Pelvic Floor Dysfunction

Original Editors - Sarah Barnes, Chris Van Wyk, Amy McCarthy, Gina McLoughlin, John Lavin, Claire Ramsden and Carolinne Cieslak.

Top Contributors - Sarah Barnes, Carolinne Cieslak, Gina McLoughlin, Kim Jackson and Claire Ramsden  

Introduction

Speaking about the nether-regions is never an easy thing to do! Problems that affect the pelvic floor include: incontinence, leaking, and pelvic organ prolapse. There is no easy way to approach this subject, and clients are often worried that there may be something wrong! Pelvic floor dysfunction is heavily under-reported as so many people don't feel comfortable speaking up about it. Many people find talking about pelvic health to be a difficult conversation to bring up. In fact, 41-50% of women over 40 are affected by pelvic organ prolapse (information below). Only 17% of those with urinary incontinence seek medical help. Pelvic floor dysfunction affects more women than men, however, men are affected!!! From these figures, 46% of people suffer from their symptoms for 1 to 5 years, 42% of people suffering from their symptoms for 5 years or more. Issues with the pelvic floor are well known to have negative effects on the quality of life for both men and women. Many individuals have reported negative effects on their home and work activities, personal relationships, social lives, and mental well-being. Pelvic floor dysfunction is also associated with depression, social isolation, anxiety and generally reduced quality of life [1].

Pelvic-floor-muscles hammock.jpg
The following video takes a very sensitive and personal topic and attempts to take a more lighthearted approach to pelvic floor health.

Physiotherapists and other healthcare professionals have an important role in reducing the financial constraints placed on the NHS. It is now understood that physiotherapists can improve patient outcomes predominantly by promoting self-management[2]. This can be done through education on pelvic floor muscle training and lifestyle modifications. Future focus on these areas should have a positive financial impact on the NHS.

Currently, pelvic floor dysfunction places a huge financial burden to both the patient and the health service. Recent data on the exact costs for Scotland was not identified and the costs to the NHS as a whole do not appear to be well established. This may be due to the difficulty in quantifying the overall costs including direct costs (incontinence pads, diagnostic costs, treatment costs) and indirect costs (lost wages, lost productivity due to absenteeism)[3]. However, some data does exist which gives us an indication of the problem

  • Hagen et al. (2014) highlight that about 29,000 prolapse repairs were done in England between 2010 and 2011 which cost around £60 million[4]
  • Estimations for the UK have been made by examining other countries' data. For example, Cooper et al. (2015) note that urinary incontinence in Sweden and the US accounts for 2% of their healthcare budget[5]. They highlight that 2% of the UK budget would equate to £2.1 billion.
  • Milsom et al. (2014) reviewed the combined economic burden of urinary incontinence in several countries[3]. Their findings indicate that for Canada and five European countries including the UK the combined cost was €7 billion a year with the UK accounting for €595 million of this total.
  • Other evidence reviewed suggested that the combined burden for five European countries including the UK was €2.9 billion[3]. Interestingly, the review also noted that the cost of urinary incontinence is expected to rise by 25% in the next ten years due to the aging population[3].

Overall the financial burden that pelvic floor dysfunction places on the NHS is very evident. Physiotherapists may have a potential role in reducing this burden through both their treatments and through promoting self-management.

Pelvic Floor Anatomy

Pelvic Floor Muscles: Male (left) and Female (right)
The pelvic floor is made up of a layer of muscles covering the bottom of the pelvis that support the bladder and bowel in men [6] and bladder, bowel and womb in women[7]. These structures that sit on top of the pelvic floor are known as our pelvic organs. The muscles run like a hammock from the front of the pelvis to the tailbone (coccyx) at the back, and side-to-side from one sitting bone to the other [7]
  • The pelvic floor is a funnel shaped structure covering the base of the pelvis from the pubic symphysis anteriorly to the coccyx posteriorly and stretches from one ischial tuberosity to the other. It consists of two main muscles, the levator ani, and the coccygeus.[8]
  • The levator ani muscle is a broad thin muscle that is made up of a group of 3 muscles, pubococcygeus, puborectalis and iliococcygeus. The muscles join in the middle of the pelvis except for at the prostrate in males and vagina and urethra in females.
    • Pubococcygeus originates from both sides of the body of the pubis lateral to the puborectalis muscle and anterior to the obturator canal at the tendinous arch. It travels posterior and medial to insert onto the perineum, coccyx and anococcygeal ligament.
    • Puborectalis is a U-shaped muscle that originates on both sides on the pubic body just lateral to the pubic symphysis. The muscle runs posterior and encircles the rectum so both side join together. Some fibers join the external anal sphincter. CThe cntraction of this muscle causes the anorectal junction to bend 90 degrees. This maintains facal continence during contraction and enables defecation on relaxation. Some fibers may extend towards the urethra in both male sand females and to the vagina in females, aiding with urinary continence.
    • Iliococcygeus originates from the ishial spines and posterior portion of the obturator internus. It travels posterior and medially and inserts onto the anococcygeal ligament and coccyx. [9]
  • Coccygeus is also known as the ischiococcygeus muscle. It is a small muscle that makes up the posterior portion of the pelvic floor. It originates from the sacrospinous ligament and ischial spine and inserts on to the lateral borders of inferior sacrum and superior coccyx.[10]
  • Urogenital Diaphragm: Deep transverse perineal, Sphincter urethrae
  • Sphincters and erectile muscles of the urogenital and intestinal tract: External anal sphincter, Bulbospongiosus, Ischiocavernosus, Superficial transverse perineal

