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 - Laura Ritchie

Introduction[edit | edit source]

Pelvic Floor Musculature[edit | edit source]

The pelvic floor consists of three layers of muscles, tendons, ligaments and connective tissue that form a bowl-like structure that extend from the pubic bone to the tailbone.[1] The pelvic floor musculature (PFM) provide several key functions, which can be summarized by the "4S” acronym:[2][3]

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

Pelvic Floor Dysfunction[edit | edit source]

Pelvic floor dysfunction (PFD) occurs when the PF musculature cannot be properly relaxed, coordinated, or controlled, and can be a primary or secondary condition expressed as incontinence, leaking, and/or pelvic organ prolapse. Other manifestation of PFD include pain during/after sex or erectile dysfunction in men.[4]

Cancer and the Pelvic Floor[edit | edit source]

Individuals with bladder or anal cancer, women with gynecological cancers (endometrial, ovarian, cervical, vulvar and vaginal), and men with prostate cancer can all experience PFD.

Surgical procedures involved in cancer treatment can affect the pelvic floor depending on the tumor size, location and stage. Surgical procedures within the pelvic region can directly affect PFM through scar tissue restriction and swelling.[1] 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 chemotherapies and radiation may also impact the pelvic floor. Radiation (external beam or internal brachytherapy) during cancer therapy can lead to fibrosis (hardening) of the pelvic floor musculature, this may lead to shortening or narrowing of the vaginal canal in women.[5] This same hardening of pelvic floor (men and women) and the vaginal canal (women) can lead to incontinence and/or urgency of bowel and bladder, pelvic pain, and sexual dysfunction. According to multiple long term cross sectional studies and systematic reviews on effects on pelvic floor musculature after surgeries and adjuvant therapies in gynecologic cancers survivors, there was increase in report of lower libido, changes in sexual response, altered body image, and distress related to sexual health.[6][7][8]

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.[7]

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

Prevalence[edit | edit source]

More than half of women with gynecologic malignancies report baseline urinary incontinence (UI) and 10.9% felt a pelvic organ prolapse.[9] Moreover, women with benign hysterectomies had poorer quality of life and increased PFDs compared to women who have not undergone surgery. Survivors of gynecological cancer also experience significantly more pelvic floor symptoms and an associated reduction in quality of life.[10]

There is limited PFD prevalence data in men cancer survivors, however, PFM training with or without biofeedback reduces time to continence in men after radical prostatectomy. Furthermore, PFM exercises resulted in improved erectile function in men after radical prostatectomy).[11][12]

Physical Therapy Management[edit | edit source]

Education[edit | edit source]

Physical therapists (PT) play a key role in educating both male and female cancer patients/survivors regarding the effects of cancer treatment on PFM function and health. This will encourage patient “by in” on active PFM rehabilitation to address PFD and unwanted symptoms. Education regarding the PFM can be sensitive and here are some tips in patient education for PTs:

  1. Referring to PFM as “internal hammock” that functions to support the pelvic organs
  2. Explain the function of this “internal hammock” in the context of the patients’ lives (occupation, hobbies, exercise etc)
  3. Using the “tightening the tab” analogy for leakage and urinary incontinence issues
  4. “If there is an issue, there is a tissue”: be mindful of not just the musculature but the biopsychosocial aspect of the patient that may impact or be impacted by PFD

Pelvic Floor Physical Therapy[edit | edit source]

The right PF physical therapy can entirely decrease or eliminate symptoms of PFD. In addition to education, PF physical therapy includes a combination of physical exercise (pelvic and core), manual and biofeedback therapy techniques to strengthen and restore normal function of PFM. Here is a seven-step overview of what typically goes on in a PF physical therapy evaluation:[3]

  1. 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.
  2. Postural examination: in both standing and sitting. As posture skeletal alignment will affect the length and tension of PFMs. And addressing postural misalignments/habits, relaxing/strengthening tight muscles, and strengthening weak muscles can directly change PFM function.
  3. Movement analysis: looks into the quality of movements and if 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.
  4. Orthopedic assessment: as a specialized branch of physical therapy, PF PTs will also look at the patient’s spine, sacroiliac joints, hip joints, rib cage and analyze breathing patterns before the internal exam is done.
  5. 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.
  6. Patient education: is crucial in PF physical therapy, as many patients have gone through ringer prior to seeing a PF PT. Frustration, depression, and helplessness are common mental health findings when patients start the process of PF physical therapy.
  7. Treatment: PF physical therapy 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 PFM

References[edit | edit source]

  1. 1.0 1.1 Ccgynonc. Cancer and the Pelvic Floor [Internet]. Colorado Gynecologic Oncology Specialists. 2018 [cited 2021Jun30]. Available from: https://ccgynonc.com/cancer-and-the-pelvic-floor/
  2. Pelvic Floor Muscle Function and Strength [Internet]. Physiopedia. [cited 2021Jul2]. Available from: https://www.physio-pedia.com/Pelvic_Floor_Muscle_Function_and_Strength
  3. 3.0 3.1 The First Day of Pelvic Floor Physical Therapy [Internet]. Voted Best Physical Therapy Clinic in Denver, CO by Our Clients: N2 Physical Therapy. [cited 2021Jun30]. Available from: https://n2physicaltherapy.com/b/the-first-day-of-pelvic-floor-physical-therapy
  4. Pelvic Floor Dysfunction: Symptoms, Causes & Treatment [Internet]. Cleveland Clinic. [cited 2021Jun30]. Available from: https://my.clevelandclinic.org/health/diseases/14459-pelvic-floor-dysfunction
  5. 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.
  6. Hazewinkel MH, Sprangers MAG, van der Velden J, van der Vaart CH, Stalpers LJA, Burger MPM, et al. Long-term cervical cancer survivors suffer from pelvic floor symptoms: A cross-sectional matched cohort study. Gynecologic Oncology. 2010;117(2):281–6.
  7. 7.0 7.1 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.
  8. Bernard S, Ouellet M-P, Moffet H, Roy J-S, Dumoulin C. Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review. Journal of Cancer Survivorship. 2015;10(2):351–62.
  9. Thomas SG, Sato HR, Glantz JC, Doyle PJ, Buchsbaum GM. Prevalence of Symptomatic Pelvic Floor Disorders Among Gynecologic Oncology Patients. Obstetrics & Gynecology. 2013;122(5):976–80.
  10. Neron M, Bastide S, Tayrac Rde, Masia F, Ferrer C, Labaki M, et al. Impact of gynecologic cancer on pelvic floor disorder symptoms and quality of life: an observational study. Scientific Reports. 2019;9(1).
  11. MacDonald R, Fink HA, Huckabay C, Monga M, Wilt TJ. Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU International. 2007;100(1):76–81.
  12. Sighinolfi MC, Rivalta M, Mofferdin A, Micali S, De Stefani S, Bianchi G. Potential Effectiveness of Pelvic Floor Rehabilitation Treatment for Postradical Prostatectomy Incontinence, Climacturia, and Erectile Dysfunction: A Case Series. The Journal of Sexual Medicine. 2009;6(12):3496–9.