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Pelvic Floor Dysfunction and Cancer Treatment

Original Editor - Laura Ritchie, posting on behalf of Lily Xiong, MPT Class of 2021 at Western University, project for PT9585.

Top Contributors - Halah Abou Nouh, Laura Ritchie, Temitope Olowoyeye, Sehriban Ozmen, Kim Jackson, Khloud Shreif, Kirenga Bamurange Liliane and Nupur Smit Shah

Introduction

The pelvic floor (PF) is a dome-shaped structure that extends from the pubic bone to the tailbone. It provides several key functions, which can be summarised by the "4S” acronym[1]:

  1. Support of pelvic organs (bladder, bowel; female: uterus and vaginal canal; men: prostate).
  2. Sphincteric control and relaxation for continence and urination/defecation, respectively.
  3. Sexual superficial muscles of PF support clitoral and penile erection and arousal.
  4. Stabilisation of hip, pelvis, and lumbar spine.

Pelvic Floor Muscles (PFM) & Sexual Structural Differences

Understanding the structural differences between male and female pelvic floor and corresponding musculature is key to understand the oncological and treatment implications on the pelvic floor. As the primary cancer site, the surgical impact, the radiation effect on different tissue types and muscular vulnerability differences, act as major factors to the consequences on pelvic health and pelvic floor integrity.

Pelvic Floor Muscles (PFM) Dysfunction and Pelvic Floor Disorders (PFD)

PFM dysfunction refers to impaired coordination, relaxation, strength, or control of the pelvic floor musculature, which may disrupt normal urinary, bowel, and sexual function. PFM dysfunction may contribute to or coexist with several forms of Pelvic floor disorders (PFD) comprise a broader spectrum of structural and functional pelvic floor abnormalities, including urinary or fecal incontinence, pelvic organ prolapse, chronic pelvic pain, defecatory dysfunction, and sexual dysfunction. This can significantly affect quality of life and daily functioning.[2][3]

Oncology & Pelvic Floor

Cancer and oncological treatments, including surgery, radiotherapy, chemotherapy, and hormonal therapy, may adversely affect pelvic floor muscle function and contribute to the development or progression of pelvic floor disorders (PFD).[4][5][6][7]

Prevalence

PFD are underrecognized yet common and disabling complications in women treated for gynecologic cancers.[4] The prevalence of PFD in women gained a great attention in the literature, with a noticed prevelance of sexual dysfunction. In a metanalysis after cervical cancer, it was concluded that sexual dysfunction affects nearly half of the survivor population, while urinary issues affect roughly one in three.[8] Another evidence indicates a profound link between oncological history and sexual health, with the incidence of female sexual dysfunction affecting between 30% and 80% of women with cancer. When compared to the general population, cancer survivors face a 2.7 to 3.5 times higher risk of experiencing sexual health issues.[9] The prevalence was also noted in other another review where post-cancer sexual dysfunction affects an estimated 33% to 43% of women, though reporting suggests the incidence can reach as high as 85%. The most prevalent clinical symptoms are loss of libido (38–95%), vaginal dryness (22–88%), and painful intercourse (17–65%). Furthermore, quality of life and sexual health are negatively impacted by bowel dysfunction and body image issues.[10] Sexual dysfunction is exceptionally common among women with breast cancer, with the highest prevalence seen during the initial year following their diagnosis and treatment.[11] A review of seven studies on Arab female cancer survivors found a pooled sexual dysfunction prevalence of 51% (ranging from 16.7% to 67%). The most frequently reported issues were dyspareunia (22.2% to 65%) and vaginal dryness (19.8% to 54.2%), while erectile dysfunction in partners was also a significant concern, ranging from 38% to 61%. Notably, many survivors highlighted a significant gap in communication and a lack of information regarding sexuality from their healthcare providers.[12] Complex surgeries for colorectal cancer, such as pelvic exenteration, often result in severe sexual dysfunction regardless of whether vaginal reconstruction is performed. Similarly, patients treated for breast cancer face high rates of sexual dysfunction driven by mastectomies, adjuvant treatments, and body image dissatisfaction. Across both groups, a critical lack of professional sexual counseling and long-term data remains a significant barrier to patient care. [13]

