Pelvic Floor Dysfunction

Welcome to Queen Margaret University's Current and Emerging Roles in Physiotherapy Practice project. This space was created by and for the students at Queen Margaret University in Edinburgh, UK. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

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, Claire Ramsden, Chris Van Wyk, Amy McCarthy, John Lavin, Vidya Acharya, Rachael Lowe and Nicole Hills  

How's yours hangin'??!!

Introduction

Speaking about you netherregions is never an easy thing to do! Problems with you pelvic floor (including incontinence, leaking, and pelvic organ prolapse) is no easy subject to bring up, especially when you are worried that there may be something wrong! Pelvic floor dysfunction is heavily underreported as so many people don't feel comfortable speaking up about it.

This physiopedia page has been written to provide the public with some information on pelvic floor health, providing information on what the pelvic floor is, how to exercise it and what can happen if you don't. This patient guide also has information on how to access treatment from local NHS services, for example physiotherapy.

It perhaps may feel that you are the only person experiencing problems with your undercarriage, but that is because people are afraid to talk about it as it is personal and a bit of a taboo subject! In fact, 41-50% of women over 40 are affected by pelvic organ prolapse. 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 with their symptoms for 1 to 5 years, 42% of people suffering with their symptoms for 5 years or more.

Issues with your netherregions are well known to have negative effects on your quality of life for both men and women . Many individuals have reported negative affects on their home and work activities, personal relationships, social lives and mental wellbeing. Pelvic floor dysfunction is also associated with depression, social isolation, anxiety and generally reduced life satisfaction.

With all of this taken into consideration, we believe it is important to provide you with all the information to better enable you to take charge of your undercarriage and be leak free!!

Patient resource with physio resource at the bottom. SCOTTISH SLANG - LOCAL COLOQUISMS. FILTER THESE THROUGH

(in conclusion-->Be empowered by the knowledge and to speak out and seek help/your capacity to self-manage and take control of your own pelvic floor health---> use this there).

Huge financial burden to patient and the health service.

Urinary incontinence has been estimated to cost the UK 595 million per year.

The cost of urinary incontinence is expected to rise by 25% in the next decade

Learning Outcomes

After exploring this wiki page, the reader should be able to:

Overview

What is the Pelvic Floor?

The pelvic floor is made up of a layer of muscles spanning the bottom of the pelvis that support the bladder and bowel in males and bladder, bowel and uterus/womb in women. these structures that are supported are known as our pelvic organs. These muscles run like a hammock from the front of the pelvis to the tailbone at the back, and side-to-side from one sitting bone to the other .

Our pelvic organs sit on top of this layer of muscle. The muscles also have holes through which the urethra (tube through which urine exits our body from the bladder) and anus (exit at the end of our digestive system through which faeces pass) pass through in males and urethra, anus and vagina pass through in females. The muscles are snug against these structures in order to hold the passages closed. Both the anus and urethra have extra circular muscles (called sphincters) that help to keep the passages closed and prevent leakage of urine or faeces.

Our pelvic floor muscles are similar to a trampoline, as they have the ability to move up and down. This occurs during breathing as when we inhale our diaphragm (breathing muscle) pulls down to open our lungs. This pushes down of our internal organs. To avoid squashing these organs our pelvic floor and abdominal muscle relax and create more space for the organs to move down. When we exhale the diaphragm springs back to its normal position and as it does so the abdominals and pelvic floor muscles return to their resting position. A common problem experienced by people is holding their breath during lifting activities or bowel movements, which can lead to pelvic floor dysfunctions by adding excess stress on these muscles.

Pelvic floor muscles may be hidden but we do have voluntary control of them and therefore they can be trained like muscles in our arms or legs.

