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Pelvic Floor Dysfunction In Females

A. JABBAR DENTAL CLINIC KARACHI

Sadia Khan

Overview

Pelvic floor dysfunction is characterized by impaired function, coordination, or control of the muscles, ligaments, and connective tissues in the pelvic floor.

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Pelvic floor dysfunction encompasses a range of disorders that can lead to symptoms such as pelvic pain, urinary and fecal incontinence, sexual dysfunction, and pelvic organ prolapse. The condition can significantly affect individuals&#39; daily activities, social interactions, and sexual function, leading to psychological distress and reduced quality of life. Aging, childbirth history, <a href="https://merisehat.pk/disease/obesity">obesity</a>, and certain medical conditions contribute to the development of pelvic floor dysfunction. 
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The prevalence of pelvic floor dysfunction varies across populations and is influenced by factors such as age, gender, and childbirth history. Moreover, the symptoms and conditions of pelvic floor dysfunction span a wide range, the overall incidence is difficult to determine.

Approximately 50% of women of childbearing age can experience pelvic floor dysfunction<a href="#accordion">[1]</a>. A cross-sectional study conducted in the United States reported a prevalence of 23.7%<a href="#accordion">[2]</a>. This prevalence was seen to double in women aged 80 years or above<a href="#accordion">[2]</a>.

Sexual dysfunction and pelvic organ prolapse are common problems encountered by women of reproductive age. An estimated 40% of women worldwide will experience pelvic organ prolapse, with women over the age of 50 bearing the largest burden<a href="#accordion">[3]</a>.

A study conducted across hospitals in Lahore, Pakistan reported that 35% of women that underwent normal vaginal delivery experienced symptomatic pelvic floor dysfunction<a href="#accordion">[5]</a>. The disorders were more common among obese women with multiple vaginal births. Pelvic organ prolapse is also a common occurrence among women in Pakistan. Studies have found a prevalence of 10.3% across rural areas of the country<a href="#accordion">[4]</a>. 
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Pelvic floor dysfunction encompasses various disorders that can manifest in different ways. The following are the different types of pelvic floor disorders<a href="#accordion">[6]</a>. 
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<ul>
	<li>Urinary Incontinence: Urinary incontinence refers to the involuntary leakage of urine. It can be categorized into different types, including stress incontinence, urgency, and mixed incontinence (a combination of both stress and urge incontinence).</li>
	<li>Fecal Incontinence: Fecal incontinence is the inability to control bowel movements, resulting in involuntary leakage of feces. It can range from occasional small leaks to a complete loss of bowel control. Fecal incontinence can significantly affect the quality of life and may be associated with other pelvic floor disorders.</li>
	<li>Pelvic Organ Prolapse: Pelvic organ prolapse occurs when the pelvic organs, such as the bladder, uterus, or rectum, descend or bulge into the vaginal canal due to weakened or damaged pelvic floor support. This can cause symptoms such as a feeling of pressure or fullness in the pelvis, tissue protrusion from the vagina, and difficulty emptying the bladder or bowels. 
	&nbsp;</li>
</ul>

Signs and Symptoms

The signs and symptoms of pelvic floor dysfunction can vary depending on the specific condition and individuals. These include<a href="#accordion">[8]</a>:

<ul>
	<li>Pelvic pain or discomfort</li>
	<li>Chronic pelvic pain syndrome</li>
	<li>Pain in the pelvic region, perineum, rectum, or lower abdomen</li>
	<li>Pain or discomfort during or after sexual intercourse (dyspareunia)</li>
	<li>Urinary symptoms such as urinary frequency, urgency, hesitancy, weak stream, or<a href="https://merisehat.pk/disease/urinary-incontinence-in-women"> incontinence</a></li>
	<li>Bowel symptoms including <a href="https://merisehat.pk/disease/constipation">constipation</a>, straining during bowel movements, incomplete evacuation, or fecal incontinence</li>
	<li>Pelvic organ prolapse, characterized by a bulging sensation, pressure, or tissue protrusion in the vaginal or rectal area</li>
	<li>Reduced sexual desire or difficulty reaching orgasm</li>
	<li>Muscle spasms or tightness in the pelvic floor region</li>
</ul>

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It is important to note that these signs and symptoms can overlap and vary among individuals. Additionally, some individuals may experience multiple symptoms while others may have only a few. 
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Note: If you experience any symptoms of pelvic floor dysfunction, such as urinary incontinence, pelvic organ prolapse, or chronic pelvic pain, it is important to seek timely medical attention. Early intervention and treatment can help prevent the progression of the condition and improve outcomes. 
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<h5><a href="https://merisehat.pk/disease/pelvic-floor-dysfunction-males">Pelvic Floor Dysfunction In Men</a></h5>