Moreover, research shows that treating pelvic cancers with radiotherapy frequently leads to urinary incontinence (UI) and symptoms of overactive bladder. While the data on bowel and sexual health varies across patient groups, research indicates that defecatory urgency tends to worsen as time passes.[14]

Research in male populations is scarce. Data is currently limited to prostate cancer, neglecting the sexual health needs of men with other genitourinary malignancies. Survival and urinary continence rates are excellent, but erectile dysfunction remains a high-risk side effect with inconsistent outcomes, where male patients face significant psychological hurdles, such as embarrassment and a systemic lack of access to sexual health interventions.[15][16]

Oncological Treatments Implications

Individuals with bladder or anal cancer, women with gynaecological cancers (endometrial, ovarian, cervical, vulvar, and vaginal), and men with prostate cancer and penile cancer can all experience PFD. Penile cancer is uncommon, affecting less than 1 in 100,000 men in the U.S. and leading to roughly 2,200 new cases and 440 deaths annually. Survival rates are low, highlighting the need for specialised, multidisciplinary oncological treatment approaches.[17]

Oncological surgical procedures can affect the pelvic floor depending on the tumor size, location, and stage. Surgical procedures within the pelvic region can cause damage to the muscles and other structures of the pelvic floor.[18] Moreover, surgical procedures can affect pelvic floor musculature indirectly, such as through hormonal mechanisms after oophorectomies. More specifically, common surgical procedures that affect the PFM include:

  1. Tumor debulking (removal of cancerous tissue)
  2. Hysterectomy (extraction of uterus)
  3. Salpingo-oophorectomy (removal of ovaries and fallopian tubes)

Adjuvant therapies like chemotherapy and radiation may also impact the pelvic floor. Radiation (external beam or internal brachytherapy) during cancer therapy can lead to fibrosis of the pelvic floor musculature, which may lead to shortening or narrowing of the vaginal canal in women.[19] This same fibrosis of the pelvic floor (men and women) and the vaginal canal (women) can lead to incontinence and/or urgency of the bowel and bladder, pelvic pain, and sexual dysfunction. According to the above studies mentioned in the prevalence section, on effects on pelvic floor musculature after surgeries and adjuvant therapies in patients with gynaecologic cancer, there was an increase in reports of lower libido, changes in sexual response, altered body image, and distress related to sexual health.[8][9][10][11][13][12]

In addition, the extraction of pelvic lymph nodes can also lead to lymphedema, or chronic swelling in the abdomen, genitals, and legs. Genital lymphedema in the pelvic region can impact bladder function and sexual wellness.[20][21]

Despite the abundance of studies and evidence presented on cancer treatment’s effect on pelvic floor health, the degree of these treatment effects varies on a case -by- case basis. Some patients will have no PFD symptoms, and some may have mild to severe symptoms immediately after treatment or develop overtime.

Physiotherapy Management

A holistic approach is essential for oncological populations, especially those with pelvic floor complications, with physiotherapy serving as the primary driver for addressing both physical health and the neglected personal concerns. By integrating a detailed assessment, a specialized rehabilitation program including pelvic floor strengthening and coordination, and comprehensive education, physiotherapy provides a synchronized framework to resolve patient issues—particularly those that have been previously ignored or dismissed as a "normal" side effect of cancer. This proactive model ensures that patients receive structured support for complications they might otherwise feel too embarrassed or discouraged to discuss.

Assessment

Subjective History Taking:

This involves sitting down with the patient and taking an extensive history of the pain, symptoms, bowel and bladder functions, diet composition, biopsychosocial factors, occupation, stress levels, pregnancy history, trauma, medications, etc.