Functions of the Pelvic Floor Muscles:

• Support internal pelvic organs in the correct positions (Bladder, bowel and vagina).
• Allow conscious control of bladder and bowel habits using the sphincter muscles. This allows us to control the release of urine, faeces and gas and to delay emptying until a convenient time. This works as the pelvic floor muscles contract the organs are lifted up and the sphincter tighten around the openings of the urethra and anus.
• Allow the passage of urine and faeces out of the body due to the pelvic floor muscles relaxing and allowing the passages to open.
• Sexual function
  • In males the pelvic floor muscles are important in erectile function by increasing rigidity and ejaculation by improving control and coordination between circulation, pelvic floor muscles.
  • In females voluntary contraction of the pelvic floor muscles can contribute to sexual sensation.
• Additionally in pregnant women the pelvic floor offers support to the foetus during pregnancy and also assists in the childbirth process.

Strong pelvic floor muscles are important when we cough, laugh, sneeze or during lifting activities as there is extra force added to the abdomen and therefore additional pressure down onto the pelvic floor. If these muscles are weak, stretched or not working as they should, pelvic floor dysfunction (PFD) may occur which can 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.

Prolapse is another condition that can occur due to weak pelvic floor muscles. This occurs due to the bladder, bowel, uterus, urethra, rectum or vagina moving out of their normal positions.

 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. Many individuals have described some of these problems and feelings as normal, as they have been happening for so long. However, this shouldn't be the case!!

The following list of signs and symptoms are common for people with weak pelvic floor muscles.

If you are unsure whether you have a pelvic floor dysfunction or would like further information on each sign and symptom, the following website is extremely useful!! Women's and men's health physiotherapy.

Men:

• Constipation or bowel strains
• Ongoing pain in your pelvic region, genitals or rectum.
• 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.
• Feelings of urgency in needing to the bathroom, or not making it there in time.
• Frequent need to urinate.
• Difficultly emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.
• The feeling of needing to have several bowel movements during a short period of time.
• Accidentally passing wind.
• Pain in your lower back that cannot be explained by other causes.
• Pain in the testicles, penis (referred pain from the pelvic floor) or pelvis during intercourse.
• Erectile dysfunction.
• Painful ejaculation.
• Premature ejaculation.

For further information on the male pelvic floor go to: Pelvic floor advice for men - download the advice leaflet. OR. Male pelvic floor.

Women:

• Pain or numbness during intercourse.
• 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.
• Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence).
• Feelings of urgency in needing to the bathroom, or not making it there in time.
• Frequent need to urinate.
• Difficultly emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.
• The feeling of needing to have several bowel movements during a short period of time.
• Constipation or bowel strains.
• Accidentally passing wind.
• Pain in your lower back that cannot be explained by other causes.

Helpful websites for further information on the signs and symptoms of pelvic floor dysfunction: Health line or Pelvic floor first.

For further support for urinary or faecal incontinence you can visit the following NHS site: Living with incontinence.

Common Misconceptions

[1]- A patient personal experience of pelvic floor dysfunction, This is an interesting, personal and relatable video that explains pelvic floor dysfunction in real life terms .

It’s my fault isn’t it?

• Woman normalize symptoms – feel that it is part of being a woman and getting older especially after childbirth
• Lack of self control- woman feel is it their own fault for not being able to control bladder
• Woman experiencing POP and associated symptoms such as incontinence feel “deserving”, due to lack of consistency or failure to complete PFMT post childbirth. Woman, blame themselves for having these symptoms.
• Lack of priority given to PFMT post childbirth due to occupation with new baby , lack of perineal sensitivity post delivery have left PFMT low on the priority list. Woman experience self blame for allowing his to occur
• Shame associated with incontinence issues - woman are less willing to seek help from health care professionals as they feel they will be judged reprimanded or blamed for lack of consistency in PFMT
• Lack of understanding – woman have revealed that lack of understanding about PFMT , such as how to actually do a PFM contraction has prevented them from  PFMT effectively . Difficulty discussing this issue with healthcare professionals due to the sensitive nature of area.

