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, Nicole Hills and Rachael Lowe  

How's yours hangin'??!!

Introduction[edit | edit source]

DECISION TREE????? Outline of the wiki. Breaking down each section.

Speaking about your nether-regions 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[1] 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. This page has been designed to build upon previous resources available and to bring together important and valuable information on pelvic floor health, so it is all within one page for your easy reading.

A am' nae talkin' about whats under ma breeks!!![edit | edit source]

Do you feel you are the only person with problems with your undercarriage?. . . .

You are not alone. Many people talking about pelvic health to be a difficult conversation to bring up.

In fact, 41-50% of women over 40 are affected by pelvic organ prolapse (information below)[2]. Only 17% of those with urinary incontinence seek medical help[3]. Pelvic floor dysfunction affects more women than men[4], however, men are affected!!! From these figures, 46% of people suffer with their symptoms for 1 to 5 years[3], 42% of people suffering with their symptoms for 5 years or more[3].

Issues with your netherregions are well known to have negative effects on your quality of life for both men and women [4]. Many individuals have reported negative affects on their home and work activities, personal relationships, social lives and mental wellbeing[1]. Pelvic floor dysfunction is also associated with depression, social isolation, anxiety and generally reduced quality of life[4].

Fear not! We have designed this patient guide to provide you with the information you need to take charge of your undercarriage and be leak free!!

Have a read through this guide and test yourself on the quick quiz at the bottom of the page.

There is a physiotherapy information section at the bottom of this page.

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[5].

The cost of urinary incontinence is expected to rise by 25% in the next decade[5]

Learning Outcomes[edit | edit source]

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

Learning outcomes for Pelvic Floor Health.jpg

Any problems with your water works??[edit | edit source]

Overview[edit | edit source]

What is the Pelvic Floor?[edit | edit source]

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 [6] 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 [7].

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[7]. 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.[8]

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[9]. 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.[10]

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:[edit | edit source]

Main Pelvic Floor Muscle Functions
  • Support internal pelvic organs in the correct positions (Bladder, bowel and vagina).[6][11]
  • Allow conscious control of bladder and bowel habits using the sphincter muscles. This allows us to control the release of urine (wee), faeces (poo) and gas and to delay emptying until a convenient time. This works as the pelvic floor muscles contract and the pelvic organs are lifted up. The sphincter then tightens around the openings of the urethra and anus.[6][11]
  • Allow the passage of urine and faeces out of the body due to the pelvic floor muscles relaxing and allowing the passages to open.[6][10]
  • Sexual function[6]
    • 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.[12][11]
    • In females voluntary contraction of the pelvic floor muscles can contribute to sexual sensation.[11]
  • As mentioned above the pelvic floor muscles play a role in breathing by relaxing and increasing the space the lungs have to expand.[10]
  • Additionally in pregnant women the pelvic floor offers support to the foetus during pregnancy and also assists in the childbirth process.[6]

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[10]. 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.[13]

Urinary dysfunction, erectile dysfunction, premature ejaculation, painful ejaculation and chronic pelvic pain are some conditions that can be linked with weak pelvic floor muscles. Erectile function requires contraction of the pelvic floor muscles to block blood from leaving the penis. When the muscles are weak the outflow of blood from the penis is not stopped resulting in erectile dysfunction. Through learning voluntary control of the pelvic floor muscles this can help prevent premature ejaculation by learning how to relax and contract the muscles.[14] Urinary incontinence has a direct relationship with pelvic floor muscles. These muscles tighten as a closure mechanism for the tube from the bladder to the exit (urethra) and weakness of these muscle can cause leaking and dribbling.[15]

Prolapse is a common condition that can occur due to weak pelvic floor muscles in women. This occurs due to the womb, bladder, bowel or top of the vagina moving out of their normal positions and pushing into the vagina.This can cause pain and discomfort but can be improved with pelvic floor exercises and lifestyle changes which are mentioned in the treatment section of this wiki[16].

 Signs and Symptoms of Pelvic Floor Dysfunction[edit | edit source]

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:[edit | edit source]

  • Constipation or bowel strains[17]
  • Ongoing pain in your pelvic region, genitals or rectum.[18][19]
  • 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.[20][21][19]
  • Feelings of urgency in needing to the bathroom, or not making it there in time.[20][21][22]
  • Frequent need to urinate.[22]
  • Difficultly emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.[22]
  • The feeling of needing to have several bowel movements during a short period of time.
  • Accidentally passing wind.[20]
  • Pain in your lower back that cannot be explained by other causes.[20]
  • Pain in the testicles, penis (referred pain from the pelvic floor) or pelvis during intercourse.[18]
  • Erectile dysfunction.[18][21][19]
  • Painful ejaculation.[18][21][19]
  • Premature ejaculation. [18][21]

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

Women:[edit | edit source]

