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    Pelvic Floor Dysfunction

    What is pelvic floor dysfunction?

    • Pelvic floor dysfunction is the inability to control the muscles of your pelvic floor.

    How common is pelvic floor dysfunction?

    • It is a very common problem (1).
    • Approximately 67% of women will experience one of the main symptoms related to pelvic floor dysfunction (4).
    • Pelvic floor dysfunction can affect men also.

    Should I worry?

    • No.
    • People who have had a change in bladder or bowel habit should seek a GP assessment.
    • If any bulges are noticed or changes to bladder or bowel control, medical attention should be sought urgently.

    Who is most likely to suffer from pelvic floor dysfunction?

    • Women are more likely to experience pelvic floor dysfunction compared to men.
    • During and after pregnancy.
    • If you are very overweight.
    • During and after menopause.
    • After a period of constipation or if constipation is persistent.

    What are the common symptoms?

    • Pelvic pain.
    • A feeling of heaviness or pressure in the pelvic region.
    • Pain during sex.
    • Urinary incontinence.
    • Incomplete when emptying faeces.
    • Organ protrusion.

    What can I do?

    • Most people can generally self-manage well and be treated with non-surgical options such as exercises and strength training, or use a pessary device to hold organs in place.
    • Stress incontinence can be improved by using pelvic floor exercises or seeing a pelvic health physiotherapist.
    • In some cases, minor surgery/a minimally invasive procedure is needed which can be very successful (2).

    How long will it take to recover?

    • This will depend upon several factors including, but not limited to, medical/lifestyle factors, stage of injury, your ability to follow your rehabilitation, etc.
    • With the right rehabilitation approach, improvements should be seen within 1-2 months and maximum recovery is expected within 3-6 months.
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    1. Introduction

    The pelvic floor muscles lie across the base of your pelvis to help keep the pelvic organs – bladder, uterus and bowel – in the correct position. The muscles are held in place by ligaments that support the organs, especially when there is an increase of pressure in the abdomen that occurs with lifting, bending, carrying and straining. This is called intra-abdominal pressure and when it increases the pelvic floor and abdominal muscles brace so that the internal organs such as the uterus and bladder are not pushed downwards. The pelvic floor muscles work to help keep the bladder and bowel openings closed to prevent unwanted leakage (incontinence) and they relax to allow easy bladder and bowel emptying. Good pelvic floor muscles can help with sex by improving the vaginal sensation and your ability to grip.

    Up to two-thirds of all women experience a problem with their pelvic floor muscles at some time during their life. The most common problems are leaking with activity, sneezing or coughing (stress urinary incontinence) and pelvic organ prolapse (a feeling of something coming down in the vagina). All the bladder, bowel and sexual functions require good pelvic floor muscles. Effective pelvic floor muscles in pregnancy will reduce the risk of postnatal stress urinary incontinence (SUI).

    Pelvic floor dysfunction is more than often not serious; exercises can help recovery considerably. As the pelvic floor muscles aid with toileting, it is not unusual to experience stress incontinence or urgency/frequency. This should be addressed but does not necessarily mean you have a prolapse or that it will progress to a more severe pelvic floor disorder.

    Pelvic floor disorders can result in faecal and urinary issues relating to control. They can also result in prolapses. If you feel you have any associated signs or symptoms relating to this you should contact your GP urgently.

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    2. Signs & Symptoms

    The main symptoms are usually:

    3. Causes

    • Pregnancy – during and after.
    • Being very overweight.
    • Menopause – during and after.
    • A period of constipation or if constipation is persistent.
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    4. Risk Factors

    This is not an exhaustive list. These factors could increase the likelihood of someone developing pelvic floor dysfunction due to increased pressure on the pelvic floor system. It does not mean everyone with these risk factors will develop symptoms.

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    5. Prevalence

    Pelvic floor dysfunction is a very common problem (1). Approximately 67% of women will experience one of the main symptoms related to pelvic floor dysfunction at some point in their life (4). Pelvic floor dysfunction can also affect men.

    6. Assessment & Diagnosis

    If you are experiencing any of the symptoms of pelvic floor dysfunction then a consultation with your GP or medical professional should be your first step (2, 3). They will typically ask you a series of questions, and look to understand your symptoms and how they are affecting you. Tests can then be carried out to explore further. These can include:

    • Cystoscopy – test to examine the insides of the bladder to look for problems, such as bladder stones, tumours or inflammation.
    • Urinalysis – urine test to detect if you have a bladder infection, kidney problems or diabetes.
    • Urodynamics – test to evaluate how the bladder and urethra are working.
    • Anal manometry – test to evaluate the strength of the anal sphincter muscles.
    • Colonoscopy or sigmoidoscopy – procedure to examine the inside of the colon or the sigmoid (the part of the bowel near the rectum) to look for signs of disease or inflammation that may be causing symptoms.

    7. Self-Management

    Lifting – always try to avoid unnecessary strain on your pelvic floor muscles. If you have to lift in your job or daily routine, get advice about safe lifting and equipment to help.

    The knack – tighten your pelvic floor muscles before any activity which involves a rise in intra-abdominal pressure – coughing, sneezing, lifting, carrying, bending – even laughing sometimes!

    Constipation – get help from your doctor if you tend to strain on the toilet. Make sure that your diet has enough fibre and that you drink at least 1.5 litres of fluid per day.

    Bladder problems – do not reduce your fluid intake to try and reduce the frequency as it may make your urine stronger which can cause more irritation of the bladder. Avoid fizzy and caffeinated drinks. To help with the urgency of needing to go to the toilet, sit down if you can, use your pelvic floor muscles to help the bladder relax and wait until the strong urge passes.