While pelvic floor dysfunction is commonly associated with women, it can also affect men. Various factors can contribute to pelvic floor dysfunction in men<a href="#accordion">[7]</a>. These may include chronic stress or tension in the pelvic floor muscles, postural abnormalities, previous pelvic surgeries, prostate conditions (such as <a href="https://merisehat.pk/disease/prostatitis">prostatitis </a>or <a href="https://merisehat.pk/disease/benign-prostatic-hyperplasia">benign prostatic hyperplasia</a>), neurological conditions (e.g., <a href="https://merisehat.pk/disease/multiple-sclerosis">multiple sclerosis</a>), or trauma to the pelvic region.

Pelvic floor dysfunction in men can cause chronic pelvic pain, also known as chronic prostatitis or chronic pelvic pain syndrome. The pain may be located in the pelvic region, perineum, rectum, or lower abdomen. It can be persistent and may vary in intensity, affecting daily activities and quality of life. Urinary symptoms can also manifest. These may include urinary frequency, urgency, hesitancy, weak urinary stream, incomplete bladder emptying, or urinary incontinence. Moreover, bowel function can also be affected. It may present as constipation, straining during bowel movements, incomplete evacuation, or fecal incontinence<a href="#accordion">[7]</a>.

Pelvic floor dysfunction can also impact sexual function in men. <a href="https://merisehat.pk/disease/erectile-dysfunction">Erectile dysfunction</a> may occur due to impaired blood flow or nerve function related to the pelvic floor. Other sexual symptoms can include pain during or after ejaculation, reduced sexual desire, or difficulty reaching orgasm<a href="#accordion">[7]</a>.

Men who have undergone prostatectomy (surgical removal of the prostate) for prostate cancer may experience pelvic floor dysfunction as a postoperative complication. Pelvic floor muscle rehabilitation is often recommended as part of the recovery process. 
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Causes

Pelvic floor dysfunction can have various causes, and it often results from a combination of factors. These include<a href="#accordion">[1]</a> <a href="#accordion">[7]</a>: 
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<ul>
	<li>Pregnancy And Childbirth: Pregnancy and childbirth can put significant strain on the pelvic floor muscles and tissues. The stretching and weakening of these structures during pregnancy, as well as the trauma during vaginal childbirth, can contribute to pelvic floor dysfunction.</li>
	<li>Age And Hormonal Changes: The natural aging process can lead to changes in the pelvic floor muscles and connective tissues, resulting in decreased strength and support. Hormonal changes, such as a decrease in estrogen levels during menopause, can also contribute to pelvic floor dysfunction.</li>
	<li>Obesity And Excessive Weight: Excess weight and obesity can put added pressure on the pelvic floor, leading to weakened muscles and an increased risk of pelvic floor dysfunction.</li>
	<li>Chronic Straining: Chronic straining during bowel movements due to conditions like chronic constipation can strain the pelvic floor muscles and contribute to dysfunction.</li>
	<li>Chronic Coughing: Persistent coughing, such as that seen in chronic respiratory conditions like chronic obstructive pulmonary disease (COPD) or smoking-related cough, can increase intra-abdominal pressure and strain the pelvic floor muscles.</li>
	<li>Pelvic Surgery: Previous pelvic surgeries, such as prostate or bladder surgery, can affect the integrity and function of the pelvic floor muscles and contribute to dysfunction.</li>
	<li>Neurological Disorders: Certain neurological conditions, such as multiple sclerosis, spinal cord injury, or stroke, can disrupt the communication between the brain and the pelvic floor muscles, leading to dysfunction.</li>
	<li>Pelvic Trauma: Trauma to the pelvic region, such as a fall or injury, can damage the pelvic floor muscles or nerves and result in dysfunction.</li>
	<li>Chronic Pelvic Pain: Chronic pelvic pain conditions, such as chronic prostatitis in men or interstitial cystitis in both men and women, can cause pelvic floor muscle tension and contribute to dysfunction. 
	&nbsp;</li>
</ul>

While there may not be standardized universal screening tests for pelvic floor dysfunction, healthcare providers may evaluate and diagnose pelvic floor dysfunction based on a combination of medical history, physical examination, and specific assessment tools. 
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During an evaluation, healthcare professionals may ask questions about symptoms related to urinary, bowel, and sexual function, as well as pain or discomfort in the pelvic region. They may also perform a physical examination to assess the strength, tone, and coordination of the pelvic floor muscles and to check for any signs of prolapse or abnormalities.