  • Pain or numbness during intercourse.[20][17][19]
  • 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.[20]
  • Accidentally leaking urine when you exercise, laugh, cough or sneeze (stress incontinence).[19][22]
  • Feelings of urgency in needing to the bathroom, or not making it there in time.[22]
  • Frequent need to urinate.[20][22]
  • Difficultly emptying your bladder (discontinuous urination – stop and start multiple times) and bowels.[20][22]
  • The feeling of needing to have several bowel movements during a short period of time.
  • Constipation or bowel strains.[17]
  • Accidentally passing wind.[20]
  • Pain in your lower back that cannot be explained by other causes.[20]

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[edit | edit source]

[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?[23][edit | edit source]

Being a female in the 21st century is certainly not an easy task. The role of a woman is diverse, demanding and challenging . Woman chop and change from being a mother, a lover, a homemaker to a successful business woman managing the hiring and firing in some of the worlds most successful and glamorous companies . Woman are athletes, breaking records for the highest jump in the Olympic games and setting new personal bests that challenges not only them but every other female on this planet to beat . Woman are the backbone of the fashion industry , selling our souls for the latest Louis Vuitton autumn spring collection which of course consists of utterly devine leather pants. The overall picture is , WOMAN ARE BUSY ! ... Woman who experience symptoms associated with Pelvic organ dysfunction such as incontinence , leaking, increase urgency and prolapse blame themselves[24] . Some woman feel "deserving" of these symptoms, due to lack of consistency or failure to prioritize PFMT post childbirth or throughout the aging process due to commitments in other roles[24] . Now , lets talk about the shame that comes with this! Shame, that awful uncomfortable , just brush it under the carpet word that woman associate with symptoms as mentioned above. Shame prevents reporting of such symptoms to healthcare professionals, not only due to the uncomfortable nature of the topic but interestingly, woman fear they will be judged or reprimanded for failure to train pelvic floor muscles as expected over the years[23] . Eye opening, right ? Some woman feel that leaking, incontinence and even prolpase are "part of the parcel" of being a woman, and these are side effects that come with the job [24].Some woman accept this faith , and resign to a life of incontinence wear and multiple red cheeked situations . A pelvic floor contraction .... Queue the tumbleweed! One of the more difficult things in life to explain , we can all agree with that ! Some woman have highlighted the difficulty communicating with healthcare professionals about how to actually do a pelvic floor contraction. Resulting in poor or incorrect technique , and never truly exercising the pelvic floor muscle .

The silent private exercise:[25][edit | edit source]

Many things in life can be described as mysterious for example, the Louchness monster, the misplacement of socks post laundry day , that deminishing tub of ice-cream in the freezer when you swear you only had one bite . But , the biggest mystery of all , the nature of a pelvic floor contraction. Finding the appropriate yet explicit language to explain a pelvic floor contraction is not an easy task . Exercising muscles that cannot be seen, are located in a private area of the body and associated with private function are not easily discussed . Hence the mystery that surrounds pelvic floor muscle training . A study was conducted to evaluate healthcare professionals skills at explaining pelvic floor muscle contraction to patients . One patient involved in this study , described the explanation given as "sketchy and confusing [25]". Difficulty grasping this technique has been a cause of embarrassment for woman and many feel silly as they struggle to get their head around engaging the pelvic floor muscles correctly ! In an attempt to contract the pelvic floor muscle , some common errors are made . Contraction of other muscles such as the rectus abdominus (tummy muscle ) glutes and adductors ( The muscle the Kardashians have made famous!) instead of the true internal pelvic floor muscles . Also , compensatory movements such as pelvic tilts , breath holding and straining can give the illusion of a pelvic floor contraction . Infact this study found that 57% of woman adopt some form of compensatory movement when attempting to contract the pelvic floor[24] . Frustrating , right ?

Will pelvic floor muscle training work?[25] [24][edit | edit source]

  • 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[25]

Prolapse and incontinence, it’s a female problem right?[26][edit | edit source]

  • 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[26]

Add your content to this page here!

Are you at risk?[edit | edit source]

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 diagram below in yellow circles. Predispositions unique to each gender include blue circles for males and pink for females.

Risk factors related to the development PFD in men and women.

Men:[edit | edit source]

  • Prostate surgery: Specific PFDs include urinary incontinence and erectile dysfunction, which are quite common post-operatively in up to 89% of men[27]. Frequently, after the procedure, these conditions present as having poor bladder control, weakness in pelvic floor muscles (especially urinary sphincters) and changed pelvic nerve supply [28].