The silent private exercise:

• The internal unseen nature of the PFM has led to difficulty for many woman understanding how to train the PFM
• The  mysterious nature of the PFMT seems in part due to the difficulty of finding appropriate yet explicit language to explain PFM exercises
• Exercise using muscles that cannot be seen and are located in a private area of the body and are associated with private function not easily discussed
• Study conducted to evaluate health care professionals skills in explaining the PFM contraction- patient described explanation as “sketchy “
• Woman feel silly as they may struggle to grasp technique
• ERRORS – common errors made in an attempt to contract pelvic floor muscles .COMMOV- contraction of other muscles ( using rectus abdominus, glutes and adductors ) MOV- pelvic tilts , breath holding and straining  performed in addition to or instead of an actual pelvic floor muscle contraction
• 57% of woman show Commov when assessing technique.  

Will pelvic floor muscle training work?

• Lack of understanding – Lack of clarity, as to why PFM should be exercised . Woman are unsure as to why these exercises need to be done.  Due to the lack of understanding , woman are unable to make informed decision to partake in PFMT
• Waste of time- Woman may find it difficult to continue with PFMT in the absence of noticeable benefit. No immediate effect from training  leads woman to feel as though there is no return for their efforts  and that PFMT is waste of time
• The nature of PFMT – woman have described PFM exercises as tedious, a daily battle, a nuisance and boring
• Timing? This study conducted found that woman feel the PFMT is difficult to factor into their daily schedule. Due to the personal nature of the exercise need to be done alone and in a quiet place for concentration also many feel embarrassed to do exercises around others

Prolapse and incontinence, it’s a female problem right?

• Study investigated male perceptions of incontinence and pelvic floor muscle training – 66% of men were unaware that males are required to do PFMT
• Widely perceived as a female issue
• Stigma and embarrassment – leads to under reporting of symptoms within the male population
• Lack of research regarding male experiences in PFMT , body of research lies within the female population

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Risk Factors

The following risk factors (modifiable: usually lifestyle related such as smoking, and non-modifiable, such as age/genetics), may contribute to the growing population with pelvic floor dysfunction (PFD). The predisposition for pelvic organ prolapse (POP), urinary/fecal incontinence, erectile dysfunction as part of PFD has several factors. A combination of changes in anatomy/physiology, genetics, and lifestyle play a role in the presentation of pelvic floor conditions.

The common risk factors for both males and females, have been illustrated in the middle of the diagram below. Predispositions unique to each gender, have been presented on the left and right side of the diagram respectively.

Figure 1: Risk factors related to the development of PFD in men and women.

Men:

• Prostate surgery: It appears that scientific literature examining pelvic floor dysfunction (PFD) among males is limited. However, prostate surgery has been identified as a potential risk factor .Specific PFDs include urinary incontinence and erectile dysfunction, which are quite common post-operatively (up to 89% men suffer from these conditions). 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 probability for 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. Cavernous nerves responsible for erectile function, may also be disrupted.

Women:

• Age: Females experiencing menopause, are at increased risk for developing pelvic organ prolapse (POP) by 21.1%.This is most likely due to 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 this life stage.
• Direct injury to levator ani and loss of tone in pelvic muscles: The explanation lies within the compensatory mechanism of musculature whereby, the pelvic structures rely on the connective tissue for support. Over time, this alteration results in weakening of the tissue and occurrence of POP.
• Pregnancy and the nature of childbirth: Overstretching/damaging of the prudanal nerve during vaginal birth, prolonged labour, instrumental 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 (PFD) risk by 4-16%.
• Genetics and ethnicity: Women who have a positive family history of POP, are more likely to inherit the condition, than women who do not. Additionally, it has been shown that females experiencing urinary incontinence, the connective tissue in the pelvic floor muscles may be genetically weak . Furthermore, Kuncharpu et al.’s (2010)and Vergeldt et al.’s (2015) findings, reveal that those with Hispanic descent had greater risk for POP when compared to their African-American and White counterparts.
• Low socioeconomic status (SES):This factor, especially among racial minorities, may contribute to poorer access to adequate information regarding PFD.The lack of resources create a challenge for women, making it difficult to recognize the symptoms and importance of seeking professional support in a timely manner.Hartigan and Smith (2018), presented that women of poorer SES scored lower on the incontinence quiz than their higher SES counterparts. Consequently, there is a strong emphasis on public education at large to reduce the risk of PFD.
• Hysterectomy (surgical removal of uterus): This procedure often damages and weakens the pelvic muscles. Therefore, it is known to increase chances of being more predisposed to POP.The risk also increases to 60% for developing urinary incontinence post-hysterectomy among middle-aged women