Additionally, healthcare professionals may use specific assessment tools or questionnaires to gather more detailed information about symptoms, such as urinary or bowel diaries, to assess patterns and severity of dysfunction. 
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Diagnosis

Pelvic floor dysfunction is typically diagnosed through a combination of medical history assessment, physical examination, and specific diagnostic methods. These include<a href="#accordion">[7]</a> <a href="#accordion">[9]</a>: 
&nbsp;

<ul>
	<li>Medical History: A healthcare professional will begin by taking a detailed medical history, asking questions about the individual&#39;s symptoms, their duration, severity, and any associated factors. They may inquire about urinary, bowel, or sexual symptoms, as well as any pain or discomfort in the pelvic region. The medical history assessment helps identify patterns, triggers, and potential underlying causes of pelvic floor dysfunction. 
	&nbsp;</li>
	<li>Physical Examination: A physical examination is an essential component of the diagnostic process. Healthcare professionals specializing in pelvic floor disorders can perform a comprehensive assessment of the pelvic floor muscles, ligaments, and surrounding structures. They may visually inspect the pelvic area for signs of prolapse, muscle spasms, or abnormalities. A manual examination may also be performed. It involves using the fingers to assess muscle strength, tone, and coordination, as well as checking for areas of tenderness or trigger points. 
	&nbsp;</li>
	<li>Assessment Tools and Questionnaires: To gather more detailed information about symptoms and their impact on the individual&#39;s quality of life, healthcare professionals may use specialized assessment tools and questionnaires. These tools can help quantify symptom severity, assess the impact on daily activities, and evaluate the individual&#39;s quality of life. Examples include the Pelvic Floor Distress Inventory (PFDI) and the Pelvic Floor Impact Questionnaire (PFIQ). 
	&nbsp;</li>
	<li>Diagnostic Tests: In some cases, healthcare professionals may recommend additional diagnostic tests to aid in the diagnosis of pelvic floor dysfunction. These tests can include:
	<ol>
		<li>Urodynamic Testing: Urodynamic testing evaluates bladder and urethral function by measuring pressures and flow rates during the filling and emptying of the bladder. It helps assess bladder capacity, detrusor muscle function, and urinary flow dynamics.</li>
		<li>Imaging Studies: Imaging techniques such as pelvic ultrasound, magnetic resonance imaging (MRI), or specialized studies like cystoscopy or defecography may be used to assess the structure and function of the pelvic organs and identify any abnormalities or conditions contributing to pelvic floor dysfunction.</li>
		<li>Electromyography (EMG): Electromyography measures the electrical activity of the pelvic floor muscles, providing information about muscle function, coordination, and potential abnormalities in muscle activity.</li>
		<li>Anal Manometry: The noninvasive test measures the strength of the muscles forming the anal sphincter. 
		&nbsp;</li>
	</ol>
	</li>
</ul>

Treatment

The treatment of pelvic floor dysfunction depends on the specific condition and underlying causes. Healthcare professionals typically employ a combination of non-surgical and surgical approaches to manage pelvic floor dysfunction<a href="#accordion">[1]</a> <a href="#accordion">[10]</a>. 
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<h5>Lifestyle Modifications</h5>

<ul>
	<li>Dietary Changes: In cases where dietary factors contribute to symptoms, healthcare professionals may recommend dietary modifications such as reducing caffeine intake, increasing fiber intake, or avoiding bladder-irritating foods.</li>
	<li>Weight Reduction: Patients are often advised weight loss to help decrease urinary incontinence and symptoms of pelvic organ prolapse. 
	&nbsp;</li>
</ul>

<h5>Non-surgical Treatment</h5>

<ul>
	<li>Physical Therapy: This is a cornerstone of non-surgical treatment for pelvic floor dysfunction. It involves exercises, techniques, and therapies to strengthen and relax the pelvic floor muscles, improve muscle coordination, and alleviate symptoms. Pelvic floor muscle exercises (Kegels), biofeedback, electrical stimulation, manual therapy, and behavioral modifications. Kegels involve routinely contracting and relaxing the pelvic floor muscles. It can help alleviate symptoms of urinary incontinence and prolapse.</li>
	<li>Behavioral Modifications: These may include adopting healthy bowel habits, maintaining a balanced diet with adequate fiber and fluids, practicing good toilet habits, managing stress, and avoiding activities that exacerbate symptoms.</li>
	<li>Bladder and Bowel Retraining: Retraining the bladder and bowel involves establishing a regular schedule for bladder or bowel movements. Thus, the individual gradually increases the time between bathroom visits and learns techniques to improve control and coordination.</li>
	<li>Electrical Stimulation: Electrical stimulation involves the use of low-intensity electrical currents to stimulate the pelvic floor muscles. It can help strengthen weak muscles and improve muscle control and coordination.</li>
	<li>Medications: Medications may be prescribed to manage specific symptoms associated with pelvic floor dysfunction. For example, muscle relaxants or antispasmodic medications can help alleviate pelvic muscle spasms, while certain medications may be used to treat urinary incontinence or an overactive bladder.</li>
	<li>Vaginal Pessary: This is a plastic device inserted into the vagina to help support the pelvic organs. It is used to improve bladder control and treat pelvic organ prolapse.</li>
</ul>

