![1116 Muscle of the Perineum](https://upload.wikimedia.org/wikipedia/commons/e/e8/1116_Muscle_of_the_Perineum.jpg)
Pelvic floor dysfunction is a term used for a variety of disorders that occur when
pelvic floor
The pelvic floor or pelvic diaphragm is composed of muscle fibers of the levator ani, the coccygeus muscle, and associated connective tissue which span the area underneath the pelvis. The pelvic diaphragm is a muscular partition formed by the lev ...
muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth.
Although this condition predominantly affects women, up to 16 percent of men are affected as well. Symptoms can include
pelvic pain
Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis.
Common causes in include ...
, pressure,
pain during sex,
urinary incontinence
Urinary incontinence (UI), also known as involuntary urination, is any uncontrolled leakage of urine. It is a common and distressing problem, which may have a large impact on quality of life. It has been identified as an important issue in geria ...
(UI),
overactive bladder
Overactive bladder (OAB) is a condition where there is a frequent feeling of needing to urinate to a degree that it negatively affects a person's life. The frequent need to urinate may occur during the day, at night, or both. If there is loss ...
,
bowel incontinence, incomplete emptying of feces,
constipation
Constipation is a bowel dysfunction that makes bowel movements infrequent or hard to pass. The stool is often hard and dry. Other symptoms may include abdominal pain, bloating, and feeling as if one has not completely passed the bowel movement ...
, myofascial pelvic pain and
pelvic organ prolapse
Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting.
In me ...
.
When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus.
Common treatments for pelvic floor dysfunction are surgery, medication, physical therapy and lifestyle modifications.
The term "pelvic floor dysfunction" has been criticized since it does not represent a particular pelvic floor disorder.
It has therefore been recommended that the term not be used in medical literature without additional clarification.
Epidemiology
Pelvic floor dysfunction is defined as a herniation of the pelvic organs through the pelvic organ walls and pelvic floor. The condition is widespread, affecting up to 50 percent of women at some point in their lifetime.
About 11 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse by age 80. Women who experience pelvic floor dysfunction are more likely to report issues with
arousal
Arousal is the physiological and psychological state of being awoken or of sense organs stimulated to a point of perception. It involves activation of the ascending reticular activating system (ARAS) in the brain, which mediates wakefulness, th ...
combined with
dyspareunia
Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the f ...
. For women, there is a 20.5% risk for having a surgical intervention related to
stress urinary incontinence
Stress incontinence, also known as stress urinary incontinence (SUI) or effort incontinence is a form of urinary incontinence. It is due to inadequate closure of the Urinary bladder, bladder outlet by the Urethral sphincters, urethral sphincter.
...
. The literature suggests that white women are at increased risk for stress urinary incontinence.
Though pelvic floor dysfunction is thought to more commonly affect women, 16% of men have been identified with pelvic floor dysfunction.
Pelvic floor dysfunction and its multiple consequences, including urinary incontinence, is a concerning health issue becoming more evident as the population of advancing age individuals rises.
Causes
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.
People with an inherited deficiency in their collagen type may be more likely to develop pelvic floor dysfunction. Additionally, people with congenitally weak connective tissue and fascia are at an increased risk for stress urinary incontinence and pelvic organ prolapse.
Recent literature demonstrates that defects in endopelvic fascia and compromised
levator ani
The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.
It is attached to the inner surface of each side of the ...
muscle function have been categorized as important etiologic factors in the development of pelvic floor dysfunction. Some circumstances are clearly associated with collagen defects. These include vaginally delivering a child, being post-menopausal, and being of advanced age.
Some lifestyle behaviors can lead to pelvic floor dysfunction. This includes avoiding urinating or bowel movements, obesity, use of muscle relaxants or narcotics, and use of antihistamines or anticholinergics. Using muscle relaxants or narcotics can lead to increased smooth and skeletal muscle relaxation, potentially related to urinary incontinence. Antihistamines and anticholinergics have additive effects that lead to urinary hesitancy and retention, ultimately leading to pelvic floor dysfunction. Urinary incontinence can also affect athletes, especially those in sports that require high impact such as jumping.
Gymnasts, for example, report a high prevalence of urinary incontinence. Studies show that athletes in sports requiring high spinal stability may also have this condition, as the activation of abdominal wall muscles can cause urinary alterations during activities.
In some cases, sexual abuse can also be associated with chronic pelvic pain and pelvic floor dysfunction.
Pelvic floor dysfunction can result after pelvic radiation, as well as other treatments for
gynecological cancers.
Diagnosis
![Rectocele Diagram](https://upload.wikimedia.org/wikipedia/commons/5/5e/Rectocele_Diagram.png)
Pelvic floor dysfunction can be assessed with a strong
clinical history
The medical history, case history, or anamnesis (from Greek: ἀνά, ''aná'', "open", and μνήσις, ''mnesis'', "memory") of a patient is information gained by a physician by asking specific questions, either to the patient or to other peo ...
and
physical exam
In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patie ...