Women:[edit | edit source]

  • Age: Menopausal age (48-55) increases risk for developing POP by 21.1% [29][30]
  • Direct injury to pelvic floor muscles controlling urination and loss of pelvic floor muscle tension: The injury to this muscle, often forces other anatomical structures called ligaments, to compensate by giving more support than normal to the affected pelvic floor muscles. However, ligaments and muscles have a different biological design and serve a unique purpose in the body mechanics. By changing their normal functioning, over time, the pelvic floor structures lose their strength, resulting in the occurrence of POP [31].
  • Pregnancy and the nature of childbirth: Vaginal birth, prolonged labour, instrumental delivery, episiotomy (surgical procedure to increase opening in vagina), parity (weight and number of children) have also been known to increase the PFD risk by 4-16% [29][31][32].
  • Genetics and family history: Women who have a family history of POP, are more likely to have the condition[33].In females who are experiencing urinary incontinence, the connective tissue (supports pelvic floor) may be genetically weak[34] [35]
  • 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[30] [36]. The risk also increases to 60% for developing urinary incontinence after hysterectomy among middle-aged women [37]. 

Both Genders:[edit | edit source]

  • Previous injury to pelvic region (e.g. fall or pelvic radiotherapy): A fall causing injury to the pelvic structures, including those responsible for urination or reproduction can present as PFD. Side effects of pelvic radiotherapy involve weakening of pelvic floor muscles in both men and women. In men, radiation for prostate cancer influences erectile dysfunction, and urinary incontinence[38]. For women, pelvic radiation may also lead to urinary incontinence [39].
  • Increased abdominal pressure: Frequent coughing (symptom of chronic lung disease, smoking, hay fever) and persistent sneezing cause overusing pelvic floor muscles. This weakens pelvic floor structures and can lead to release of urine without control [40].It is often presented as POP in women and urinary incontinence in men[31][41].
  • Constipation/heavy lifting: Constipation is caused by changes in pelvic floor muscles and increase in abdominal pressure during bowel movement. These persistent conditions can damage nerves and appear as PFD symptoms, such as fecal incontinence[42]. Occupations that require frequent heavy lifting, add pressure to the bladder and influence urinary incontinence in both genders[43]. Women who perform prolonged heavy lifting, are 9.6 times more at risk of developing POP[35]
  • Intense physical effort: Elite athletes, engaging in high impact sports (e.g. trampolining, running, gymnastics) compared to low impact sports (e.g. golf), tend to experience increase in abdominal pressure, which over time, often leads to urinary incontinence[35][34].
  • Obesity: Being overweight, may be associated with urinary incontinence in both genders and POP in women, compared to those with healthy weight[29][34][38]. Simple modifications such as healthy diet or increase in physical activity may be prescribed to reduce the risk for these conditions.
  • History of back pain: Low back pain might be 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 can prevent normal movement, including the use of pelvic floor muscles. Consequently, they become weaker, unable to support the pelvic floor organs changing urinary function[44].

For more information, you can refer to the links provided below:

For males and females

Are you at risk?[45]

Common problems with pelvic floor muscles [46]                       

Treatment  [edit | edit source]

Pelvic floor dysfunction (PFD) is a very treatable condition. Many ways exist to treat PFD conservatively and should generally be considered as the first-line option prior to more aggressive procedures such as surgery[47][48][49]. Treatment will vary according to the nature of the condition or reason behind the PFD. A health care practitioner, such as your GP or a physiotherapist, will help you decide which one is best for you:

Conservative:[edit | edit source]

Physiotherapy & Exercise:[edit | edit source]

  • 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[50]. PFMT aims to increase the strength, endurance and co-ordination of the muscles, which improves their overall function[49]. 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![51]
  • 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[51]. Please see the links below for some helpful information.
  • 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!:

[52]
[53]
[54]
[55]
[56]

Lifestyle Changes:[edit | edit source]

These may be suggested by the GP to help improve certain aspects of your condition. 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 and overall quality of life[47]. Another helpful incontinence tip is to try and reduce caffeine and other irritants of the bladder (coffee, tea, cola, alcohol etc.),[57] 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 pelvic floor 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.[50]

Pharmacological:[edit | edit source]

  • Various drugs can be prescribed if based on the 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[49]. 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.[58]
  • Pharmacological treatment is even more effective when used in combination with other strategies like PFMT and lifestyle changes.[58]

For more information, please see this NHS website.

Surgical:[edit | edit source]

  • 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.[59]
  • Slightly less invasive options are also available, such as injections of Botox for urge incontinence or bulking agents to help reduce stress incontinence.[60]

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[2].
  • 30% require repeat operations[2].
  • Synthetic mesh is a common surgical method[2].
  • However, there are often complications and there is a 35% removal rate[2].

Access to services[edit | edit source]

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:[edit | edit source]

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:[edit | edit source]

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

Treatment for continence symptoms is offered in several departments within Edinburgh[edit | edit source]
Community Physiotherapy Service. Currently the departments offering this service are:[edit | edit source]
  • Craigroyston Health Clinic
  • Leith Community Treatment Centre
  • Slateford Medical Practice
  • South Queensferry Health Centre
  • Tollcross Health Centre
Conditions which can be helped include:[edit | edit source]
  • 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:[edit | edit source]

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:[edit | edit source]

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:-[edit | edit source]

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:[edit | edit source]

Service can be accessed by:[edit | edit source]

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:[edit | edit source]

Information for healthcare professionals (Physiotherapy specific)[edit | edit source]

Risk factors[edit | edit source]

The chances of developing pelvic floor dysfunction (PFD) among men and women have increased over the past few years. According to Berghmans et al. (2015)[61], this tendency will most likely continue. Therefore, there is a predicted  35% growth in demand for management for pelvic floor conditions between 2010-2030 [62].