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<h5>Surgical Treatment</h5>

Surgical treatments for pelvic floor dysfunction may be considered when non-surgical approaches have been ineffective or in cases where structural abnormalities or organ prolapse require intervention.

<ul>
	<li>Pelvic Organ Prolapse Repair: Different surgical techniques may be employed, including the use of mesh or tissue repairs, to restore the organs to their normal position and provide support to the pelvic floor.</li>
	<li>Pelvic Floor Reconstruction: In cases where there is weakness or damage to the pelvic floor muscles, ligaments, or connective tissues, pelvic floor reconstruction surgery may be performed. This procedure involves repairing or reinforcing the pelvic floor structures to restore normal anatomical support and improve pelvic floor function.</li>
	<li>Sling Procedures: Sling procedures are surgical techniques used to treat stress urinary incontinence, a common symptom of pelvic floor dysfunction. During a sling procedure, a synthetic mesh or the patient&#39;s tissue is used to create a sling-like support under the urethra to help improve urinary control.</li>
	<li>Sacral Nerve Stimulation: In some cases of pelvic floor dysfunction, sacral nerve stimulation may be considered. This procedure involves the implantation of a small device that delivers electrical impulses to the sacral nerves, which help control bladder, bowel, and pelvic floor function. Sacral nerve stimulation can help manage symptoms such as urinary or fecal incontinence or overactive bladder. 
	&nbsp;</li>
</ul>

Note: Not all women can undergo the above surgical interventions. Moreover, prolapse can recur despite the surgery. 
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If left untreated, pelvic floor dysfunction can give rise to various complications that can impact a person&#39;s quality of life. These include: 
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<ul>
	<li>Chronic Pelvic Pain: Pelvic floor dysfunction can contribute to chronic pelvic pain, which is persistent pain in the pelvic region that lasts for at least six months. The pain can be dull or sharp and may be associated with muscle spasms, pressure, or discomfort. Chronic pelvic pain can significantly impact daily activities, work, and emotional well-being.</li>
</ul>

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<ul>
	<li>Sexual Dysfunction: Pelvic floor dysfunction can affect sexual function and lead to sexual dysfunction. This can include pain during intercourse (dyspareunia), decreased libido, difficulty achieving orgasm, or erectile dysfunction in men. Sexual dysfunction can have a profound impact on intimate relationships and overall quality of life.</li>
</ul>

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<ul>
	<li>Emotional And Psychological Impact: Dealing with the symptoms and complications of pelvic floor dysfunction can lead to emotional and psychological distress, including anxiety, depression, and decreased self-esteem. The impact on daily activities, relationships, and overall well-being can be significant. 
	&nbsp;</li>
</ul>

The following factors are associated with an increased risk of pelvic floor dysfunction: 
&nbsp;

<ul>
	<li>Family history of pelvic organ prolapse or urinary incontinence</li>
	<li>Aging</li>
	<li>Pregnancy and childbirth</li>
	<li>Obesity</li>
	<li>Chronic constipation</li>
	<li>Chronic coughing</li>
	<li>Pelvic surgery or radiation therapy in the pelvic region 
	&nbsp;</li>
</ul>

The following measures can help reduce the risk of pelvic floor dysfunction. 
&nbsp;

<ul>
	<li>Maintain A&nbsp;Healthy Weight: Maintaining a healthy weight through a balanced diet and regular exercise can help reduce the strain on the pelvic floor muscles and decrease the risk of developing pelvic floor dysfunction.</li>
	<li>Practice Pelvic Floor Exercises: Engaging in regular pelvic floor exercises, also known as Kegel exercises, can help strengthen the pelvic floor muscles and improve their function.</li>
	<li>Avoid Straining During Bowel Movements: Straining during bowel movements can put excessive pressure on the pelvic floor muscles. It is important to maintain healthy bowel habits by consuming a high-fiber diet, drinking plenty of fluids, and avoiding prolonged straining.</li>
	<li>Manage Chronic Coughing: If one has a chronic cough due to a respiratory condition, it is important to manage and treat the underlying cause to minimize the strain on the pelvic floor muscles.</li>
	<li>Practice Proper Lifting Techniques: When lifting heavy objects, it is important to use proper lifting techniques to avoid placing excessive strain on the pelvic floor muscles. This includes lifting with the legs, not the back, and avoiding lifting objects that are too heavy. 
	&nbsp;</li>
</ul>