For more information on the anatomy of the pelvic floor please visit: http://teachmeanatomy.info/pelvis/muscles/pelvic-floor/

Here is a video demonstrating the anatomy of the pelvic floor muscles:

The pelvic floor muscles are similar to a trampoline, as they have the ability to move up and down. This occurs during breathing and is much easier to imagine if we think of our body as a cylinder. When we breath in, our diaphragm (breathing muscle) pulls down to open our lungs[11], this is like the top of the cylinder pulling down. This pushes down on our internal organs and in order to avoid squashing these organs, our pelvic floor and abdominal muscles relax and stretch down and out. This is like the bottom and sides of the cylinder stretching down and out to create more space for the organs. When we exhale, the top of the cylinder (the diaphragm) springs back to its normal position. As it does so, the abdominals and pelvic floor muscles return to their normal positions. A common problem experienced by people,is holding their breath during lifting activities or bowel movements. This can lead to pelvic floor weakness or dysfunctions by adding excess stress on these muscles [12].

Click here to see a visual diagram of the diaphragm and pelvic floor muscles working together.

Functions of the Pelvic Floor Muscles

The pelvic floor serves many important functions, from being a hammock to hold our organs to stopping us from leaking and even improving your sexual experience and function. The picture and paragraph below run through some of the main functions of your pelvic floor in more detail.
Main Pelvic Floor Muscle Functions
  1. Support internal pelvic organs in the correct positions (Bladder, bowel and womb).[6][13]
  2. Allows self-control of bladder and bowel habits using the sphincter muscles. This allows us to control the release of urine, faeces, and gas. This allows us to delay emptying until a convenient time when a toilet is available. This works by the pelvic floor muscles tightening and lifting the pelvic organs up while the sphincter tightens around the openings of the urethra and anus.[6][13]
  3. When relaxed, they allow the passage of urine and faeces out of the body.[6][12]
  4. Sexual function[6]
    • In males the pelvic floor muscles are important in maintaining an erection during sex and preventing early ejaculation.[14][13]
    • In females awareness of the tightening of the pelvic floor muscles can contribute to sexual sensation and orgasm.[13]
  5. The pelvic floor muscles play a role in breathing by relaxing and increasing the space the lungs have to expand.[12]
  6. During pregnancy, the pelvic floor offers support to the baby and also assists in childbirth [6]

Strong pelvic floor muscles are important when we cough, laugh, sneeze and during lifting activities as there is extra force added to the abdomen and pelvic floor[12]. If these muscles are weak, stretched or not working as they should, pelvic floor dysfunction may occur and lead to the signs and symptoms mentioned below. Some of these symptoms may be pressure felt in the pelvic region and/or bladder or bowel leaking occurring during laughing, coughing, sneezing or lifting.[15]

The following video if from pelvic health physiotherapist Claire Baker. In this video she gives a very informative TED talk on general pelvic floor health, signs and symptoms of dysfunction and on how to do pelvic floor exercises.

Types of Prolapse

Normal bladder (Left) Cystocele Prolapse (Right)
A prolapse is when a structure has slipped down from its normal position and bulges into the vagina. There are multiple types of prolapse depending on which structures have moved.
  • Cystocele prolapse, also known as dropped bladder, is the bulging of the bladder into the vagina (see image ). It occurs due to the weakening of the pubo-cervical fascia between the bladder and vaginal wall allowing the bladder to displace downwards and backwards against the anterior wall of the vagina. A pouch may also form in the bladder resulting in the retention of residual urine. Symptoms include urinary frequency, incomplete emptying of the bladder, recurrent UTI’s and stress incontinence.[16]
  • Urethrocoele prolapse is the displacement of the female urethra into the vagina, see image below. Due to the urethra being closely attached to the anterior wall of the vagina it can sag backwards and downwards when it receives insufficient support from the vagina or surrounding fascia. This is the least common form of prolapse and is most common in post-menopausal women and pre-pubertal girls.[17]
Normal Pelvic Anatomy (Left), Urethrocele Prolapse (Right)
  • Cystourethrocoele is a combination of a cystocoele and urethrocoele and it is the most common type of prolapse (see image). This is when the bladder and urethra bulge into the vagina. Symptoms may be associated with urinary stress incontinence, and urinary retention or recurrent urinary tract infections or both.[18]
Normal Pelvic Organs (Left), Enterocoele Prolapse (Right)
  • Enterocoele is when the small bowel pushes down from the abdomen onto the posterior wall of the vagina through the rectovaginal septum and causes a herniation (Space between rectum and vagina). An enteroceoele usually accompanies a uterine prolapse.[19]
Normal Pelvic Organs (Left), Uterine Prolapse (Right)
  • Uterine prolapse occurs when there is a lack of support allowing the uterus and cervix to descend from its normal position towards the vaginal opening and sometimes protrude out of the vagina. This can occur along with a vaginal prolapse where the vaginal vault descends due to weakening in the vaginal walls causing the vagina to invert. This prolapse is associated with a cystocoele and enterocoele prolapses. There are 3 degrees of uterine prolapse:
    • First degree- the cervix remains within the vagina
    • Second degree – descent if the cervix to the introitusThird degree- the entire uterus descends outside the introitus of the body,
    • causing total inversion of the vagina. [16]
Normal Pelvic Organs (Left), Rectocele Prolapse (Right)
  • Rectocele prolapse occurs when the bowel and rectum bulge forwards against the lower part of the posterior wall of the vagina. Inadequate or ineffective suturing of episiotomies and perineal tear post childbirth. Constipation. Perineal splinting for bowel movement.[20]

Here is a video showing a summary of the pelvic floor anatomy and types of prolapses that can occur:

Signs and Symptoms of Pelvic Floor Dysfunction

There are a few well-known signs and symptoms that people experience when they have a problem with their pelvic floor muscles. The following list of signs and symptoms are common for people with weak pelvic floor muscles. Urinary dysfunction, erectile dysfunction, premature ejaculation, painful ejaculation, and chronic pelvic pain are some conditions that can be linked with weak pelvic floor muscles.