, though imaging is often needed for diagnosis. As part of the clinical history, a healthcare provider may ask about obstetric history, including how many pregnancies and deliveries, what mode of delivery and if there were any complications during delivery.
Providers will also ask about presence and severity of symptoms such as
pelvic pain
Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis.
Common causes in include ...
or pressure, problems with urination or defecation,
painful sex, or
sexual dysfunction
Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as ...
. The physical exam may include both examination with a
speculum to visualize the
cervix
The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...
and check for inflammation, as well as manual examination with the provider's fingers to assess for pain and strength of pelvic floor muscle contraction.
Imaging provides a more complete picture of the type and severity of pelvic floor dysfunction than history and physical exam alone. Historically,
fluoroscopy
Fluoroscopy () is an imaging technique that uses X-rays to obtain real-time moving images of the interior of an object. In its primary application of medical imaging, a fluoroscope () allows a physician to see the internal structure and functio ...
with defecography and
cystography
In radiology and urology, a cystography (also known as cystogram) is a procedure used to visualise the urinary bladder.
Using a urinary catheter, radiocontrast is instilled in the bladder, and X-ray imaging is performed. Cystography can be used t ...
were used. More recently,
MRI
Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio waves ...
has been used to complement and sometimes replace fluoroscopic assessment of the disorder. This technique is less invasive, and allows for less radiation exposure and increased patient comfort, though an
enema
An enema, also known as a clyster, is an injection of fluid into the lower bowel by way of the rectum.Cullingworth, ''A Manual of Nursing, Medical and Surgical'':155 The word enema can also refer to the liquid injected, as well as to a device ...
is required the evening before the procedure. Both fluoroscopy and MRI assess the pelvic floor at rest and during maximum strain using
coronal and
sagittal
The sagittal plane (; also known as the longitudinal plane) is an anatomical plane that divides the body into right and left sections. It is perpendicular to the transverse and coronal planes. The plane may be in the center of the body and divid ...
views.
When grading individual organ prolapse for severity, the rectum, bladder and uterus are individually assessed. Prolapse of the rectum is referred to as a
rectocele
In gynecology, a rectocele ( ) or posterior vaginal wall prolapse results when the rectum bulges ( herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pel ...
, bladder prolapse through the anterior vaginal wall is called a
cystocele
A cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complicat ...
, and prolapse of the small bowel is an
enterocele
An enterocele is a protrusion of the small intestines and peritoneum into the vaginal canal.
It may be treated transvaginally or by laparoscopy.
An enterocele may also obstruct the rectum, leading to symptoms of obstructed defecation. Enteroceles ...
.
To assess the degree of dysfunction, three measurements are 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
The pubic symphysis is a secondary cartilaginous joint between the left and right superior rami of the pubis of the hip bones. It is in front of and below the urinary bladder. In males, the suspensory ligament of the penis attaches to the pubic ...
at the midline with the junction of the first and second
coccygeal
The coccyx ( : coccyges or coccyxes), commonly referred to as the tailbone, is the final segment of the vertebral column in all apes, and analogous structures in certain other mammals such as horses. In tailless primates (e.g. humans and other ...
elements on a
sagittal
The sagittal plane (; also known as the longitudinal plane) is an anatomical plane that divides the body into right and left sections. It is perpendicular to the transverse and coronal planes. The plane may be in the center of the body and divid ...
image. After this, the location of the
puborectalis muscle
The levator ani is a broad, thin muscle group, situated on either side of the pelvis. It is formed from three muscle components: the pubococcygeus, the iliococcygeus, and the puborectalis.
It is attached to the inner surface of each side of the ...
sling is assessed, and a perpendicular line between the pubococcygeal line and muscle sling is drawn. This line provides a reference point for the measurement of ''pelvic floor descent.'' Descent greater than 2 cm below this line is considered mild and descent greater than 6 cm is 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 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 for ''organ prolapse'' relative to the hiatus is more strict. Any descent below the hiatus is considered abnormal, and descent greater than 4 cm is considered severe.
Ultrasound
Ultrasound is sound waves with frequency, frequencies higher than the upper audible limit of human hearing range, hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hea ...
can also be used to diagnose pelvic floor dysfunction.
Transabdominal,
transvaginal, transperineal and endoanal ultrasound (EUS) are important tools for diagnosing pelvic floor dysfunction. For EUS, an ultrasound probe is inserted into the anal canal and can be used to visualize and assess the anatomy and function the pelvic floor. Ultrasound is easily accessible and noninvasive; however, it may compress certain structures, does not produce high-quality images and cannot be used to visualize the entire pelvic floor.