Objective Examination:

  1. Postural examination: in both standing and sitting as posture changes, skeletal alignment will affect the length and tension of PFM. Addressing postural misalignments, habits, relaxing, stretching tight muscles, and strengthening weak muscles can directly change PFM function.
  2. Movement analysis looks at the quality of movements and whether patients exhibit movement pattern impairments. For example, if a mother gets incontinence whenever she picks her kid’s toy off the floor, the therapist will ask her to mimic picking of a toy off the floor and address her movement pattern dysfunction through teaching proper squatting or lifting techniques.
  3. Orthopedic assessment: as a specialized branch of physiotherapy, PF physiotherapist will also look at the patient’s spine, sacroiliac joints, hip joints, rib cage and analyze breathing patterns before the internal exam is done.
  4. Pelvic floor assessment: includes an external and internal examination of the vagina and/or rectum. The external examination usually includes a skin and external musculature examination of the perineum, for issues like skin irritation and external PFM atrophy/asymmetry. The perineum is examined for any prolapse (vaginally or rectally). For the internal assessment, the PFM’s strength, length, and quality are evaluated. The internal assessment also includes trigger points and tension examinations.

Treatment Program Development

The right PF physiotherapy can entirely decrease or eliminate symptoms of PFD. In addition to education, PF physiotherapy includes a combination of pelvic floor muscle training, exercise (PFM and core), manual therapy, and biofeedback PFM training are techniques used to strengthen and restore normal function of the PFM.

  1. Patient education is crucial in PF physiotherapy, as many patients have gone through ringer prior to adressing therapy. Frustration, depression, and helplessness are common mental health findings when patients start the process of PF physiotherapy.
  2. Treatment ProgramsPF physiotheray intervention/treatment includes:
    • Trigger point release to PFM
    • Joint mobilization for: hips, coccyx, lumbar or thoracic spine
    • Muscle energy techniques
    • PFM re-education (manual feedback, electrical stimulation)
    • Biofeedback: to assist in relaxation of the PFM or contraction/strengthening of PF
  3. Developing a standardized framework is currently hampered by a lack of published clinical guidelines and the vast diversity of oncological populations, ranging from direct pelvic malignancies to non-pelvic cancers that cause secondary pelvic complications. [4][5][6][7] Consequently, an effective practice guideline must be highly individualized, accounting for the specific cancer site, the presence of lymphedema, and the distinct nature of tissue damage, distinguishing between surgical fibrosis and radiation-induced fibrosis. Furthermore, treatment must target the specific manifestation of pelvic floor dysfunction, whether it is sexual, muscular, urinary, or colorectal in nature. Given these complexities, the most robust clinical approach involves extracting evidence from similar cohorts in the literature and tailoring those findings to the unique presentation of the individual patient.

Education

Physiotherapists play a key role in educating both male and female individuals with cancers or previously treated for cancer regarding the effects of oncological treatment on PFM function and health. This will encourage patients to “buy in” to active PFM rehabilitation to address PFD and unwanted symptoms. Education regarding the PFM can be sensitive, so below are some tips for patient education for Pysiotherapists:

  1. The "Internal Hammock": Describe the PFM as a supportive structure for the pelvic organs, grounding the explanation in the context of the patient's daily life, such as their hobbies, career, or fitness routine.
  2. "Tightening the Tap": Use this simple analogy to help patients visualize the control needed to manage urinary leakage and incontinence.
  3. "If there is an issue, there is a tissue": This mantra reminds therapists to look beyond just muscle physiology but to incorporate the biopsychosocial aspect of the patient that may impact or be impacted by PFD.
  4. Habit Modification: Provide structured education on healthy bowel and bladder behaviors to complement physical training.
  5. Support the patient through regaining confidence in their bodies and improve their body image, fostering a mental environment where the healing process can truly take hold. By validating the patient's experiences and addressing the psychological impact of physical changes, the therapist helps bridge the gap between functional recovery and emotional well-being.

Occupational Therapy Management

Alongside physiotherapy, Occupational therapy (OT) play a significant role in oncology by addressing the physical, emotional, cognitive, and psychosocial challenges that individuals with cancer and their families face throughout their cancer journey. While both services may have similar goals to improve the overall quality of life and function of patients, there may be different approaches taken to accomplish them.

Physiotherapy addresses impairments causing functional limitations, while oncological OT aims to enable patients to achieve maximum functional performance in daily living skills, regardless of their life expectancy, both physically and psychologically.[22]

OT starts by evaluating an individual's physical, cognitive, and emotional abilities, daily routines, and roles, and collaborating with the patient to set personalized goals to maintain or improve their functional independence and quality of life.