Both:

• Previous trauma to 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 . In women, pelvic radiation, as suggested by Walters (2017) has created an additional risk factor for urinary incontinence and for developing PFD symptoms. In order to assure quality of life and avoid many discomforts, men and women should require further screening to receive the optimal medical treatment.
• Increased abdominal pressure: Chronic coughing (symptom of chronic lung disease, smoking, hay fever) and frequent sneezing, have been shown to contribute to POP in women. It has been related to overuse of pelvic floor muscles and ligaments supporting the pelvic organs that occurs as the pressure increases within the abdomen.This weakens the anatomical structures and leads to POP. 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.
• Constipation/heavy lifting: Constipation is caused by the altered mechanics (incoordination) of the pelvic floor muscles and increase in intra-abdominal pressure during attempted evacuation. These persistent conditions can lead to nerve damage and appearance of PFD symptoms, such as fecal incontinence. Occupations that require frequent heavy lifting, to add pressure to the bladder and influence urinary incontinence in both genders. However, women who perform prolonged heavy lifting, are 9.6 times more at risk of developing POP.
• 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 been shown to experience increase abdominal pressure, which over time often leads to urinary incontinence.
• Increased BMI (above 25)/Obesity: Being overweight as measured by BMI (general indication of body fat), was strongly associated with urinary incontinence symptoms in both genders as was true for POP in women, compared to those with normal BMI values (18.5-24.9) .
• History of back pain: has been noted to be closely related to pelvic floor muscle dysfunction. This is because the pelvic muscles have a 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.

Collectively, there are many modifiable and non-modifiable risks for PFD in both genders. Being able to recognize the predispositions, especially those related to lifestyle, can aid in incorporating preventative measures in a timely manner. This also includes seeking the appropriate professional support. The specialists can provide relevant and evidence-based information regarding monitoring, assessment, and intervention available to the public.

Treatment  

Pelvic floor dysfunction (PFD) is a very treatable condition. Many strategies exist to treat PFD conservatively and should generally be considered as the first-line option prior to more aggressive procedures such as surgery. Treatment will vary according to the nature of the condition or reason behind the PFD. Your appropriate licensed health care practitioner, such as your GP or a physiotherapist, will help you decide which one is best for you:

Physiotherapy & Exercise:

• Pelvic floor exercises or pelvic floor muscle training (PFMT) is a very important aspect of improving PFD and is valuable to both men and women. PFMT aims to increase the strength, endurance and co-ordination of the muscles, which improves their overall function. Weak or damaged PF muscles can’t do their job properly and this can contribute to many problems such as incontinence and organ prolapse. A strong pelvic floor will help to prevent incontinence, provide support to pelvic organs and even improve your sex life.

• There are many different methods to perform PFMT, a physiotherapist or GP that specializes in pelvic health is best suited to educate you in doing these essential exercises. Some specialists may use other various techniques as well to aid treatment.