Men

  • Constipation or bowel strains[21]
  • Ongoing pain in your pelvic region, genitals or rectum.[22][23]
  • A prolapse – may feel as though there is a bulge/ pressure in the rectum or a feeling of needing to use your bowels without actually needing to go.
  • Accidentally leaking urine when you exercise, laugh, cough or sneeze.[24][25][23]
  • Feelings of urgency in needing to the bathroom, or not making it there in time.[24][25][26]
  • Frequent need to urinate.[26]
  • Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.[26]
  • The feeling of needing to have several bowel movements during a short period of time.
  • Accidentally passing wind.[24]
  • Pain in your lower back that cannot be explained by other causes.[24]
  • Pain in the testicles, penis (referred pain from the pelvic floor) or pelvis during intercourse.[22]
  • Erectile dysfunction.[22][25][23]
  • Painful ejaculation.[22][25][23]
  • Premature ejaculation. [22][25]

Erectile function requires contraction of the pelvic floor muscles to block blood from leaving the penis. When the muscles are weak the outflow of blood from the penis is not stopped resulting in erectile dysfunction. Through learning voluntary control of the pelvic floor muscles this can help prevent premature ejaculation by learning how to relax and contract the muscles.[27] Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscles can cause leaking and dribbling.[28]

Women

  • Pain or numbness during intercourse.[24][21][23]
  • Ongoing pain in your pelvic region, genitals or rectum.
  • A prolapse – may be felt as a bulge in the vagina (feeling or seeing a bulge or lump in or coming out of your vagina) or a feeling of heaviness, discomfort, pulling, dragging or dropping sensation.[24]
  • Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence).[23][26]
  • Feelings of urgency in needing to the bathroom, or not making it there in time.[26]
  • Frequent need to urinate.[24][26]
  • Difficulty emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.[24][26]
  • The feeling of needing to have several bowel movements during a short period of time.
  • Constipation or bowel strains.[21]
  • Accidentally passing wind.[24]
  • Pain in your lower back that cannot be explained by other causes.[24]

Prolapse is a common condition that can occur due to weak pelvic floor muscles in women. This occurs due to the womb, bladder, bowel or top of the vagina moving out of their normal positions and pushing into the vagina. This can cause pain and discomfort but can be improved with pelvic floor exercises and lifestyle changes [29]. Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscles can cause leaking and dribbling.[28]

Does Pelvic Floor Muscle Training Work?

The simple answer is yes but some people really struggle to commit to pelvic floor exercises due to the absence of noticeable benefit, making some feel that pelvic floor muscle training is a waste of time.[30][31] Some woman find pelvic floor exercises tedious, a daily battle and downright boring[31]

Finding the appropriate yet explicit language to explain a pelvic floor contraction is not an easy task. Exercising muscles that cannot be seen, that are located in a private area of the body and associated with private function are not easily discussed. Hence, the mystery that surrounds pelvic floor muscle training. A study was conducted to evaluate healthcare professionals' ability to explain a pelvic floor muscle contraction. One patient involved in this study described the explanation given as "sketchy and confusing [31]. Difficulty grasping this technique has been a cause of embarrassment for women as they struggle to engage the pelvic floor muscles correctly![31]. In an attempt to contract the pelvic floor muscle, some common errors are made[30]. Contraction of other muscles such as the rectus abdominus (tummy muscle) glutes (bottom muscles) and adductors (inner thigh muscles) instead of the true internal pelvic floor muscles.[30] Also, compensatory movements such as pelvic tilts, breath-holding, and straining can give the illusion of a pelvic floor contraction[30]. In fact, this study found that 57% of woman incorrectly use other movements when attempting to contract the pelvic floor [30]

Prolapse, Incontinence, and Leaking, Only Affects Females, Right?

Men are from Mars and woman are from Venus, as the saying goes. Maybe in some respects yes! But, when it comes to the pelvic floor muscle, we all originate from the same planet! Meaning, regardless of gender pelvic floor muscle training is essential for both men and woman.[32] Prolapse, incontinence and leakage are widely believed to be a female issue[32], but Males are not exempt from pelvic floor muscle training, as the same risks apply. Studies conducted found that nearly 66% of men are unaware that males are required to do pelvic floor muscle training[32]. There is a general under-reporting of symptoms within the male population when it comes to the telltale signs that all is not well in the land of the pelvic floor, stigma, embarrassment and the discomfort associated with discussing this issue prevents a lot of males reporting these symptoms[32]. The body of evidence in this area is largely within the female population[32], there is a lack of research investigating the male experience of pelvic floor muscle training.

Risk Factors

The chances of developing pelvic floor dysfunction among men and women have increased over the past few years. According to Berghmans et al. (2015)[33] this trend is likely to continue. The incidence of pelvic floor problems is predicted to increase by 35% between 2010-2030 [34].