Cancer side effects like fatigue, pain, weakness, cognitive difficulties, anxiety, depression, and impaired self-esteem can be addressed through interventions aimed at restoring function, modifying activities, and adjusting environments. The Scope of Practice for Occupational Therapy includes activities of daily living (ADLs), education, and instrumental activities of daily living (IADLs), which include self-care activities, learning, and multistep care for self and others, such as household management, financial management, and childcare.[22]

References

  1. ↑ Afolabi I. Overview of Female Pelvic Floor Muscle Anatomy and Physiology Course. Plus , 2021.
  2. ↑ Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, Monga A, Petri E, Rizk DE, Sand PK, Schaer GN; International Urogynecological Association; International Continence Society. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn. 2010;29(1):4-20. doi: 10.1002/nau.20798. PMID: 19941278.
  3. ↑ Doumouchtsis, S.K., de Tayrac, R., Lee, J. et al. An International Continence Society (ICS)/ International Urogynecological Association (IUGA) joint report on the terminology for the assessment and management of obstetric pelvic floor disorders. Int Urogynecol J 34, 1–42 (2023). https://doi.org/10.1007/s00192-022-05397-x
  4. ↑ 4.0 4.1 4.2 Kurtuluş D, Arkan K, Suçeken FY, Akgöl S, Can B, Behram M. Pelvic Floor Dysfunction Following Gynecologic Cancer Surgery and Adjuvant Therapy: Epidemiology, Mechanisms, and Management-A Systematic Review. Int Urogynecol J. 2026 Jan 24. doi: 10.1007/s00192-026-06522-w. Epub ahead of print. PMID: 41579191.
  5. ↑ 5.0 5.1 Pérez, C.D.A., Rocha, A.K.L., Volpato, M.P. et al. Prevalence of Pelvic Floor Dysfunction in Women After Pelvic Radiotherapy: Systematic Review and Meta-Analysis. Int Urogynecol J (2026). https://doi.org/10.1007/s00192-026-06557-z
  6. ↑ 6.0 6.1 Pérez, C.D.A., Rocha, A.K.L., Volpato, M.P. et al. Prevalence of Pelvic Floor Dysfunction in Women After Pelvic Radiotherapy: Systematic Review and Meta-Analysis. Int Urogynecol J (2026). https://doi.org/10.1007/s00192-026-06557-z
  7. ↑ 7.0 7.1 Cyr, MP., Jones, T., Brennen, R. et al. Effectiveness of Pelvic Floor Muscle and Education-Based Therapies on Bladder, Bowel, Vaginal, Sexual, Psychological Function, Quality of Life, and Pelvic Floor Muscle Function in Females Treated for Gynecological Cancer: A Systematic Review. Curr Oncol Rep 26, 1293–1320 (2024). https://doi.org/10.1007/s11912-024-01586-7
  8. ↑ 8.0 8.1 Shan X, Qian M, Wang L, Liu X. Prevalence of pelvic floor dysfunction and sexual dysfunction in cervical cancer survivors: a systematic review and meta-analysis. Int Urogynecol J. 2023 Mar;34(3):655-664. doi: 10.1007/s00192-022-05326-y. Epub 2022 Aug 24. PMID: 36001098.
  9. ↑ 9.0 9.1 Sousa Rodrigues Guedes T, Barbosa Otoni Gonçalves Guedes M, de Castro Santana R, Costa da Silva JF, Almeida Gomes Dantas A, Ochandorena-Acha M, Terradas-Monllor M, Jerez-Roig J, Bezerra de Souza DL. Sexual Dysfunction in Women with Cancer: A Systematic Review of Longitudinal Studies. Int J Environ Res Public Health. 2022 Sep 21;19(19):11921. doi: 10.3390/ijerph191911921. PMID: 36231221; PMCID: PMC9564951.
  10. ↑ 10.0 10.1 Mejia-Gomez J, Petrovic I, Doherty M, Kennedy E, Wolfman W, Jacobson M, Brezden C, Philippopoulos E, Lukovic J. Sexual dysfunction in female patients with anal cancer treated with curative intent: A systematic review of the literature. Radiother Oncol. 2023 Jan;178:109437. doi: 10.1016/j.radonc.2022.109437. Epub 2022 Dec 5. PMID: 36481383.
