Common Women's Pelvic Health Conditions

Original Editor - Jess Bell based on the course by Ibukun Afolabi
Top Contributors - Jess Bell, Kim Jackson and Olajumoke Ogunleye

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Introduction

Women may seek help from pelvic health physiotherapists for several reasons. This page will explore some common conditions that pelvic health physiotherapists might encounter in clinical practice. Management strategies are discussed in detail here. LINK

Pelvic Floor

The pelvic floor muscles work synergistically with the diaphragm by contracting and lengthening with every breath. The amount of movement depends on the size of the breath. However, like any skeletal muscle, the pelvic floor muscles can become tight. Reduced range of motion in the pelvic floor can affect bowel and bladder function, sexual pleasure, core support, and athletic performance.

There are two extremes of pelvic floor states:

• Underactive pelvic floor (i.e. “low in position, lax, unsupportive, hypotonic, long or lengthened, disconnected”)
  • Characterised “by an inability to meet the demands of maintaining continence or pelvic organ support due to deficits in power, endurance, or correctly timed coordination of contraction.”
  • The pelvic floor muscles:
    • May be sluggish
    • May or may not have tender areas
    • Will have difficulty lifting and contracting
    • Will likely be weak

• Overactive pelvic floors (i.e. “high, tight, stiff/rigid, short, hypertonic, non-relaxing”)
  • Characterised “by an inability to fully relax and lengthen. Most frequently, the overactive pelvic floor is associated with symptoms of pelvic pain, urinary frequency/urgency, and defecatory dysfunction.”
  • Symptoms associated with this type of pelvic floor are:
    • Tenderness to the touch
    • Possibly painful or sensitive
    • Difficulty lifting and contracting
    • Often considered weak

In reality, these states exist along a continuum. Some women may experience elements of both overactivity and underactivity and, thus, have a mixed pelvic floor.

Signs associated with underactive and overactive pelvic floors are summarised in Table 1.

Table 1. Signs associated with underactive or overactive pelvic floor muscles

Underactive pelvic floor	Overactive pelvic floor
Leaking with running, jumping, coughing, sneezing, laughing (i.e. anything that places pressure on the bladder)	Leaking with running, jumping, coughing, sneezing, laughing (i.e. anything that places pressure on the bladder)
Sudden urgency of bladder or bowels	Sudden urgency of bladder or bowels
Difficulty lifting the pelvic floor	Difficulty lifting the pelvic floor
Pelvic floor contractions feel weak	Pelvic floor contractions feeling weak or low endurance
Tampons or menstrual cups may fall out	Difficulty starting to void or fully emptying the bladder
Sex might be described as "not feeling like it used to before kids"	Pain with penetration
Feeling of heaviness or pressure or dragging	Pain during or after intercourse
Feeling of sitting on an egg or a golf ball between legs	Persistent pain in pelvic, abdominal, groin, or genital region
Noticing a protrusion at the entrance to the vagina	Ongoing low back, hip, or groin pain
Inability to make it to the bathroom in time	Trauma, tearing, or assisted delivery during childbirth
Inability to entirely empty bowels or bladder	Doing Kegels or holding Kegels makes symptoms worse
Sacroiliac joint pain, hip pain	Diagnosis of endometriosis, interstitial cystitis, vaginismus, dyspareunia
Chronic constipation	Chronic constipation

Because there is some crossover in symptoms, it is essential to perform a careful initial assessment and ongoing evaluation to select the correct treatment paths. LINK TO LATER COURSE

Common Pelvic Health Conditions

Pelvic floor conditions can be:

• Pressure conditions
• Pelvic support conditions
• Neuromuscular or myofascial conditions
• Pain conditions
• Mixed conditions

Common conditions are discussed below.

Incontinence

Incontinence is the uncontrolled loss of urine, gas, or stool of any amount.

Urinary Incontinence

Urinary incontinence (UI) can be categorised as:

• Stress UI:
  • An involuntary loss of urine that occurs during movements / activities (such as coughing, sneezing, laughing, running, heavy lifting) that increase abdominal pressure (i.e. stress) on the bladder
• Urge UI:
  • An unintentional loss of urine which can occur when the bladder muscle contracts
  • There is often a sense of urgency
• Mixed UI:
  • An individual has both stress and urgency urinary incontinence
• Overflow incontinence:
  • Urinary incontinence occurs when the bladder is excessively full (with no cause identified)
• Functional incontinence:
  • It occurs when there are cognitive, functional, or mobility issues that affect an individual’s ability to use the toilet
  • No bladder / neurological causes
  • Also referred to as “toileting difficulty”

The prevalence of UI varies widely in different studies. It is estimated that between one in two and one in three women experience incontinence.

Yet many individuals do not seek out treatment. Lukacz et al. found that only 25 percent of affected women receive treatment. Possible reasons for not seeking care include:

• Embarrassment
• Lack of awareness about treatment options
• A belief that it is a “normal” part of ageing

It is important to note that, rather than a diagnosis, incontinence is a symptom that is caused by underlying issues in the continence system. These issues include:

• Poor pressure management
• Pelvic floor muscle dysfunction
• Postural or movement dysfunctions
• Abnormal voiding patterns
• Uncoordinated inner core system
• Behavioural factors (going “just in case”, etc)

Other bladder conditions include:

• Frequency
• Urgency (i.e. overactive  bladder)
• Voiding hesitancy
• Urinary retention
• Pain or burning with urination
• A sensation of incomplete emptying
• Frequent night-time voiding
• Recurrent urinary tract infections (UTI)
• Pain with urination

These conditions are discussed in more detail here.