    Toileting position – using a step or stool under your feet while on the toilet helps create a squatting position which will reduce pressure into your rectum when passing a stool. This will reduce pressure on the ligaments and muscles in this area. It is also important to ensure you always sit and relax on the toilet and not get in a habit of hovering as this does not allow your pelvic floor to relax completely while you empty your bladder.

    Relaxation – it is just as important to have pelvic floor muscles that can relax as it is for them to be strong. Increased stress can cause changes to your posture and breathing and this can put more tension in all our muscles, our pelvic floor included. Practising some mindfulness techniques can help to improve our breathing techniques, as well as relax our muscles.

    There are many apps available online that can help with this. You can also find out more about simple relaxation methods in our booklet on the ‘Mitchell Method of Relaxation’.

    • Weight – if you are overweight, try to lose weight. Even quite small changes in weight can help with your symptoms. Seek help from your doctor if you have tried but not succeeded with weight loss.
    • Exercise – if you find that you have stress urinary incontinence with exercise, try a low impact activity such as Pilates/walking/swimming. You might need to avoid very high impact exercises which involve jumping, heavy weights or prolonged increases in intra-abdominal pressure, e.g. double leg lifts, (until your symptoms have been assessed).
    • Smoking – try to give up if you can. Your doctor might be able to refer you to a smoking cessation group.
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    8. Rehabilitation

    Pelvic floor exercises can help strengthen the muscles around your bottom, bladder and vagina or penis. Strengthening the muscles around your pelvic floor can help reduce the symptoms associated with pelvic floor dysfunction. Strengthening this area can also help reduce erectile dysfunction.

    A pelvic health specialist physiotherapist/women’s health physiotherapist can offer advice and self-management tools to support you.

    Sometimes in addition to self-management the pelvic health team may use a transvaginal electrical stimulation (TVES) to aid in initial strengthening; this is not painful and will be fully directed by the team.

    In some cases where the pelvic floor is not recovering and dysfunction remains, there may be an option for surgery. This is not something that is sought unless it is absolutely necessary. You would have a full discussion regarding this with the team if it was required.

    As part of your management for this condition, it is important to improve the function of your pelvic floor. The guide below provides the current recommended guidelines regarding how to achieve this.

    9. Pelvic Floor Dysfunction Rehabilitation Plan

    Treatment Plan

    This guide provides the current recommended guidelines regarding how to improve the function of your pelvic floor muscles. This should not exceed any more than 2/10 on your perceived pain scale.

    Treatment Plan - Rating
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    10. Return to Sport/Normal Life

    For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a women’s/men’s health specialist physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.

    As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish an appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

    11. Other Treatment Options

    Treatments such as acupuncture, manual therapy, maternity belt prescription or mobility aid prescription may also provide relief, but they are not recommended as stand-alone treatments (2). If your pain is severe then regular pain relief might be needed (5). Your GP can discuss options with you.

    12. Links for Further Reading

    1. https://www.nice.org.uk/guidance/GID-NG10123/documents/draft-scope
    2. Pelvic floor exercises – NHS www.nhs.uk
    3. Pelvic Obstetric and Gynaecological Physiotherapy: Pelvic floor exercises for women: https://thepogp.co.uk/Resources/115/pelvic_floor_muscle_exercises_for_women
    4. NHS Squeezy app: https://www.nhs.uk/apps-library/squeezy/
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    Book an Appointment

    Please book an appointment with one of our physiotherapists if you think you are suffering from this condition and would like to find out more.

    We have Pure Physiotherapy clinics across the country including Norwich, Great Yarmouth, Manchester, Stockport, Sheffield and Rotherham. Please view our clinics to find the closest physiotherapy clinic for you.

    References

    1. Continence Foundation of Austraila. (2016), ‘Working your pelvic floor’ http://www.pelvicfloorfirst.org.au/pages/working-your-pelvic-floor.html: Accessed 14/4/21.
    2. Ghaderi, F., Bastani, P., Hajebrahimi, S., Jafarabadi, M.A. and Berghmans, B., (2019). Pelvic floor rehabilitation in the treatment of women with dyspareunia: a randomized controlled clinical trial. International urogynecology journal, 30(11), pp.1849-1855.
    3. Hall, L.M., Aljuraifani, R. and Hodges, P.W., (2018). Design of programs to train pelvic floor muscles in men with urinary dysfunction: Systematic review. Neurourology and urodynamics, 37(7).
    4. Kepenekci I, Keskinkilic B, Akinsu F, Cakir P, Elhan AH, Erkek AB, Kuzu MA. (Jan 2011).Prevalence of pelvic floor disorders in the female population and the impact of age, mode of delivery, and parity. Dis Colon Rectum. 54(1):85-94. doi: 10.1007/DCR.0b013e3181fd2356. PMID: 21160318.
    5. Li, W., Hu, Q., Zhang, Z., Shen, F. and Xie, Z. (2020). Effect of different electrical stimulation protocols for pelvic floor rehabilitation of postpartum women with extremely weak muscle strength: Randomized control trial. Medicine, 99(17).
    6. POGP .(2018). ‘The Pelvic Floor Muscles – a guide for woman’, 18xxxx-POGP-PelvicFloorA5.indd (csp.org.uk): Accessed12/4/2021.
    7. Wu, C., Newman, D., Schwartz, T.A., Zou, B., Miller, J. and Palmer, M.H. (2021). Effects of unsupervised behavioral and pelvic floor muscle training programs on nocturia, urinary urgency, and urinary frequency in postmenopausal women: Secondary analysis of a randomized, two-arm, parallel design, superiority trial (TULIP study). Maturitas, 146, pp.42-48.
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