These statistics emphasize the importance of expanding knowledge related to the risk factors for PFD. When assessing a patient, physiotherapists should focus on detailed subjective examination including past medical history and presenting condition/complaint, as this may reveal potential predispositions. Goal-centred conversations with the patients can provide guidance in planning a treatment, and where applicable, liaising with appropriate healthcare professionals to ensure a holistic approach to care.

Men

  • Prostate surgery: In general, scientific literature examining PFD among males is limited. However, prostate surgery has been identified as a potential risk factor according to available evidence-based sources [63][64]. Specific PFDs include urinary incontinence and erectile dysfunction, which are quite common post-operatively (up to 89% men suffer from these conditions)[27]. 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[28]. Cavernous nerves responsible for erectile function, may also be disrupted[65].

Women

  • Age:Females experiencing menopause, are at increased risk for developing POP by 21.1%[29]. Wu et al. (2014)[30] assessed the relationship between age and number of pelvic floor disorders. They revealed that with each decade, the risk dramatically increased. This is most likely due to the 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 aging [66].
  • Direct injury to levator ani and loss of tone in pelvic muscles: This involves the levator ani changing position and widening of genital hiatus, causing the pelvic structures to rely on the connective tissue for support. Over time, this alteration results in weakening or tearing of the tissue/collagen and may contribute to the occurrence of POP [31].
  • Pregnancy and the nature of childbirth: Overstretching/damaging of the pudendal 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 PFD risk by 4-16%[29][31][32]. These findings have been supported through biomechanical models of the pelvic floor. The researchers revealed that during the crowning of fetal head in vaginal birth, there is a greater risk for the avulsion of levator ani leading to a potential prolapse. Additionally, episiotomy has been suggested to increase anal lacerations and therefore, incontinence risk [32]. A set of studies within the systematic review noted parity to be a risk factor for primary POP as well[29].
  • Genetics: Women who have a positive family history of POP, are more likely to inherit the condition[33]. Campneau et al. (2011)[67], showed that the risk for POP increased 1.4 times in the genetically predisposed group, after controlling for vaginal deliveries, hysterectomy and incontinence. Additionally, evidence shows that in females who are experiencing urinary incontinence, the connective tissue of the pelvic floor muscles may be genetically weak[34][35].
  • Low socioeconomic status (SES):  This factor, especially among racial minorities, may contribute to poorer access to adequate information regarding PFD[30] [31].The lack of resources create a challenge in recognizing the symptoms and importance of seeking professional support in a timely manner. Hartigan and Smith (2018)[68], 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 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[30] [36]. In the study group, the incidence of postoperative complications after hysterectomy, including urinary and fecal incontinence was significantly higher than in the control group[36]. Being middle-aged, as an additional factor to post-hysterectomy, increases the risk to 60% for developing urinary incontinence[37] .

Both genders

  • 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[38]. In women, pelvic radiation, as suggested by Walters (2017)[39] 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 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[31]. 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[41]. For men, it usually presents as urinary incontinence. The frequent increase in intra-abdominal pressure can lead to opening of the sphincter, despite absence of bladder contraction[40] .
  • 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[69]. Occupations that require frequent heavy lifting, add pressure to the bladder and influence urinary incontinence in both genders[43]. Evidence also shows that women who perform prolonged heavy lifting, are 9.6 times  more at risk of developing POP[35].
  • 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 reported to experience an increase in abdominal pressure through overstretching/overloading of the pelvic floor muscles. Over time the strain and changes in strength of pelvic floor muscles, have shown to be a  potential risk for urinary incontinence[34][35][70]. The implications were also suggested in a study that compared women training competitively on a weekly basis with a non-athletic group. The authors found that athletes were 2.5 times more likely to develop urinary incontinence than the non-athletic group[35].
  • Increased BMI (above 25)/Obesity: Being overweight as measured by BMI, 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)[29][34][38]. With every 5 unit increase in BMI, the urinary incontinence risk rises to 20-70%. This is because of the increased intra-abdominal pressure that adds vesical compression and urethral movement. The continued weakening of pelvic floor muscles, nerve supply, and supporting structures, contribute to ineffective function[71].
  • History of back pain: Low 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. The researchers have found that due to pain levels in the low back, participants’ abilities to maximally contract the pelvic floor muscles was limited. Additionally, low back pain was attributed to loss of motor control in pelvic floor muscles, presenting as genito-urinary dysfunctions (i.e.urinary incontinence)[44].
  • 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:[edit | edit source]

  • 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[72].
  • Other countries spend 2% of their budget on pelvic floor dysfunction[3].
  • 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[edit | edit source]

see adding references tutorial.