These statistics emphasize the importance of expanding knowledge related to the risk factors for pelvic floor dysfunction. When assessing a patient, physiotherapists should focus on a detailed subjective examination including past medical history and presenting condition/complaint, as this may reveal potential predispositions. Goal-centered conversations with the patients can provide guidance in planning treatment, and where applicable, liaising with appropriate healthcare professionals to ensure a holistic approach to care.

Men

  • Prostate surgery: In general, scientific literature examining pelvic floor dysfunction among males is limited. However, prostate surgery has been identified as a potential risk factor [35][36]. Specific pelvic floor disorders include urinary incontinence and erectile dysfunction, which are quite common post-operatively (up to 89% of men suffer from these conditions)[37]. Individuals who undergo this procedure may experience disturbance in pelvic floor muscles (especially urinary sphincters) and altered nerve supply to the area. In prostatectomy, the prostate (partially regulating continence) is removed, increasing the probability of incontinence. The urinary sphincter nerves may occasionally be damaged during surgery due to their proximity to the prostate. As a result, the patients might later experience poor bladder control[38]. Cavernous nerves, which are responsible for erectile function, may also be disrupted[39].

Women

  • Age: Females experiencing menopause are at increased risk for developing pelvic organ prolapse by 21.1%[40]. Wu et al. (2014)[41] assessed the relationship between age and number of pelvic floor disorders. They revealed that with each decade, the risk dramatically increased. This is most likely due to the hormonal fluctuations which change the functioning of female urogenital structures. It includes weakening of the pelvic floor, as the muscle mass tends to decrease during aging [42].
  • Direct injury to levator ani (ex. vaginal delivery, fall on groin) and loss of tone in pelvic muscles: This involves the levator ani changing position and widening of genital hiatus, causing the pelvic structures to rely on the connective tissue for support. Over time, this alteration results in weakening or tearing of the tissue/collagen and may contribute to the occurrence of pelvic organ prolapse [43].
  • Pregnancy and the nature of childbirth: Overstretching/damaging of the pudendal nerve during vaginal birth, prolonged labour, instrumental (forceps) delivery,episiotomy (surgical procedure to increase opening in vagina), weight and number of children (parity) have also been known to increase the pelvic floor dysfunction risk by 4-16%[40][43][44]. These findings have been supported through biomechanical models of the pelvic floor. The researchers revealed that during the crowning of the fetal head in a vaginal birth, there is a greater risk for the avulsion of levator ani leading to a potential prolapse. Additionally, an episiotomy has been suggested to increase anal lacerations and therefore, incontinence risk [44]. Findings within the systematic review noted parity to be a risk factor for primary pelvic organ prolapse as well[40].
  • Genetics: Women who have a positive family history of pelvic organ prolapse, are more likely to inherit the condition[45]. Campneau et al. (2011)[46] showed that the risk for pelvic organ prolapse increased 1.4 times in the genetically predisposed group, after controlling for vaginal deliveries, hysterectomy, and incontinence. Additionally, some evidence suggests that in females who are experiencing urinary incontinence, the connective tissue of the pelvic floor muscles may be genetically weak[47][48].
  • Low socioeconomic status: This factor, especially among racial minorities, may contribute to poorer access to adequate information regarding pelvic floor dysfunction[41] [43]. The lack of resources create a challenge in recognizing the symptoms and importance of seeking professional support in a timely manner. Hartigan and Smith (2018)[49], presented that women of poorer socioeconomic status scored lower on the incontinence quiz than their higher socioeconomic status counterparts. Consequently, there is a strong emphasis on public education to reduce the risk of pelvic floor dysfunction.
  • Hysterectomy (surgical removal of the uterus): This procedure often damages and weakens the pelvic muscles. Therefore, it may be a predisposing factor for pelvic organ prolapse [41][50]. Lukanovic and Drazic (2010) suggest that that the incidence of postoperative complications after hysterectomy, including urinary and fecal incontinence was significantly higher in the group who undertook the surgery for vaginal prolapse compared to a control group with no diagnosis of prolapse[50]. Being middle-aged, as an additional factor to post-hysterectomy, increases the risk to 60% for developing urinary incontinence[51]