• The NHS has also developed a very handy app to help provide information, additional resources and even reminders about doing pelvic floor exercises! Please visit their site for more information: The Squeezy app

Please see the links below for more information on PFMT:

Female information leaflet from the British Association of Urological Surgeons

Male information leaflet from the British Association of Urological Surgeons

Youtube video: Pelvic floor exercises for men

Youtube video: Pelvic floor exercises for beginners

Below are links for progressive pelvic floor exercises that you can try at home!:

Lifestyle Changes:

Lifestyle changes may be suggested by the GP to help improve certain contributing factors. For example, quitting smoking, increasing your physical activity and improving your diet to achieve a healthier weight are all great strategies to improve your symptoms/condition and overall quality of life. One may also try to reduce caffeine and other irritants of the bladder (Coffee, tea, cola, alcohol etc.), while also trying to get enough water intake throughout the day. Certain strategies may be used in day to day situations as well. For example, tightening up your PF muscles prior to lifting heavy loads, or when possible, sharing the load with another person to lighten it. This will help to prevent any unwanted leakage or damage.

Pharmacological:

• Various drugs can be prescribed if indicated based on the underlying reason for PFD and your GP will decide with you if these are necessary. Drug therapy is particularly common for urinary incontinence and depending on the type of incontinence you’re experiencing; different medications are available. For example, if you have a stress incontinence, there are drugs to that help reduce leakage and hormone replacement therapies for post-menopausal women.  If you have an over-active bladder or urge incontinence, there are medications to help relax the bladder and reduce the frequency of urination.

• Pharmacological treatment is even more effective when used in combination with other strategies like PFMT and lifestyle changes.

For more information, please see this NHS website.

Surgical:

• In some cases, when other strategies have been unsuccessful in achieving your treatment goals, surgery may be a treatment option for you. Depending on your specific condition, various procedures exist to address the problem.

• For example, urge and stress incontinence have multiple types of procedures to alter the pelvic structures or insert supports such as mesh slings, both in the goal of improving functions.

• Slightly less invasive options are also available, such as injections of Botox for urge incontinence or bulking agents to help reduce stress incontinence.

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

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

Surgery implications:

• For those who have a pelvic floor disorder, 1 in 9 will undergo surgery.
• Prolapse surgery is often prone to failure.
• 30% require repeat operations.
• Synthetic mesh is a common surgical method.
• However, there are often complications and there is a 35% removal rate.

References:

AYELEKE, R., HAY-SMITH, E. & OMAR, M., 2015. Pelvic floor muscle training added to another active treatment versus the same active treatment alone for urinary incontinence in women. Cochrane Database of Systematic Reviews.

CLEVELAND CLINIC., 2018. Pelvic floor dysfunction. [online]. [viewed March 10, 2018]. Available from: https://my.clevelandclinic.org/health/diseases/14459-pelvic-floor-dysfunction/management-and-treatment

PHYSIOTHERAPY NEW ZEALAND., 2018. How Physio can help: Pelvic Floor Disorders. [online]. [viewed March 10, 2018]. Available from: http://physiotherapy.org.nz/your-health/how-physio-can-help/pelvic-floor-disorders

ROBERT, M. & ROSS, S., 2006. Conservative management of urinary incontinence. Journal of Obstetrics and Gynaecology Canada. Vol. 28 (12), pp. 1113-1118

Access to services

Each NHS Boards across Scotland has different process and guidelines to get referred to a Pelvic health/women’s health physiotherapist. Below outline this process in different areas to help direct each patient to the right area.

NHS Forth Valley:

For Women’s health you are able to self refer through the following link - Self referral form

If you are having continuance problems during and after pregnancy or pelvic floor dysfunction- NHS forth valley ask you to complete the screening tool ICIQ Form (Link below), this will help you decide if you need to refer for a 1:1 assessment with a specialist physiotherapist. If you score more than 10 when you add the totals for questions number 3,4 and 5 we would suggest  print, read and complete the self Pelvic Bladder Self Referral Form (link below) and send to the physiotherapy department at either Forth Valley Royal Hospital or Stirling Community Hospital.