  1. ↑ 1.0 1.1 ABRAMS, P., SMITH, A.P. and COTTERILL, N., 2015. The impact of urinary incontinence on health‐related quality of life (HRQoL) in a real‐world population of women aged 45–60 years: results from a survey in France, Germany, the UK and the USA. BJU International. vol. 115, no. 1, pp. 143-152.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 MAXWELL, M., SEMPLE, K., WANE, S., ELDERS, A., DUNCAN, E., ABHYANKAR, P., WILKINSON, J., TINCELLO, D., CALVELEY, E. and MACFARLANE, M., 2017. PROPEL: implementation of an evidence based pelvic floor muscle training intervention for women with pelvic organ prolapse: a realist evaluation and outcomes study protocol. BMC Health Services Research. vol. 17, no. 1, pp. 843.
  3. ↑ 3.0 3.1 3.2 3.3 COOPER, J., ANNAPPA, M., QUIGLEY, A., DRACOCARDOS, D., BONDILI, A. and MALLEN, C., 2015. Prevalence of female urinary incontinence and its impact on quality of life in a cluster population in the United Kingdom (UK): a community survey. Primary Health Care Research & Development. vol. 16, no. 4, pp. 377-382.
  4. ↑ 4.0 4.1 4.2 BEDRETDINOVA, D., FRITEL, X., ZINS, M. and RINGA, V., 2016. The effect of urinary incontinence on health-related quality of life: is it similar in men and women? Urology. vol. 91, pp. 83-89.
  5. ↑ 5.0 5.1 MILSOM, I., COYNE, K.S., NICHOLSON, S., KVASZ, M., CHEN, C.I. and WEIN, A.J., 2014. Global prevalence and economic burden of urgency urinary incontinence: a systematic review. European Urology. Jan, vol. 65, no. 1, pp. 79-95.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 CONTINENCE FOUNDATION OF AUSTRALIA., 2018. Pelvic Floor Muscles in Men [online] [viewed 28 March 2018] Available from:https://www.continence.org.au/pages/pelvic-floor-men.html
  7. ↑ 7.0 7.1 PELVIC FLOOR FIRST., 2016. The Pelvic Floor [online] [viewed 23 March 2018]. Available from:http://www.pelvicfloorfirst.org.au/pages/the-pelvic-floor.html
  8. ↑ PELVIC OBSTETRIC AND GYNAECOLOGICAL PHYSIOTHERAPY., 2016. Pelvic Floor Muscles Exercise for Men [online] [viewed 22 March 2018]. Available from:http://pogp.csp.org.uk/publications/pelvic-floor-muscle-exercises-men
  9. ↑ PELVIC CORE FIRST., 2016. The Pelvic Floor and Core [online] [viewed 29 March 2018]. Available from:http://www.pelvicfloorfirst.org.au/pages/the-pelvic-floor-and-core.html
  10. ↑ 10.0 10.1 10.2 10.3 PELVIC HEALTH AND REHAB CENTRE., 2017. Understanding Pelvic Floor Movement [online] [Viewed 28 March 2018]. Available from:https://www.pelvicpainrehab.com/low-tone-pelvic-floor-dysfunction/4587/pelvic-floor-movement/
  11. ↑ 11.0 11.1 11.2 11.3 FOUNDATION PHYSIOTHERAPY., 2018. 5 Basic Functions of your Pelvic Floor [online] [viewed 29 March 2018]. Available from:http://www.foundationphysio.com/5-basic-functions-of-your-pelvic-floor/
  12. ↑ PROSTATE.NET., 2016. Erectile Dysfunction and the Pelvic Floor Connection [online] [viewed 19 March 2018]. Available from: https://prostate.net/articles/erectile-dysfunction-pelvic-floor-connection
  13. ↑ BETTER HEALTH CHANNEL., 2017. Pelvic Floor [online] [viewed 28 March 2018]. Available from:https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pelvic-floor
  14. ↑ MALE PELVIC FLOOR., 2012. Sexual Dysfunction and the Male Pelvic Floor [online] [viewed 29 March 2018]. Available from:http://malepelvicfloor.com/sd.html
  15. ↑ MALE PELVIC FLOOR., 2012. Urinary Dysfunction and the Male Pelvic Floor [online] [viewed 29 March 2018]. Available from:http://malepelvicfloor.com/urinary.html
  16. ↑ NHS CHOICES., 2018. Pelvic Organ Prolapse Overview [online] [viewed 29 March 2018]. Available from: https://www.nhs.uk/conditions/pelvic-organ-prolapse/
  17. ↑ 17.0 17.1 17.2 HEALTHLINE., 2017. Pelvic Floor Dysfunction [online] [viewed 26 March 2018]. Available from: https://www.healthline.com/health/pelvic-floor-dysfunction#symptoms