Both Genders

  • Previous trauma to the pelvic region (e.g. fall or pelvic radiotherapy): This is particularly common in less physically active men who underwent pelvic radiotherapy for prostate cancer. The side effects of the treatment, including decreased tone of pelvic floor muscles, are more prominent in this group of patients. As a result of the pelvic muscles weakening, men are more susceptible to experience erectile impairment and urinary incontinence symptoms[52]. In women, pelvic radiation, as suggested by Walters (2017)[53] has created an additional risk factor for urinary incontinence and for developing pelvic floor dysfunction symptoms. In order to assure quality of life and avoid many discomforts, men and women should require further screening to receive the optimal treatment.
  • Increased abdominal pressure: Chronic coughing (a symptom of chronic lung disease, smoking, hay fever) and frequent sneezing, have been shown to contribute to pelvic organ prolapse in women[43]. It has been related to overuse of pelvic floor muscles and ligaments supporting the pelvic organs that occur as the pressure increases within the abdomen. This weakens the anatomical structures and leads to pelvic organ prolapse [54]. For men, it usually presents as urinary incontinence. The frequent increase in intra-abdominal pressure can lead to the opening of the sphincter, despite the absence of bladder contraction[40].
  • Constipation/heavy lifting: Constipation is caused by the altered mechanics (incoordination) of the pelvic floor muscles and an increase in intra-abdominal pressure during attempted evacuation. These persistent conditions can lead to nerve damage and the appearance of pelvic floor dysfunction symptoms, such as fecal incontinence[55]. Occupations that require frequent heavy lifting, add pressure to the bladder and influence urinary incontinence in both genders[56]. Evidence also shows that women who perform prolonged heavy lifting, are 9.6 times more at risk of developing pelvic organ prolapse[48].
  • Prolonged vigorous physical exertion: Elite athletes, engaging in high impact sports (e.g. trampolining, running, gymnastics) compared to low impact sports (e.g. golf), have reported to experience an increase in abdominal pressure through overstretching/overloading of the pelvic floor muscles. Over time the strain and changes in the strength of pelvic floor muscles, have shown to be a  potential risk for urinary incontinence[47][48][57]. The implications were also suggested in a study that compared women training competitively on a weekly basis with a non-athletic group. The authors found that athletes were 2.5 times more likely to develop urinary incontinence than the non-athletic group[48].
  • Increased BMI (above 25)/Obesity: Being overweight as measured by BMI, was strongly associated with urinary incontinence symptoms in both genders as was true for pelvic organ prolapse in women, compared to those with normal BMI values (18.5-24.9)[40][47][52]. With every 5 unit increase in BMI, the urinary incontinence risk rises to 20-70%. This is because of the increased intra-abdominal pressure that adds vesical compression and urethral movement. The continued weakening of pelvic floor muscles, nerve supply, and supporting structures, contribute to ineffective function[58].
  • History of back pain: Low back pain has been noted to be closely related to pelvic floor muscle dysfunction. This is because the pelvic muscles have the role of providing stability for the lower back and bladder control continence. As a result, the discomfort experienced may cause individuals to avoid movement including the use of pelvic floor muscles. These muscles then become weak, unable to support the pelvic floor organs and alter urinary function. The researchers have found that due to pain levels in the low back, participants’ abilities to maximally contract the pelvic floor muscles were limited. Additionally, low back pain was attributed to loss of motor control in pelvic floor muscles, presenting as genito-urinary dysfunctions (i.e.urinary incontinence)[59].

The common risk factors for both males and females have been illustrated in the diagram below in yellow circles. Risks unique to each gender include blue circles for males and pink for females.

Risk factors related to the development of pelvic floor dysfunction in men and women.

Medical Management 

Pelvic floor dysfunction is a very treatable condition. Many ways exist to treat pelvic floor problems conservatively (non-surgical) and should generally be considered as the first-line option prior to more aggressive procedures such as surgery[60][61][62]. Treatment will vary according to the nature of the condition or reason behind the dysfunction.

Pharmacological (Medication)

  • Various drugs can be prescribed depending on the reason for the pelvic floor problems. Drug therapy is particularly common for urinary incontinence and will depend on the type of incontinence that your client is experiencing[62].
  • The ageing process can lead to hormonal changes which can negatively impact the pelvic floor muscles and lead to increased laxity/stretching. Therefore, hormone replacement therapies for post-menopausal women can be used to manage or improve the symptoms.
  • If your client has an over-active bladder or urge incontinence, there are medications to help relax the bladder and reduce the frequency of urination.[63]
  • Drug therapy is even more effective when used in combination with other strategies like pelvic floor exercises and lifestyle changes.[63]

For more information, see this NHS website.

Surgical

  • In some cases, when other strategies have been unsuccessful in achieving treatment goals, surgery may be the best treatment option. Depending on the specific condition, various procedures exist to address the problem.
  • Incontinence and prolapse have multiple types of procedures to alter the pelvic structures or insert supports such as synthetic mesh slings, both in the goal of improving functions.[64][65]
  • For those who have a pelvic floor disorder, 1 in 9 will undergo surgery, however, there are risks associated with surgery as they don't always succeed. Regarding synthetic mesh sling surgery, roughly 30% will require a second operation, and roughly 35% will need to be removed.[64]
  • Slightly less invasive options are also available, such as injections of Botox for urge incontinence or bulking agents to help reduce stress incontinence.[66]

For more information on bladder procedures, please visit this site.

For more information on urinary incontinence procedures, please visit this NHS website.

Physiotherapy Management

Education is the key and physiotherapists need to educate both male and female patients, on the function of the pelvic floor muscle[67]. Assist the patient to understand the function of the pelvic floor muscle and how exercising this muscle can strengthen and reduce the risk of unwanted symptoms. This can help achieve that all important “buy in” and encourage the patient to be consistent with pelvic floor muscle training [67]. However, explaining this can be tricky for any Physiotherapist due to the sensitivity of the subject! We have put together some tips that may be helpful to ensure a smooth, clear and lighthearted delivery!