  11. ↑ 11.0 11.1 Rodrigues-Machado N, Bonfill-Cosp X, Quintana MJ, Santero M, Bártolo A, Olid AS. Sexual dysfunction in women with breast cancer: a systematic review. Support Care Cancer. 2025 Mar 31;33(4):332. doi: 10.1007/s00520-025-09352-6. PMID: 40163251; PMCID: PMC11958476.
  12. ↑ 12.0 12.1 Alananzeh I, Green H, Meedya S, Chan A, Chang HCR, Yan Z, Fernandez R. Sexual activity and cancer: A systematic review of prevalence, predictors and information needs among female Arab cancer survivors. Eur J Cancer Care (Engl). 2022 Nov;31(6):e13644. doi: 10.1111/ecc.13644. Epub 2022 Jul 11. PMID: 35816027; PMCID: PMC9786682.
  13. ↑ 13.0 13.1 Liu Y, Sun D, Wen Y, Zhao H, Long Y, Yu Q, Jia Q, Yu Y. The prevalence and risk factors of female sexual dysfunction in breast cancer survivors: a systematic review and meta-analysis. J Sex Med. 2026 Jan 7;23(2):qdag005. doi: 10.1093/jsxmed/qdag005. PMID: 41563059.
  14. ↑ Pérez CDA, Rocha AKL, Volpato MP, Juliato CRT, Pereira SB, Riccetto CLZ. Prevalence of Pelvic Floor Dysfunction in Women After Pelvic Radiotherapy: Systematic Review and Meta-Analysis. Int Urogynecol J. 2026 Mar 13. doi: 10.1007/s00192-026-06557-z. Epub ahead of print. PMID: 41824028.
  15. ↑ Schubach K, Niyonsenga T, Turner M, Paterson C. Experiences of sexual well-being interventions in males affected by genitourinary cancers and their partners: an integrative systematic review. Support Care Cancer. 2023 Apr 14;31(5):265. doi: 10.1007/s00520-023-07712-8. PMID: 37058163; PMCID: PMC10104925.
  16. ↑ de Moraes CMT, Lyra C, Fontes AM, Junior JB, Nahas WC, Filho LAR, Suartz CV. Partial prostatectomy in prostate cancer: a systematic review of current evidence. Clinics (Sao Paulo). 2025 Jan-Dec;80:100777. doi: 10.1016/j.clinsp.2025.100777. Epub 2025 Sep 12. PMID: 40945279; PMCID: PMC12834066.
  17. ↑ Stecca CE, Alt M, Jiang DM, Chung P, Crook JM, Kulkarni GS, Sridhar SS. Recent advances in the management of penile cancer: a contemporary review of the literature. Oncology and therapy. 2021 Jun;9:21-39.
  18. ↑ Brennen R, Lin KY, Denehy L, Frawley HC. The effect of pelvic floor muscle interventions on pelvic floor dysfunction after gynecological cancer treatment: a systematic review. Physical therapy. 2020 Aug;100(8):1357-71.
  19. ↑ Huffman LB, Hartenbach EM, Carter J, Rash JK, Kushner DM. Maintaining sexual health throughout gynecologic cancer survivorship: A comprehensive review and clinical guide. Gynecologic Oncology. 2016;140(2):359–68.
  20. ↑ Bergmark K, Avall-lundqviste E, Dickman PW, Henningsohn L, Steineck G. Lymphedema and bladder-emptying difficulties after radical hysterectomy for early cervical cancer and among population controls. International Journal of Gynecological Cancer. 2006;16(3):1130–9.
  21. ↑ Decorte T, Cerckel M, Kheir GB, Monten C, Vandecasteele K, Vanden Bossche L, Pauwels NS, Randon C. Risk factors for lower limb lymphedema after gynecological cancer treatment: a systematic review. Front Oncol. 2025 May 20;15:1561836. doi: 10.3389/fonc.2025.1561836. PMID: 40463868; PMCID: PMC12129805.
  22. ↑ 22.0 22.1 Hendershot G, Pidkowicz J, Therrattil D. Physical and Occupational Therapy. Blood and Marrow Transplant Handbook: Comprehensive Guide for Patient Care. 2021:115-25.
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