Pelvic floor dysfunction

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Pelvic floor dysfunction
Specialty Obstetrics and gynaecology

Urology

Physical therapy
The perineum muscles play roles in urination in both sexes, ejaculation in men, and vaginal contraction in women. 1116 Muscle of the Perineum.jpg
The perineum muscles play roles in urination in both sexes, ejaculation in men, and vaginal contraction in women.

Pelvic floor dysfunction is a term used for a variety of disorders that occur when pelvic floor muscles and ligaments are impaired. The condition affects up to 50 percent of women who have given birth. [2] Although this condition predominantly affects women, up to 16 percent of men are affected as well. [3] Symptoms can include pelvic pain, pressure, pain during sex, urinary incontinence (UI), overactive bladder, bowel incontinence, incomplete emptying of feces, constipation, myofascial pelvic pain and pelvic organ prolapse. [4] [5] When pelvic organ prolapse occurs, there may be visible organ protrusion or a lump felt in the vagina or anus. [5] [6] Research carried out in the UK has shown that symptoms can restrict everyday life for women. However, many people found it difficult to talk about it and to seek care, as they experienced embarrassment and stigma. [7] [8]

Contents

Common treatments for pelvic floor dysfunction are surgery, medication, physical therapy and lifestyle modifications. [2]

The term "pelvic floor dysfunction" has been criticized since it does not represent a particular pelvic floor disorder. [9] It has therefore been recommended that the term not be used in medical literature without additional clarification. [9]

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. [10] About 11 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse by age 80. [11] Women who experience pelvic floor dysfunction are more likely to report issues with arousal combined with dyspareunia. For women, there is a 20.5% risk for having a surgical intervention related to stress urinary incontinence. The literature suggests that white women are at increased risk for stress urinary incontinence. [12]

Though pelvic floor dysfunction is thought to more commonly affect women, 16% of men have been identified with pelvic floor dysfunction. [13] 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. [10] 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. [10] Recent literature demonstrates that defects in endopelvic fascia and compromised levator ani 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. [13]

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 may 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. [13] 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. [14] In some cases, sexual abuse can also be associated with chronic pelvic pain and pelvic floor dysfunction. [13]

Pelvic floor dysfunction can result after pelvic radiation, as well as other treatments for gynecological cancers. [15]

Diagnosis

A rectocele is a bulge, or herniation, of the front wall of the rectum into the back of the vagina. A cystocele is when the wall between the bladder and the vagina weakens. Uterine prolapse Rectocele Diagram.png
A rectocele is a bulge, or herniation, of the front wall of the rectum into the back of the vagina.
A cystocele is when the wall between the bladder and the vagina weakens. Cystocele.png
A cystocele is when the wall between the bladder and the vagina weakens.
Uterine prolapse Uterine Prolapse.png
Uterine prolapse

Pelvic floor dysfunction can be assessed with a strong clinical history and physical exam, 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. [5] Providers will also ask about presence and severity of symptoms such as pelvic pain or pressure, problems with urination or defecation, painful sex, or sexual dysfunction. The physical exam may include both examination with a speculum to visualize the cervix 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. [13]

Imaging provides a more complete picture of the type and severity of pelvic floor dysfunction than history and physical exam alone. Historically, fluoroscopy with defecography and cystography were used. More recently, MRI 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 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 views. [17]

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, bladder prolapse through the anterior vaginal wall is called a cystocele, and prolapse of the small bowel is an enterocele. [17] 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 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 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. [6]

Ultrasound 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. [18] 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. [19]

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. [20] 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. [20] Through vaginal palpation exams and the use of biofeedback, 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. [14] PFM training can also increase female sexual satisfaction by improving sexual function and the ability to orgasm. [21] In men, PFM exercises can also help maintain a strong erection. [22]

In addition, abdominal muscle training has been shown to improve pelvic floor muscle function. [23] 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. [24] 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 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. [4]

Devices

A pessary is a plastic or silicone device that may be used for women with pelvic organ prolapse. Vaginal pessaries can immediately relieve prolapse and prolapse-related symptoms. [25] 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. [26]

Other devices train the pelvic floor via internal exercises with biofeedback mechanisms. [27]

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. [14] For those that already have diagnosed pelvic floor dysfunction, symptoms can be eased by physical activity, especially abdominal exercises and pelvic floor exercises (Kegels) 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. [13]

Surgery

Surgery is performed when desired by the patient or when less invasive treatments, such as lifestyle modification and physical therapy, are not effective. [28] 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. Uterine prolapse is 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, also known as repair of the vaginal wall. [29] 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 followed by postoperative pelvic floor muscle therapy is an option. [30]

Related Research Articles

<span class="mw-page-title-main">Urinary incontinence</span> Uncontrolled leakage of urine

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 geriatric health care. The term enuresis is often used to refer to urinary incontinence primarily in children, such as nocturnal enuresis. UI is an example of a stigmatized medical condition, which creates barriers to successful management and makes the problem worse. People may be too embarrassed to seek medical help, and attempt to self-manage the symptom in secrecy from others.