  • The Internal hammock - Try referring to the pelvic floor muscle as “ a hammock “ or a “trampoline “ which lies on the floor of the pelvis and supports organs such as the womb, bladder, bowel. This can make the function of the pelvic floor muscle easier to understand! And plus, who doesn’t want to learn about their very own internal trampoline, right?!
  • Context is key! - Place emphasis on the strain that is put on the hammock or trampoline during everyday activities such as working, household duties, looking after family, exercising[68]. Apply this to the patients’ life, by discussing their occupation, pastimes, and family situation and how the pelvic floor muscle or “trampoline “ is at risk of being overstretched as a result. This will help the patient to add context.
  • Leaking waterworks?…. Time tighten up those taps! - Lack of bladder or bowel control can be a symptom of a weak pelvic floor and or a prolapse. [69]This is an opportunity to empower the patient and show them they can still take control of their situation, through pelvic floor muscle training[68]. Leaking, incontinence and increased urgency do not need to be tolerated! Ensure that the patient understands that there is an opportunity to tighten those taps right up! The only requirement is the right mindset and a top-notch spanner!
  • Rome was not built in a day people! - It is important that physiotherapists stress that pelvic floor muscle training takes time, effort and consistency. Improvements in continence status and or stages of prolapse will not improve overnight and may take up to 3 weeks for any improvement to be felt. [67]Be mindful of this and ensure that the patient is supported, as feelings of frustration may arise!
  • If there is an issue, here is a tissue! - Physiotherapists deal with more than just muscles, we deal with emotions! It is important to be mindful of the impact that incontinence, leaking and prolapse can have on patient quality of life[70]. Support, empathy, and compassion are an absolute necessity, to ensure the patient feels at ease. Listening to the patient and allowing them to tell you their concerns, hardships, and battles allow the patient to offload their worries and boost their feelings of self-efficacy as they begin their journey of self-management. Lending them your ear can be the greatest gift you can give.

The Correct Technique

Explaining a pelvic floor contraction is not an easy task! It is a difficult area, given the sensitivity of the subject that many patients feel uncomfortable with.[31] Also, it is very confusing.  Medical and anatomical terminology can leave patients feeling lost or too embarrassed to ask questions. It is vital that exercising this complicated internal muscle is described in a simple but clear manner. Here are some tips that may be helpful, or if you find any nuggets of gold in this feel free to use!

The Female Contraction

  • The pelvic floor muscle can be exercised in sitting standing or lying[67]. Many patients seem to prefer sitting and feel the muscle is easier to engage in this position. Advise the patient to try out different positions to find what best suits
  • In sitting, ensure both feet are placed on the floor and patient is relaxed and aware of their breathing. Encourage your patient to relax all muscles, including shoulders, abdominals, and glutes[23]. Take a few moments to become aware of the breathing pattern.
  • Ask the patient to imagine they are sitting on the toilet, having a wee. Ask them to then try and replicate the action of stopping the flow of urine mid-stream. Explain to them that this is a pelvic floor contraction involving the anterior muscles.[67]
  • Another handy example of a pelvic floor exercise is, again, ask the patient to imagine they are in a line waiting to pay for their shopping. They have been feeling bloated and the urge to pass wind has presented itself with full gusto! In order to hold that wind in it requires a contraction of the posterior pelvic floor muscles[67].
  • Ask the patient to imagine they are sitting on the toilet. Ask them to then try and replicate the action of stopping the flow of urine mid-stream AND trying to stop themselves from passing wind at the same time. This involves a combined pelvic floor contraction of both anterior and posterior muscles.[67]

Remember to remind your patients to never stop the flow of urine when actually going to the toilet as this may lead to difficulty in fully emptying the bladder in the long run!☃☃ This is simply a visualization technique that may be helpful. Ensure to remind the patient that pelvic floor exercises can be done anytime anyplace, not only when sitting on the toilet!

You can share the following videos with your client. They show how to exercise your pelvic floor (1 of 5).
[71]

[72]

[73]

[74]

The Male Contraction

Brrr. . . bet you'd wanna avoid that cold water! Pelvic floor exercises mimic this natural action [75]
The process is a little different for men and it is important to be aware of the differences so that you can teach them the exercises effectively.
  • The pelvic floor muscle can be exercised in sitting standing or lying. Some people may prefer doing it in sitting because they feel the muscle is easier to engage in this position. Try each position and see what works for you.
  • From sitting, ensure both feet are placed on the floor and you are relaxed and aware of their breathing. Try to relax all muscles, including shoulders, tummy and buttock muscles. Take a few moments to become aware of breathing pattern.
  • For men to engage their pelvic floor muscles, 'lifting and squeezing' as if trying to stop from passing gas or stop while urinating holds true. Men may also think of the sensation they get when walking into a cold lake or pool: when the water gets up to the level of their 'family jewels'. This sensation is the pelvic floor activating!

Watch the video below for another explanation to exercise the male pelvic floor:

For extra reading click on the following links:

Points To Consider

Holds, repetitions and frequency - Pelvic floor exercises are divided up into short hold contractions and long hold contractions. Both are equally important for correct training and optimal function of the pelvic floor muscle:[67]

Short holds- Ask the patient to hold the pelvic floor contraction (visualising that feeling of stopping the flow of urine suddenly and holding in wind at the same time) This is an on/off contraction, for example, squeeze – release squeeze – release squeeze – release.  8-10 repetitions are advised, to begin with, Encourage the patient to increase the number of repetitions each week, to continuously challenge the pelvic floor muscle [24]

Short holds or short contractions train the fast-twitch fibers within the pelvic floor muscle to react quickly to those spontaneous movements such as coughing, sneezing, and laughing[67]. These fibers kick into action quickly to prevent any embarrassing accidents or leaks from the waterworks. Training the pelvic floor muscle with these short and fast contractions can help keep these fibers on their toes!

