic floor muscle training programme, adherence is important. According to a consensus statement by Dumoulin et al. (2015), a structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence.
• The identified evidence fails to make any recommendations on the optimal dosage of pelvic floor muscle training.
• The NICE guidelines recommend a trial supervised PFMT programme for at least 3 months as first-line treatment for those with stress or urinary incontinence.At least 8 contractions three times a day.

REQUEST AN APPOINTMENT OR BOOK A CONSULANT – Sargam.dange.18@gmail.com