  18. ↑ 18.0 18.1 18.2 18.3 18.4 MALE PELVIC FLOOR., 2012. Male Pelvic Floor - Advanced Massage and Bodywork [online] [viewed 26 March 2018]. Available from: http://malepelvicfloor.com/sd.html
  19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 WOMEN'S AND MEN'S HEALTH PHYSIOTHERAPY., 2017. Leading the way in pelvic health [online] [viewed 28 March 2018]. Available from: http://www.wmhp.com.au/
  20. ↑ 20.0 20.1 20.2 20.3 20.4 20.5 20.6 20.7 20.8 20.9 PELVIC FLOOR FIRST., 2017. Pelvic Floor First [online] [viewed 26 March 2018]. Available from: http://www.pelvicfloorfirst.org.au/pages/how-can-i-tellif-i-have-a-pelvic-floor-problem.html
  21. ↑ 21.0 21.1 21.2 21.3 21.4 PELVIC OBSTECTRIC AND GYNAECOLOGICAL PHYSIOTHERAPY., 2016. Pelvic floor muscle exercises (for men) [online] [viewed 26 March 2018]. Available from: http://pogp.csp.org.uk/publications/pelvic-floor-muscle-exercises-men
  22. ↑ 22.0 22.1 22.2 22.3 22.4 22.5 22.6 NHS CHOICES., 2017. Living with incontinence [online] [viewed 28 March 2018]. Available from: https://www.nhs.uk/Livewell/incontinence/Pages/Livingwithincontinence.aspx
  23. ↑ 23.0 23.1 HAY-SMITH, E., RYAN, K. and DEAN, S., 2007. The silent, private exercise: experiences of pelvic floor muscle training in a sample of women with stress urinary incontinence. Physiotherapy. vol. 93, no. 1, pp. 53-61.
  24. ↑ 24.0 24.1 24.2 24.3 24.4 .MASON, L., GLENN, S., WALTON, I. and HUGHES, C., 2001. The instruction in pelvic floor exercises provided to women during pregnancy or following delivery. Midwifery. 2001, vol. 17, no. 1, pp. 55-64.
  25. ↑ 25.0 25.1 25.2 25.3 NEELS, H., DE WACHTER, S., WYNDAELE, J., VAN AGGELPOEL, T. and VERMANDEL, A., 2018. Common errors made in attempt to contract the pelvic floor muscles in women early after delivery: A prospective observational study. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 01, vol. 220, pp. 113-117.
  26. ↑ 26.0 26.1 HIRSCHHORN, A.D., KOLT, G.S. and BROOKS, A.J., 2013. Barriers and enablers to the provision and receipt of preoperative pelvic floor muscle training for men having radical prostatectomy: a qualitative study. BMC Health Services Research. vol. 13, no. 1, pp. 305.
  27. ↑ 27.0 27.1 DOREY,G., 2013. Pelvic floor exercises after radical prostatectomy. British Journal of Nursing.October,vol.14, no.5, pp.457-464.
  28. ↑ 28.0 28.1 HOYLAND, K., VASDEV, N., ABROF, A. and BOUSTEAD, G., 2014. Post-radical prostatectomy incontinence: etiology and prevention. Reviews in urology. October, vol.16, no.4, p.181-188.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 29.5 29.6 VERGELDT, T.F., WEEMHOFF, M., INTHOUT, J. and KLUVIERS, K.B., 2015. Risk factors for pelvic organ prolapse and its recurrence: a systematic review. International urogynecology journal. November, vol.26, no.11, pp.1559-1573.
  30. ↑ 30.0 30.1 30.2 30.3 30.4 WU, J.M., VAUGHN, C.P., GOODE, P.S., REDDEN, D.T., BURGIO, K.L., RICHTER, H.E. and MARKLAND, A.D., 2014. Prevalence and trends of symptomatic pelvic floor disorders in US women. Obstetrics and gynecology, January, vol. 123, no.1, p.141-148.
  31. ↑ 31.0 31.1 31.2 31.3 31.4 31.5 31.6 KUNCHARAPU, I., MAJERONI, B.A. and JOHNSON, D.W., 2010. Pelvic organ prolapse. Am Fam Physician. May, vol.81, no.9, pp.1111-1117.
  32. ↑ 32.0 32.1 32.2 HANDA, V.L., BLOMQUIST, J.L., McDERMOTT, K.C., FRIEDMAN, S. and MUNOZ, A., 2012. Pelvic floor disorders after childbirth: effect of episiotomy, perineal laceration, and operative birth. Obstetrics and gynecology. February,vol.119, no.2, p.233-239.
  33. ↑ 33.0 33.1 LINCE, S.L., van KEMPEN, L.C., VIERHOUT, M.E. and KLUVIERS, K.B., 2012. A systematic review of clinical studies on hereditary factors in pelvic organ prolapse. International urogynecology journal. October, vol.23, no.10, pp.1327-1336.