<span class="mw-page-title-main">Fecal incontinence</span> Inability to refrain from defecation

Fecal incontinence (FI), or in some forms, encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred to as anal incontinence. FI is a sign or a symptom, not a diagnosis. Incontinence can result from different causes and might occur with either constipation or diarrhea. Continence is maintained by several interrelated factors, including the anal sampling mechanism, and incontinence usually results from a deficiency of multiple mechanisms. The most common causes are thought to be immediate or delayed damage from childbirth, complications from prior anorectal surgery, altered bowel habits. An estimated 2.2% of community-dwelling adults are affected. However, reported prevalence figures vary. A prevalence of 8.39% among non-institutionalized U.S adults between 2005 and 2010 has been reported, and among institutionalized elders figures come close to 50%.

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

<span class="mw-page-title-main">Kegel exercise</span> Pelvic floor exercise

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 times a day, for several minutes at a time but takes one to three months to begin to have an effect.

A pessary is a prosthetic device inserted into the vagina for structural and pharmaceutical purposes. It is most commonly used to treat stress urinary incontinence to stop urinary leakage and to treat pelvic organ prolapse to maintain the location of organs in the pelvic region. It can also be used to administer medications locally in the vagina or as a method of contraception.

<span class="mw-page-title-main">Pelvic floor</span> Anatomical structure

The pelvic floor or pelvic diaphragm is an anatomical location in the human body, which has an important role in urinary and anal continence, sexual function and support of the pelvic organs. The pelvic floor includes muscles, both skeletal and smooth, ligaments and fascia. and separates between the pelvic cavity from above, and the perineum from below. It is formed by the levator ani muscle and coccygeus muscle, and associated connective tissue.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

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 pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The 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. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Pelvic organ prolapse</span> Descent of the pelvic organs from their normal positions

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

<span class="mw-page-title-main">Stress incontinence</span> Form of urinary incontinence from an inadequate closure of the bladder

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 bladder outlet by the urethral sphincter.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

<span class="mw-page-title-main">Pelvic examination</span> Physical medical examination

A pelvic examination is the physical examination of the external and internal female pelvic organs. It is frequently used in gynecology for the evaluation of symptoms affecting the female reproductive and urinary tract, such as pain, bleeding, discharge, urinary incontinence, or trauma. It can also be used to assess a woman's anatomy in preparation for procedures. The exam can be done awake in the clinic and emergency department, or under anesthesia in the operating room. The most commonly performed components of the exam are 1) the external exam, to evaluate the vulva 2) the internal exam with palpation to examine the uterus, ovaries, and structures adjacent to the uterus (adnexae) and 3) the internal exam using a speculum to visualize the vaginal walls and cervix. During the pelvic exam, sample of cells and fluids may be collected to screen for sexually transmitted infections or cancer.

A urethrocele is the prolapse of the female urethra into the vagina. Weakening of the tissues that hold the urethra in place may cause it to protrude into the vagina. Urethroceles often occur with cystoceles. In this case, the term used is cystourethrocele.

Urogynecology or urogynaecology is a surgical sub-specialty of urology and gynecology.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

Obstructed defecation syndrome is a major cause of functional constipation, of which it is considered a subtype. It is characterized by difficult and/or incomplete emptying of the rectum with or without an actual reduction in the number of bowel movements per week. Normal definitions of functional constipation include infrequent bowel movements and hard stools. In contrast, ODS may occur with frequent bowel movements and even with soft stools, and the colonic transit time may be normal, but delayed in the rectum and sigmoid colon.

Urethral hypermobility is a condition of excessive movement of the female urethra due to a weakened urogenital diaphragm. It describes the instability of the urethra in relation to the pelvic floor muscles. A weakened pelvic floor muscle fails to adequately close the urethra and hence can cause stress urinary incontinence. This condition may be diagnosed by primary care providers or urologists. Treatment may include pelvic floor muscle exercises, surgery, or minimally invasive procedures.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

Pelvic floor physical therapy (PFPT) is a specialty area within physical therapy focusing on the rehabilitation of muscles in the pelvic floor after injury or dysfunction. It can be used to address issues such as muscle weakness or tightness post childbirth, dyspareunia, vaginismus, vulvodynia, constipation, fecal or urinary incontinence, pelvic organ prolapse, and sexual dysfunction. Licensed physical therapists with specialized pelvic floor physical therapy training address dysfunction in individuals across the gender and sex spectra, though PFPT is often associated with women's health for its heavy focus on addressing issues of pelvic trauma after childbirth.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

References

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