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

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. Evaluation and management strategies are discussed here.

Pelvic Floor States

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:

1. Underactive Pelvic Floor

• “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

2. Overactive Pelvic Floor

• "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.”
• The overactive pelvic floor:
  • May be tender to the touch
  • May possibly be painful or sensitive
  • Might have difficulty lifting and contracting
  • Is often considered weak

In reality, these pelvic floor 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, pressure or dragging	Pain during or after intercourse
Feeling of sitting on an egg or with 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.

Common Pelvic Health Conditions

Pelvic floor conditions might be categorised as:

• 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 that can occur when the bladder muscle contracts
  • There is often a sense of urgency
• Mixed UI:
  • An individual has both stress and urge UI
• Overflow incontinence:
  • UI occurs when the bladder is excessively full, with no cause identified
• Functional incontinence:
  • 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 following video provides a detailed discussion of incontinence.

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 (e.g. going “just in case”)

Other Bladder Conditions

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

See here for more information on these conditions.

Faecal Incontinence

Faecal incontinence is an involuntary loss of gas or stool (ranging from staining / smearing on underwear to incontinence of stool). One in eight women experience faecal incontinence. It is often caused by obstetric anal sphincter injuries (OASIS) that occur during childbirth. OASIS injuries are also referred to as third or fourth degree perineal tears:

• First degree tears affect the skin of the perineum, but these tears tend to heal naturally and do not need to be sutured
• Second degree tears involve both the skin and muscle of the perineum
• Third degree tears affect the anal sphincter complex
• Fourth degree tears extend to the anal mucosa

The incidence of OASIS injuries following vaginal deliveries is said to be increasing. In addition to faecal incontinence, an OASIS injury can lead to:

• Pain
• Urinary incontinence
• Sexual dysfunction
• Depression / anxiety
• Decreased emotional health and quality of life

Other Bowel Dysfunctions

Other bowel issues that women may experience include:

• Chronic constipation
• Haemorrhoids
• Irritable bowel syndrome
• Defecation dyssynergia (i.e. incoordination during the process of defecation)

Pelvic Organ Prolapse

Figure 1. Uterine prolapse.

Pelvic organ prolapse (POP) occurs when the pelvic organs (i.e. the uterus, rectum and bladder in women) move from their optimal position. Figure 1 illustrates the stages of a uterine prolapse.

Symptoms include:

• A feeling of pressure / heaviness in the perineum
• Altered flow of urine
• A feeling of falling out
• Constipation / straining
• Discomfort during intercourse

Physical signs might include a bulge or protrusion at the entrance to the vagina.

In general, an individual’s symptoms are aggravated in positions where gravity acts on the body (e.g. standing, walking, lifting). Positions where gravity is eliminated (e.g. lying down) tend to be relieving.

POP is a subjective experience. Some clients may have a mild prolapse but experience severe symptoms, whereas others have a significant prolapse but report minimal or no symptoms. Diagnosis is made based on the clinical examination and subjective symptoms, such as:

• Bulge sensation
• A feeling of pelvic pressure
• Bladder storage symptoms
• Urinary incontinence
• Recurrent UTIs

There are two theories about the causes of POP:

1. Biomechanical
2. Biotensegrity

1. Biomechanical / Pelvic Support Model

This model posits that the pelvic floor holds up the pelvic organs. POP occurs when:

• Fascia and ligaments which suspend the organs in place become lax, tear or lose integrity
• The pelvic organs, thus, lose suspensory support from above
• If the pelvic floor muscles are compromised / weak, it can mean that there is a lack of pelvic support from below
• When combined with poorly managed pressures in the abdominal canister (i.e. the area from the diaphragm to the pelvic floor), this can lead to a descent of the pelvic organs
• More significant prolapses can bulge / protrude from the vaginal opening

2. Biotensegrity

Tensegrity is a structural / architectural principle that R. Buckminster Fuller proposed during the 1960s. According to this model: “structures are stabilized by continuous tension (tensional + integrity = tensegrity) with discontinuous compression.”

Tensegrity principles can be observed in biological systems. In this model, POP is explained in terms of an organ being “pulled” down from its optimal position by myofascial tension in the deep and superficial layers of the pelvic floor muscles rather than “falling” down.

The following video explains the biotensegral model in more detail.

Levator Ani Muscle Avulsion

Figure 2. Levator ani muscle.