  34. ↑ 34.0 34.1 34.2 34.3 34.4 34.5 BO, K., 2012. Urinary incontinence, pelvic floor dysfunction, exercise and sport. Sports Medicine. June,vol.34, no.7, pp.451-464.
  35. ↑ 35.0 35.1 35.2 35.3 35.4 35.5 35.6 NYGAARD, I.E. and SHAW, J.M., 2016. Physical activity and the pelvic floor. American Journal of Obstetrics & Gynecology. February, vol. 214, no.2, pp.164-171.
  36. ↑ 36.0 36.1 36.2 LUKANOVIC, A. and DRAZIC, K., 2010. Risk factors for vaginal prolapse after hysterectomy. International Journal of Gynecology & Obstetrics. July, vol.110, no.1, pp.27-30.
  37. ↑ 37.0 37.1 HUMALAJARVI, N., AUKEE P., KAIRALUOMA, M.V., STACH-LEMPINEN, B., SINTONEN, H., VALPAS, A. and HEINONEN, P.K., 2014. Quality of life and pelvic floor dysfunction symptoms after hysterectomy with or without pelvic organ prolapse. European Journal of Obstetrics and Gynecology and Reproductive Biology. November, vol.182, no.1, pp.16-21.
  38. ↑ 38.0 38.1 38.2 38.3 THOMAS, R.J., HOLM, M., WILLIAMS, M., BOWMAN, E., BELLAMY, P., ANDREYEV, J. and MAHER, J., 2013. Lifestyle factors correlate with the risk of late pelvic symptoms after prostatic radiotherapy. Clinical Oncology. April, vol. 25, no.4, pp.246-251.
  39. ↑ 39.0 39.1 WALTERS, M.D., 2017. Pelvic floor disorders in women: an overview. Revista de Medicina de la Universidad de Navarra. October, vol. 48, no. 4, pp.9-18.
  40. ↑ 40.0 40.1 KHANDELWAL, C. and KISTLER, C., 2013. Diagnosis of urinary incontinence. Am Fam Physician. April, vol. 87, no.8, pp.543-550.
  41. ↑ 41.0 41.1 CHOI, K.H. and HONG, J.Y., 2014. Management of pelvic organ prolapse. Korean journal of urology. November, vol.55, no.11, pp.693-702.
  42. ↑ JAMSHED, N., LEE, Z.E. and OLDEN, K.W., 2011. Diagnostic approach to chronic constipation in adults. American family physician. August, vol. 84, no.3, p.299-306.
  43. ↑ 43.0 43.1 NASER, S.S.A. and SHAATH, M.Z., 2016. Expert system urination problems diagnosis. World Wide Journal of Multidisciplinary Research and Development, vol.2, no.5, pp.9-19.
  44. ↑ 44.0 44.1 ARAB, A.M., BEHBAHANI, R.B., LORESTANI, L. and AZARI, A., 2010. Assessment of pelvic floor muscle function in women with and without low back pain using transabdominal ultrasound. Manual therapy. June, vol.15, no.3, pp.235-239.
  45. ↑ PELVIC FLOOR FIRST., 2017. Who's at risk?  [online] [viewed 28 March 2018]. Available from:  www.pelvicfloorfirst.org.au/pages/are-you-at-risk.html
  46. ↑ CONTINENCE FOUNDATION OF AUSTRALIA., 2018. Common problems with pelvic floor muscles [online] [viewed 28 March 2018]. Available from: https://www.continence.org.au/pages/what-can-happen-to-the-pelvic-floor-muscles.html
  47. ↑ 47.0 47.1 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
  48. ↑ ROBERT, M., and ROSS, S., 2006. Conservative management of urinary incontinence. Journal of Obstetrics and Gynaecology Canada. Vol. 28 (12), pp. 1113-1118.
  49. ↑ 49.0 49.1 49.2 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.
  50. ↑ 50.0 50.1 KNOWLES, K., 2018. Pelvic floor Dysfunction [online]. PHYSIOWORKS [viewed online March 26, 2018]. Available from: https://physioworks.com.au/Injuries-Conditions/Regions/pelvic-floor-dysfunction
  51. ↑ 51.0 51.1 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
  52. ↑ USMLEFastTrack. Progressive PFE Episode 1. Available from: https://www.youtube.com/watch?v=HrRjumD_o4s [last accessed 10/03/18]
  53. ↑ USMLEFastTrack. Progressive PFE Episode 2. Available from: https://www.youtube.com/watch?v=lwM_wwjerv8&list=PLqo18HBnle8zPU3gLkr9l49iAotngDB21&index=7 [last accessed 10/03/18]
  54. ↑ USMLEFastTrack. Progressive PFE Episode 3. Available from: https://www.youtube.com/watch?v=lp0ND0s3ZHQ&list=PLqo18HBnle8x4NKtYCobjU3DYmnJrOJA-&index=3 [last accessed 10/03/18]