ICIQ form

Pelvic Bladder self referral form

Alternately, your GP or midwife can also refer you to the services.

NHS Lothian:

http://www.nhslothian.scot.nhs.uk/Services/A-Z/ECPS/ClinicsServices/Pages/Continence.aspx

Community Physiotherapy Service. Currently the departments offering this service are:

• Craigroyston Health Clinic
• Leith Community Treatment Centre
• Slateford Medical Practice
• South Queensferry Health Centre
• Tollcross Health Centre

Conditions which can be helped include:

• Stress urinary incontinence (leakage on coughing, sneezing, laughing etc)
• Urgency, frequency and nocturia (needing to empty your bladder urgently and often and getting up at least twice overnight to go to the loo)
• Symptoms of mild prolapse (sensation of something coming down)
• Weak pelvic floor after childbirth including any of the above symptoms
• Men with urinary incontinence can be treated at Leith Community Treatment Centre

The service can be accessed by referral from any of the following:

Self referral – by calling nhs 24 111 or for Bladder Problems use the Self referral form

A referral from your GP or  any Health Care Professional (nurse, midwife etc)

NHS Borders:

Bladder, bowel and pelvic floor service role is to promote continence by offering advice, treatment and management options. Delivered by a skilled team comprising of:

• Principal Physiotherapist Bladder, Bowel and Pelvic Floor Service - Lead Clinician Bladder, Bowel and Pelvic Floor Service
• Specialist Physiotherapist Bladder, Bowel and Pelvic Floor Service
• Bladder, Bowel and Pelvic Floor Service Nurse

The service can be contacted in the following ways:-

A referral from your GP

A referral from any healthcare professional.

Self referral  - you can refer yourself by telephoning 01896 824555 and leaving your details on the confidential answer phone.

NHS Highland:

Service can be accessed by:

NHS Highland physiotherapists have re-launching their self referral service for continence and other pelvic health problems. New self referral forms are available from GP practices throughout Highland.

Self referral forms can be returned to the addresses on the form, or handed in to your nearest physiotherapy department. Alternatively you can leave a message for Alison Clarke on 07748761847

Pelvic health Physio self referral form

Conclusion:

Information for healthcare professionals (Physiotherapy specific)

• Detailed anatomy and overview of the pelvic floor muscles
  • http://teachmeanatomy.info/pelvis/muscles/pelvic-floor/
• Types of Prolapse: Types and Grades (1-3) Pictures of types
• Prevalence and impact for NHS
• Risk factors- socio-economic, genetics, hobbies, age
• What is the role of the physio and assessment
• Implications:
• Urinary incontinence affects 69% of those with pelvic floor disorders. - PT
• Faecal incontinence affects 3.6 per 100,000 women aged 60-89. -PT

Financial burden:

• Huge financial burden to patient and the health service.
• Very little recent data on the cost to the NHS.
• 29,000 prolapse surgeries in England between 2010 and 2011 which cost around 60 million.
• Other countries spend 2% of their budget on pelvic floor dysfunction.
• Incontinence and pelvic floor exercises, surgery for (Critique and synthesis papers) (Who most benefits from PFE)
  • Child birth
  • Neuro-post stroke- PT more focused on mobility
  • Age- Elderly
  • Males- Erectile dysfunction, post surgery

• Summary of where more research needs to be done and PFE need to be incorporated in to
• More teaching of PFH in university.
• Emerging role of physio within stroke, elderly and long term care patients to increase PFE and decrease incontinence
• ?most research has been in child birth females and lacking in elderly, stroke and males

There is a lack of research of evidence surrounding pelvic floor health from a physiotherapy perspective; most research exists from nursing etc.

There is a bigger lack of research surrounding male pelvic floor health and implications of dysfunction etc.

There is a lack of awareness through a gap in the current education of student physiotherapists.

References

see adding references tutorial.