It is important to note that levator ani muscle avulsion may also be implicated in the development of POP. This type of avulsion fracture occurs when the levator ani muscle (see Figure 2) is detached from its origins in the pubis.

It occurs in 10 to 30 percent of vaginal deliveries and is more common when forceps are used or when there is a prolonged pushing stage.

Types of Prolapse

Traditionally, POP has been categorised as: 

• 

  Figure 3. Types of pelvic organ prolapse.
  Cystocele (prolapsed bladder)
• Rectocele (prolapsed rectum)
• Uterine prolapse (prolapsed uterus)
• Urethrocele (prolapsed urethra)
• Enterocele (prolapsed intestine)
• Vaginal vault prolapse (top of the vagina prolapses - only occurs after a hysterectomy)

While these terms are still used, health care professionals are increasingly moving towards a more anatomically-based classification system and are adopting terminology such as:

• Anterior vaginal wall prolapse
• Posterior vaginal wall prolapse
• Apical prolapse

Prolapse can be measured / graded using various systems, but one of the most commonly used staging systems is the POP-Q (Pelvic Organ Prolapse Quantification System). The POP-Q uses a four-point system to determine the degree of prolapse:

• Stage 0 = no prolapse
• Stage 1 = prolapse is 1cm above the vaginal opening or higher
• Stage 2 = prolapse is 1cm away from the vaginal opening or has protruded up to 1cm out of the vagina
• Stage 3 = prolapse protrudes more than 1cm, but less than 2cm out of the vagina
• Stage 4 = the vaginal walls have completely everted, and the prolapse is maximally protruded

Physiotherapy can be an effective treatment for individuals who have stage 1 to 3 prolapses.

However, it is important to note that a prolapse may be graded differently depending on factors such as the time of day, position of evaluation and method of evaluation. Therefore, physiotherapists may instead choose to rate a prolapse as mild, moderate, significant or severe.

Persistent Pelvic Pain

Persistent pelvic pain is defined as pain that has been present in the pelvic area for more than three months. Individuals may experience pain in their lower abdomen, pelvic floor, pelvic organs, hips, groin, buttocks, low back, coccyx, perineal region, vulvovaginal area, rectum, and genitalia.

They may describe this pain as:

• Constant or intermittent
• Deep or superficial
• Provoked by touch or present regardless of touch
• Dull, sharp or burning
• And the type of pain may change depending on the activity (e.g. urinating, sitting, intercourse)

Types of pelvic pain that a pelvic floor physiotherapist may treat include:

• Dyspareunia (painful intercourse)
• Vaginismus (involuntary spasm of pelvic floor muscles when attempting penetration)
• Vulvodynia (generalised vulva pain)
• Vestibulodynia / vulva vestibulitis (pain in the vestibule region of the vulva)
• Clitroidynia (clitoral region pain)
• Coccydynia (coccyx pain)
• Dysmenorrhea (painful periods)
• Endometriosis (pain resulting from inflamed endometrial-like tissue, which is situated outside of the uterus)
• Adenomyosis (pain resulting from inflamed endometrial-like tissue, which is situated inside the muscular lining of the uterus)
• Painful bladder syndrome (has a similar presentation to interstitial cystitis - causes hypersensitivity and inflammation of the bladder wall lining)
• Levator ani syndrome or proctalgia fugax (occurs when there is tension / spasm in one major pelvic floor muscle group)
• Pudendal neuralgia or pudendal nerve entrapment (occurs when there is compression or irritation of the pudendal nerve)
• Persistent genital arousal disorder (persistent or recurrent, unwanted or intrusive, distressing, abnormal sensations that are not associated with sexual interest. Also called genitopelvic dysesthesia)
• Chronic pelvic pain syndrome (a descriptive diagnosis)
• Other types of pain which can be caused by: hormonal changes, menopause, abdominal or pelvic surgery, autoimmune disorders, internal scar tissue, gut or bladder dysfunction, pelvic girdle pain, sacroiliac joint pain, labral tears of the hip, myofascial / connective tissue dysfunction, trauma, or hypertonicity and overactivity of pelvic floor muscles

Additional information on some of these conditions is available here. In order to treat pelvic pain successfully, a physiotherapist needs to do a careful evaluation from a bio-psycho-social-spiritual and integrative framework. More information on treatment is available here.