Long holds –  Ask the patient to contract the pelvic floor muscle (Again visualizing the feeling of stopping the flow of urine suddenly and holding in wind), but holding this contraction for as long as possible, to begin with. This is difficult, but it will establish a starting point or baseline, Repeat this exercise 3-5 times. Encourage the patient to challenge themselves, and aim to increase the length of hold each week[24].

Did someone mention context? Coming right up!

Longer holds or long contractions of the pelvic floor muscle train the pelvic floor function in a different way to short holds. This type of training strategy is aimed at the slow-twitch fibers within the pelvic floor, which are responsible for strength and endurance[67]. This ensures that the internal trampoline remains firm, tight and in the correct position to keep all our internal organs exactly where they should be!

Frequency

Pelvic floor muscle training should be done as many times as possible daily[76]. However, due to the silent and hidden nature of this exercise, it can be difficult to remember! Try to help the patient establish a routine that is specific and suitable to their lifestyle[68]. This will assist to incorporate pelvic floor exercises into their daily routine. For example, try asking the patient to stick a post-it by the mirror in their bathroom. Use this as a reminder to do their pelvic floor exercises while brushing their teeth, shaving, putting on make-up. Again, that same post-it may remind the patient to repeat these exercises during their nighttime routine brushing teeth, flossing, combing hair. . . The possibilities are endless!

Am I really exercising my pelvic floor?

If the patient is unsure that the pelvic floor muscle is being exercised correctly, advise the patient to placing their thumb into the vagina and then repeat the exercise. The patient should be able to feel a gentle squeeze as the pelvic floor muscle contracts if done correctly[30].

The Knack Technique –   Get Involved People!

The knack technique can help to support pelvic floor health! Pressure builds up in the abdomen when lifting, exercising, coughing, sneezing laughing, lifting weights, turning to look out your rear window when driving. Basically, in pretty much everything we do! This creates a downward force or pressure on the pelvic floor muscles when can lead to our beloved internal “trampoline “ becoming stretched or lax[48]. The knack technique involves contracting the pelvic floor muscle, before lifting, bending, sneezing, coughing, or any movement you can think of that will increase abdominal pressure. This is a supportive measure that can help maintain and support pelvic health[48].

The knack technique offers many benefits and can help patient's become more involved in their pelvic health. Add context to this, go through patient activities of daily living, pastimes, family and suggest situations in which the knack technique can be useful. For example, lifting heavy shopping onto the kitchen counter, reminding the patient to contract the pelvic floor before lifting the bags, or contract the pelvic floor before lifting your 2-year-old teething toddler.

Lifestyle Advice -  Looking at the Bigger Picture!

Some patients may be experiencing urinary frequency, incontinence or leakage. Try discussing these tips with patients, which may help reduce symptoms and improve quality of life.

  • Keeping a fluid diary[77] – Logging fluid volumes and timings of fluids over a 3 or 4 day period can help patient identify triggers that may increase urinary symptoms. Make suggestions such as reducing caffeine intake, using more decaf or herbal teas, reducing fluid intake after 6 pm, Try sticking to water and aiming to consume consuming glasses daily may help. These simple amendments may help reduce symptoms, urgency or even improve sleep.
  • Bladder training – Keeping a bladder diary[78], this can highlight frequency of urination and can help the patient to recognize patterns or trends in their routine. If urinary frequency is the issue, try encouraging the patient to hold that urge to pass urine for 10 to 20 seconds before going to the toilet. Encourage them to increase the length of hold each week. It is possible to retrain the bladder, so plant this seed and encourage the patient to take ownership of this! Also, try to encourage patients to avoid “going to the bathroom just in case [78]”. Only go to the bathroom when needed! This habit may create poor habits for the bladder in the long run.
  • Distraction - The need to pass urine so frequently can really be debilitating and limiting for a patient. Try to encourage distraction techniques, such as meditation, listening to music, reading or painting for example[77]. Try to find an interest-specific for the patient and encourage the use of this distraction technique to avoid running toilet runs and promote bladder retraining.

Constipation – Is there anything more uncomfortable? Pelvic health issues can impact negatively on bowel function [67]This can lead to constipation, or sometimes the opposite. Depending on the underlying cause of a bowel malfunction relating to the pelvic floor muscle, Physiotherapists can advise on how to manage these symptoms: For example..

  • Feeling clogged up-? Advise using milled linseed and flaxseed, in smoothies, porridge, soup or whatever takes your fancy[79]! Simple dietary advice such as improving fiber intake, with fruits and vegetables. Promote wholegrain foods such as pasta and wholemeal bread that can promote peristalsis within the bowel and increase movement[79]. Educate regarding movement or simple exercise and the positive effect this can have on bowel movements.
  • Eat less and move more! Discuss the implications a high BMI can have on the pelvic floor muscle. Extra weight puts a strain on your pelvic floor muscles and can increase the likelihood of complications.[67]
  • Whenever, wherever! Encourage the patient to be consistent with pelvic floor exercises to prevent a problem, but also to ensure that the problem does not return. And remember, these exercises can be done, whenever wherever. Ensure the patient understands this, as often patients are concerned that those around them can tell!

Evidence for Physiotherapy

Physiotherapy is the first line of treatment for those who are diagnosed with a form of pelvic floor dysfunction. Although the literature in this area is limited, there is some evidence highlighting the importance of physiotherapy. The research has mainly focused on the role that physiotherapists can play through education on lifestyle modifications and through exercise prescription. Evidence which was identified for both of these areas is summarised below.