A recent literature review aimed to identify the effectiveness of acupuncture in treating pelvic floor dysfunction disorders<a href="#accordion">[11]</a>. The team of researchers found a total of 17 studies, 8 of which assessed the impact of acupuncture on chronic pelvic pain. Another 7 studies assessed the alternative treatment&rsquo;s effect on urinary incontinence. While the remaining 2 studies involved pelvic floor dysfunction.

According to the research, acupuncture was found to significantly reduce symptoms of pelvic floor dysfunctions. Especially, in cases that failed to respond to other conservative measures. 
&nbsp;

Key Points

<ul>
	<li>Pelvic floor dysfunction encompasses a range of disorders that involve abnormal function or coordination of the pelvic floor muscles, which support the pelvic organs, including the bladder, uterus, and rectum.</li>
	<li>Various factors can contribute to pelvic floor dysfunction, including pregnancy and childbirth, aging, obesity, hormonal changes, chronic constipation, chronic coughing, repetitive heavy lifting, pelvic surgery, trauma, and certain neurological conditions.</li>
	<li>The symptoms of pelvic floor dysfunction can vary widely and may include pelvic pain, discomfort or pressure in the pelvic region, urinary or fecal incontinence, difficulty or pain during sexual intercourse, incomplete emptying of the bladder or bowels, and pelvic organ prolapse.</li>
	<li>The diagnosis of pelvic floor dysfunction involves a thorough medical history, physical examination, and potentially additional tests such as urodynamic studies, cystoscopy, defecography, and imaging tests (MRI or ultrasound) to assess the pelvic organs and muscles.</li>
	<li>Treatment options for pelvic floor dysfunction depend on the specific condition and may include pelvic floor exercises (Kegel exercises), physical therapy, biofeedback, electrical stimulation, medications, behavioral modifications, dietary changes, lifestyle adjustments, pessary use, and in some cases, surgery.</li>
	<li>Making certain lifestyle modifications can help manage pelvic floor dysfunction. This may include maintaining a healthy weight, adopting proper body mechanics and lifting techniques, managing chronic constipation, avoiding excessive straining during bowel movements, practicing good toilet habits, and managing chronic coughing. 
	&nbsp;</li>
</ul>

[1] Grimes WR, Stratton M. Pelvic Floor Dysfunction. [Updated 2023 May 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.

[2] Hallock JL, Handa VL. The Epidemiology of Pelvic Floor Disorders and Childbirth: An Update. Obstet Gynecol Clin North Am. 2016;43(1):1-13. doi:10.1016/j.ogc.2015.10.008

[3] Wang B, Chen Y, Zhu X, et al. Global burden and trends of pelvic organ prolapse associated with aging women: An observational trend study from 1990 to 2019. Front Public Health. 2022;10:975829. Published 2022 Sep 15. doi:10.3389/fpubh.2022.975829

[4] Jokhio AH, Rizvi RM, MacArthur C. Prevalence of pelvic organ prolapse in women, associated factors and impact on quality of life in rural Pakistan: a population-based study. BMC Womens Health. 2020;20(1):82. Published 2020 Apr 28. doi:10.1186/s12905-020-00934-6

[5] Abdul Hameed, A., Bukhari, B., Nauman, M., Akram, samrood, & Ali, S. (2022). FREQUENCY OF PELVIC FLOOR DYSFUNCTIONS AFTER NORMAL VAGINAL DELIVERY. Pakistan Journal of Physical Therapy (PJPT), 5(4).

[6] About pelvic floor disorders (PFDs). Eunice Kennedy Shriver National Institute of Child Health and Human Development.

[7] Pelvic Floor Dysfunction. Cleveland Clinic.

[8] What are the symptoms of pelvic floor disorders (PFDs)? Eunice Kennedy Shriver National Institute of Child Health and Human Development.

[9] How are pelvic floor disorders (PFDs) diagnosed? Eunice Kennedy Shriver National Institute of Child Health and Human Development.

[10] How are pelvic floor disorders (PFDs) treated? Eunice Kennedy Shriver National Institute of Child Health and Human Development.

[11] Fang J. 7513: Acupuncture for Pelvic Floor Disorders: A Literature Review. Presented at: AAGL’s 51st Global Congress on MIGS; December 1, 2022; Aurora, Colorado.