Pelvic Floor Dysfunction
Pelvic floor dysfunction (PFD) involves the abnormal function of the pelvic floor musculature, often due to muscles being either too weak or too tense.
Pelvic Floor Dysfunction is a broad term that encompasses issues like difficulties controlling bladder or bowels, pelvic organ prolapse, and pelvic pain. In PFD, the pelvic floor muscles may have diminished strength (hypotonic), excess tension (hypertonic), or poor coordination. This can lead to symptoms such as urinary incontinence, fecal incontinence, pelvic organ prolapse, or chronic pelvic pain. PFD is extremely common, affecting at least one-third of adult women, yet many people don’t seek help due to embarrassment. Men can experience PFD as well, often after prostate surgery or from chronic pelvic pain syndromes, but it is most frequently diagnosed in women, particularly after childbirth or in later life.
Causes and Risk Factors
The causes of pelvic floor dysfunction are often multifactorial. Key risk factors include:
Pregnancy and Childbirth: The strain of pregnancy and vaginal delivery can stretch or tear pelvic floor muscles and connective tissues. Multiple pregnancies or delivering a large baby can increase the risk. Damage during childbirth can weaken the support for pelvic organs and injure nerves, contributing to problems like incontinence or prolapse later on.
Aging and Menopause: Aging causes muscles throughout the body to lose strength, and the pelvic floor is no exception. Menopause leads to reduced estrogen levels, which can cause the pelvic tissues to become thinner and less elastic, making the pelvic floor more prone to dysfunction.
Chronic Increases in Abdominal Pressure: Obesity places extra weight on the pelvic organs; chronic coughing (from smoking or lung conditions) repeatedly strains the pelvic muscles; frequent heavy lifting also increases downward pressure, stretching or weakening pelvic supports over time.
Surgery or Trauma: Pelvic surgeries like hysterectomy in women or prostatectomy in men can sometimes lead to PFD because they may alter or remove supporting structures. Direct pelvic trauma from an accident could also injure muscles or nerves.
Genetic Factors: Some individuals have a predisposition to weaker connective tissue or poorer collagen quality, making them more susceptible to pelvic floor issues.
Often, pelvic floor dysfunction arises from a combination of these factors. For example, a woman might have had children and later gained weight and developed a chronic cough—together, these stress the pelvic floor, leading to symptoms over time.
Common Symptoms
Because the pelvic floor supports multiple organs, PFD can produce a variety of symptoms:
Urinary Problems: These include urinary incontinence, difficulty emptying the bladder fully, a slow or intermittent urine stream, or frequent urges to urinate.
Bowel Dysfunction: PFD can lead to fecal incontinence or difficulty with bowel movements. A weakened pelvic floor or nerve injury can impair control of the anal sphincter, while a prolapse of the rectum into the vagina (rectocele) can cause incomplete evacuation or constipation.
Pelvic Organ Prolapse: This occurs when pelvic organs (bladder, uterus, rectum) drop downward due to lost support, often felt as a bulge in the vagina or a sensation of pressure or heaviness in the pelvic area.
Pelvic Pain and Sexual Dysfunction: Chronic pelvic pain, aching, or fullness can be a symptom of PFD, especially when pelvic floor muscles are overly tight. Pain might be felt in the vagina, perineum, or radiating to the hips or lower back. Intercourse can be painful if either prolapse or high muscle tension is present. In men, pelvic floor dysfunction often manifests as pain in the perineum or genital area and can be associated with erectile or ejaculatory issues.
Incomplete Emptying or Pressure Sensations: Some with PFD feel a persistent urge to urinate or have a bowel movement even if they just went, because the pelvic floor is not correctly signaling completion. Others describe a constant pressure in the rectum or vagina.
These symptoms can significantly impact quality of life. Many people avoid social and physical activities due to embarrassment, and pelvic pain can interfere with daily function and intimacy.
Diagnosis
Evaluation of pelvic floor dysfunction typically starts with a thorough history and physical exam. A healthcare provider will ask about urinary and bowel habits, childbirth history, surgeries, and specific symptoms. They may have you fill out questionnaires about the severity of symptoms.
During the physical exam, for women, this includes a pelvic exam to check for prolapse and to assess muscle tone by asking you to squeeze your pelvic floor. The provider will note if the pelvic muscles are weak or too tight. In men, a rectal exam can assess the tone of the pelvic floor muscles and check for prostate or other issues.
If incontinence is an issue, a “cough stress test” might be done to observe urine leakage. Neurological exams may also be performed to check for nerve integrity. Further tests might include ultrasound or MRI for imaging, urodynamics for bladder function assessment, and defecography for bowel-related issues.
Treatment and Management
Pelvic floor dysfunction is treatable, and the approach is tailored to the specific problems and their severity. Treatments fall into conservative (non-surgical) measures and surgical options.
Conservative Treatments
Pelvic Floor Physical Therapy (PFPT): A cornerstone of treatment, a pelvic floor therapist can guide exercises to strengthen weak muscles and techniques to relax overactive ones. Biofeedback is often used to improve coordination and strength.
Lifestyle Modifications: Avoiding excessive straining, maintaining a healthy weight, smoking cessation, and optimizing hydration and fiber intake can all reduce symptoms.
Pessary Devices: These vaginally inserted devices provide support for prolapse and incontinence, particularly useful for those avoiding surgery.
Medications: Bladder relaxants, stool softeners, vaginal estrogen, or nerve pain modulators can help manage symptoms.
Biofeedback and Neuromodulation: Electrical stimulation or nerve stimulation therapies can improve coordination and reduce pain.
Surgical Treatments
Pelvic Organ Prolapse Surgery: Procedures such as colporrhaphy or sacrocolpopexy help restore organ support.
Incontinence Surgery: Mid-urethral slings or artificial urinary sphincters can effectively treat incontinence.
Pain-Relieving Procedures: Injections, Botox, or surgical release of muscle or nerve decompression may be considered for chronic pain cases.
Living with Pelvic Floor Dysfunction
With proper treatment, most people with PFD can significantly reduce their symptoms and improve their quality of life. While PFD is typically a chronic condition, it is highly manageable through therapy and lifestyle adjustments. Open communication with healthcare providers is essential, and support groups can provide encouragement.
Maintaining general health through balanced nutrition, regular physical activity, and continued pelvic exercises even after symptom improvement helps ensure long-term pelvic health. By addressing symptoms early, individuals can regain confidence and improve daily comfort and functionality.