Lifestyle

  • Weight loss is associated with improvements in urinary incontinence (UI), particularly when combined with exercise[2].
  • Strenuous activity or heavy lifting may be a predisposing factor for prolapse. There is limited evidence to support this and recommendations appear to be based on an understanding of the anatomy and physiology of prolapse[80].
  • Some evidence suggests that decreasing fluid intake by 25% may decrease frequency, urgency and nocturia but may not improve incontinence[2].
  • Caffeine reduction has been suggested to alleviate incontinence. However, the evidence for this is limited. A review by Gurovich et al. (2016) found that caffeine restriction did not improve urinary incontinence symptoms[81]. Other evidence from Gleeson et al. (2013) suggests that urinary incontinence is more prevalent in those with high caffeine intake[82]. Reducing caffeine intake may reduce overall fluid intake which may be the mechanism leading to improved symptoms. For this reason, reducing caffeine may be useful.
  • The NICE guidelines recommend a trial of caffeine reduction in women with overactive bladder, to trial higher or lower fluid intake in women with UI or overactive bladder and recommend losing weight if BMI is over 30[83].

Exercise

  • Pelvic floor muscle training (PFMT) has been shown to be beneficial for both urinary incontinence and prolapse symptoms. A randomised control trial in adult women with pelvic floor dysfunctions suggests that using an intravaginal vibratory stimulus( IVVS) helps in improving the pelvic floor muscle strength as compared to intravaginal electrical stimulation (IVES)[84]. Findings from a review by Dumoulin et al. (2015) suggest that pelvic floor muscle training provides better outcomes compared to a control group in women with urinary incontinence. Li et al. (2016) found that those with pelvic organ prolapse undertaking pelvic floor muscle training had significantly greater improvements in subjective prolapse symptoms and objective prolapse severity compared to a control group[85].
  • Pelvic floor training also seems to improve sexual function. The findings from a review by Ferreira et al. (2015) suggest that pelvic floor muscle training can improve sexual function or at least one sexual variable in women with pelvic floor dysfunction[86].
  • Interesting findings from two RCTs also corroborate the evidence for pelvic floor muscle training[87][4]. Alves et al. (2015) found that twelve group sessions of pelvic floor muscle training increased pelvic floor muscle contractility (p = 0.01) while decreasing urinary symptoms (p < 0.01) and anterior pelvic organ prolapse (p = 0.03)[87]. Hagen et al. (2014) found similar results with one to one sessions[4]. They did note that longer-term investigations are required to strengthen the evidence.
  • When prescribing a pelvic floor muscle training programme, adherence is important. According to a consensus statement by Dumoulin et al. (2015), a structured PFMT programme, an enthusiastic physiotherapist, audio prompts, use of established theories of behavior change, and user-consultations seem to increase adherence[88].
  • The identified evidence fails to make any recommendations on the optimal dosage of pelvic floor muscle training.
  • The NICE guidelines recommend a trial supervised PFMT programme for at least 3 months as first-line treatment for those with stress or urinary incontinence.[83]At least 8 contractions three times a day[83].

Synthesis

  • Overall, the body of evidence for lifestyle modifications appears to be quite weak and the overall efficacy remains inconclusive. It seems that adjusting fluid intake may be a useful strategy and reducing caffeine intake may help to achieve this. Some evidence also supports weight loss but the justification for its use seems to be largely based on mechanistic evidence. It is worth noting that no adverse events were associated with any of the above methods and so they may be worth incorporating as a trial to gauge the patients response. Currently, the NICE guidelines seem to be the best practice to follow here.
  • The evidence for pelvic floor muscle training shows largely positive results. This seems to be an effective strategy for prolapse and urinary incontinence symptoms and for sexual function. Both group and individual sessions have been efficacious and may depend on the patients personal preference. For optimal adherence, the physiotherapist should be enthusiastic, could consider using prompts to help with technique, understand and utilise behaviour change techniques and consult regularly with their patients. Currently, the dosage of therapy is not well established. However, the NICE recommendations of 8 contractions three times a day seems to be effective and was commonly used in the research.

Conclusion

It has been recognised that the incidence of pelvic floor dysfunction is rising globally and is expected to increase by 35% by 2030 [34]. Therefore, physiotherapists and other healthcare professionals, have a growing role in recognising pelvic floor issues in patients and implementing individualised treatments. The role physiotherapists play in treating pelvic floor dysfunction can be life-changing to patients!

It is important to empower patients in seeking advice and treatment for pelvic floor dysfunction, in addition to managing their condition in the long term. While the subject of pelvic floor health is not a new concept to the physiotherapy profession, the awareness of the public to seek help is still requiring further work. With advancements in healthcare, the ageing population is living with more comorbidities such as cancer, obesity, and stroke[89] which impacts on their quality of life[89]. Poor lifestyle choices (ex. poor diet and sedentary behaviour) are contributing to these comorbidities[89]. Furthermore, these conditions have been found to correlate with pelvic floor dysfunction[90] [91][92]. As the incidence figures for individuals living with comorbidities are projected to rise in the future, this could also cause pelvic floor dysfunction to become more common[33]. Therefore, the increased involvement of physiotherapists in this area could increase accessibility to services and broaden the spectrum of treatments available to physiotherapists and their patients. Additionally, this has the potential to alleviate some of the financial burden placed upon the healthcare service by the increasing prevalence of pelvic floor dysfunction.

Resources

Information on the pelvic floor and pelvic floor exercises: Female information leaflet. Male information leaflet

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