  55. ↑ USMLEFastTrack. Progressive PFE Episode 4. Available from: https://www.youtube.com/watch?v=wRKhtfbJHdo [last accessed 10/03/18]
  56. ↑ USMLEFastTrack. Progressive PFE Episode 5. Available from: https://www.youtube.com/watch?v=OKvP3C8-Jxc&index=5&list=PLqo18HBnle8x4NKtYCobjU3DYmnJrOJA-[last accessed 10/03/18]
  57. ↑ SASKATCHEWAN MINISTRY OF HEALTH, 2014. Information for women about urinary incontinence and vaginal prolapse. [online]. [viewed March 26, 2018]. Available from: http://www.sasksurgery.ca/pdf/self-management-incontinence.pdf
  58. ↑ 58.0 58.1 NHS., 2018. Urinary Incontinence. [online]. [viewed March 10, 2018]. Available from: https://www.nhs.uk/conditions/urinary-incontinence
  59. ↑ NHS, 2018. Urinary Incontinence - Surgery and Procedures [online]. [viewed March 26, 2018]. Available from: https://www.nhs.uk/conditions/urinary-incontinence/surgery/
  60. ↑ NATIONAL INSTITUTE OF CHILD HEALTH AND HUMAN DEVELOPMENT, 2018. How are pelvic floor disorders commonly treated? [online]. [viewed March 26, 2018] Available from: https://www.nichd.nih.gov/health/topics/pelvicfloor/conditioninfo/treatment
  61. ↑ BERGHMANS, B., NIEMAN, F., LEUE, C., WEEMHOFF, M., BREUKINK, S. and VAN KOEVERINGE, G., 2016. Prevalence and triage of first contact pelvic floor dysfunction complaints in male patients referred to a Pelvic Care Centre. Neurourology and urodynamics. April,vol.35, no.4, pp.487-491.
  62. ↑ KIRBY, A.C., LUBER, K.M. and MENEFEE, S.A., 2013. An update on the current and future demand for care of pelvic floor disorders in the United States. American Journal of Obstetrics & Gynecology. August, vol.209, no.6, pp.584-e1.
  63. ↑ NHS TRUST., 2014. National Health Service [online]. [viewed 19th March 2018]. Available from: http://www.ouh.nhs.uk/patient-guide/leaflets/files/11124Ppelvic.pdf
  64. ↑ CSP., 2014. Chartered Society of Physiotherapy [online]. [viewed 19 March 2018]. Available from: www.csp.org.uk/sites/files/csp/secure/pogp-pelvicfloor-male.pdf
  65. ↑ GLINA, S., 2011. Erectile dysfunction after radical prostatectomy. Drugs & aging. April, vol.28, no.4, pp.257-266.
  66. ↑ FROTA, I.P.R., ROCHA, A.B.O., NETO, J.A.V., VASCONCELOS, C.T.M., DE MAGALHAES, T.F., KARBAGE, S.A.L., AUGUSTO, K.L., NASCIMENTO, S.L.D., HADDAD, J.M. and BEZERRA, L.R.P.S., 2018. Pelvic floor muscle function and quality of life in postmenopausal women with and without pelvic floor dysfunction. Acta obstetricia et gynecologica Scandinavica. 
  67. ↑ CAMPEAU, L., GORBACHINSKY, I., BADLANI, G.H. and Andersson, K.E., 2011. Pelvic floor disorders: linking genetic risk factors to biochemical changes. BJU international, October, vol.108, no.8, pp.1240-1247.
  68. ↑ HARTIGAN, S.M. and SMITH, A.L., 2018. Disparities in Female Pelvic Floor Disorders. Current urology reports. February, vol.19, no.2, p.16-22.
  69. ↑ JAMSHED, N., LEE, Z.E. and OLDEN, K.W., 2011. Diagnostic approach to chronic constipation in adults. American family physician. August, vol. 84, no.3, p.299-306.
  70. ↑ CONTINENCE FOUNDATION AUSTRALIA 2016. [online] [viewed 17 March 2018]. Available from: http://www.pelvicfloorfirst.org.au/pages/are-you-at-risk.html. 
  71. ↑ RAMALINGAM, K. and MONGA, A., 2015. Obesity and pelvic floor dysfunction. Best practice & research Clinical obstetrics & gynaecology. May, vol.29, no.4, pp.541-547.
  72. ↑ HAGEN, S., STARK, D., GLAZENER, C., DICKSON, S., BARRY, S., ELDERS, A., FRAWLEY, H., GALEA, M.P., LOGAN, J. and MCDONALD, A., 2014. Individualised pelvic floor muscle training in women with pelvic organ prolapse (POPPY): a multicentre randomised controlled trial. The Lancet. vol. 383, no. 9919, pp. 796-806.
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