Treatment
There are several approaches to treatment of pelvic floor dysfunction, and often several approaches are used in combination.
Physical therapy
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. Pelvic floor muscle therapy is the first line of treatment for urinary incontinence and thus should be considered before more invasive procedures such as surgery.
Being able to control the pelvic floor muscles is vital for a well functioning pelvic floor. Without the ability to control the pelvic floor muscles, pelvic floor training cannot be done successfully. Pelvic floor muscle therapy strengthens the muscles of the pelvic floor through repeated contractions of varying strength.
Through vaginal
palpation
Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...
exams and the use of
biofeedback
Biofeedback is the process of gaining greater awareness of many physiology, physiological functions of one's own body by using Electronics, electronic or other instruments, and with a goal of being able to Manipulation (psychology), manipulate t ...
, the tightening, lifting, and squeezing actions of these muscles can be determined. Biofeedback can be used to treat urinary incontinence as it records contractions of the pelvic floor muscles and can help patients become aware of the use of their muscles.
PFM training can also increase female sexual satisfaction by improving sexual function and the ability to orgasm.
In addition, abdominal muscle training has been shown to improve pelvic floor muscle function. 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 muscle weaknesses associated with pelvic floor dysfunction and can effectively treat pelvic floor dysfunction through strengthening exercises. Overall, physical therapy can significantly improve the quality of life of those with pelvic floor dysfunction by relieving symptoms.
Medication
Overactive bladder can be treated with medications, including those in the class of
antimuscarinics
A muscarinic receptor antagonist (MRA) is a type of anticholinergic agent that blocks the activity of the muscarinic acetylcholine receptor. The muscarinic receptor is a protein involved in the transmission of signals through certain parts of the ...
and beta 3 agonists. Antimuscarinics are the most commonly used, however, beta 3 agonists can be used for those that are unable to take antimuscarinics due to side effects or other reasons.
Devices
A
pessary
A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat Stress incontinence, stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to ...
is a plastic or silicone device that may be used for women with pelvic organ prolapse. This treatment is useful for individuals who do not want to have surgery or are unable to have surgery due risk of the procedure. Some pessaries have a knob that can also treat urinary incontinence. To be effective, pessaries must be fit by a medical provider and the largest device that fits comfortably should be used.
Lifestyle modifications
Treatment for pelvic floor dysfunction, especially the symptom of urinary incontinence, is essential, but so is prevention. Patients are usually encouraged to change their lifestyles; interventions such as reducing body weight, limiting the use of stimulants, quitting smoking, limiting strenuous efforts, preventing constipation and increasing physical activity can help prevent pelvic floor dysfunction.
For those that already have diagnosed pelvic floor dysfunction, symptoms can be eased by physical activity, especially abdominal exercises and pelvic floor exercises (
Kegels
Kegel exercise, also known as pelvic-floor exercise, involves repeatedly contracting and relaxing the muscles that form part of the pelvic floor, now sometimes colloquially referred to as the "Kegel muscles". The exercise can be performed many t ...
) that strengthen the pelvic floor. Symptoms of urinary incontinence can also be reduced by making dietary changes such as limiting intake of acidic and spicy foods, alcohol and caffeine.
Surgery
Surgery is performed when desired by the patient or when less invasive treatments, such as lifestyle modification and physical therapy, are not effective. There are various procedures used to address prolapse. Cystoceles are treated with a surgical procedure known as a
Burch colposuspension
The Burch colposuspension is a procedure to treat urinary incontinence due to pelvic floor relaxation. The paravaginal fascia is attached to Cooper's ligament. The purpose is to suspend the prolapsed urethra so that the urethrovesical junction an ...
, with the goal of suspending the prolapsed urethra so that the urethrovesical junction and proximal urethra are replaced in the pelvic cavity. Uterine prolapse is treated with
hysterectomy
Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures.
Usually performed by a gynecologist, a hysterectomy may b ...
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
Colporrhaphy (also vaginal wall repair, anterior and/or posterior colporrhaphy, anterior and/or posterior vaginal wall repair, or simply A/P repair or A&P repair) is a surgical procedure in humans that repairs a defect in the wall of the vagina. It ...
, also known as repair of the vaginal wall.
Though pelvic floor dysfunction is more common in women, there are also proven methods to assist men. In severe cases of pelvic floor dysfunction causing urinary incontinence, a
radical prostatectomy
Prostatectomy (from the Greek , "prostate" and , "excision") as a medical term refers to the surgical removal of all or part of the prostate gland. This operation is done for benign conditions that cause urinary retention, as well as for prosta ...
followed by postoperative pelvic floor muscle therapy is an option.
References
{{DEFAULTSORT:Postpartum Pelvic Floor Dysfunction
Gynaecologic disorders