Pelvic Floor Dysfunction
by: Tim Bertelsman & Brandon Steele, with significant contributions from ICS experts: Dr. Erika Mennerick, Dr. Cindy Howard, and Dr. Erin Ducat.
The pelvic floor is one of the body’s most complex anatomical and functional regions. (1) It serves to enclose the bony pelvic outlet and support the pelvic viscera while allowing controlled outlets for the rectum, urethra, and vagina. (2) Dysfunction of the pelvic floor muscles can produce a range of symptoms, including pain, incontinence, urgency, sexual dysfunction, and organ prolapse. Pelvic floor dysfunction is a frequently overlooked or ignored problem that significantly impacts personal, social, and work activities, mental well-being, and quality of life. (3-5)
The 3 Layers
The pelvic floor can be divided into three layers. (6) The internal layer consists of the peritoneum of the pelvic viscera. The external layer includes the skin of the vulva, scrotum, and perineum. The more robust middle layer comprises the endopelvic fascia and several muscles, including the urogenital sphincter, external anal sphincter, ischiocavernosus, bulbospongiosus, transverse perineal muscles, and levator ani group (pubococcygeus muscle, puborectalis, and iliococcygeus). (6,7) The hammock-shaped pelvic floor muscles attach anteriorly to the symphysis pubis and posteriorly to the coccyx. (7)
In addition to supporting the intestines, urinary bladder, and uterus, the pelvic floor muscles also function in unison to maintain bowel, bladder, and sexual function. (8-10) Voluntary contraction of the pelvic floor muscles lifts the pelvic contents and tightens orifices. (7) During pregnancy, the pelvic floor muscles support the developing fetus and assist with natural delivery. (8,11) Contraction of the sphincter muscles controls the release of the urine, feces, and gas, while relaxation (or the inability to maintain contraction) permits passage. (2,8,10) The pelvic floor muscles also play a significant role in sexual sensation and function for both genders. (10-13)
The pelvic floor contributes substantially to core stability. (71) Coordinated contraction of the pelvic floor muscles is necessary to pressurize the abdominal canister and generate spinal stability. (Please see the Chiro Up Spinal Instability Protocol for a more comprehensive explanation.)
Pelvic Floor Dysfunction
Like any other skeletal muscle, proper pelvic floor function requires the ability to contract both concentrically, as in a Kegel exercise, and eccentrically to accommodate the downward pressure of the diaphragm during inhalation. Pelvic floor dysfunction can arise when muscles are excessively stretched, damaged, or otherwise weakened, leading to stiff and distensile fibers that cannot generate power and sustained contraction. (15) Conversely, pelvic floor muscles can become hypertonic and overactive, causing rapid fatigue. (15) In addition to poor endurance, hypertonicity may result in excess pressure being placed on the bladder with subsequent incontinence. (16)
Estimates suggest that 1 in 4 women are affected by pelvic floor dysfunction (5,17,18) and 50% of women older than 50 years are affected by this condition worldwide, with a direct annual cost of $12 billion. (87-89) Unfortunately, only a small percentage seek medical help. (3) While females account for 95% of pelvic floor presentations, males are not immune and can experience symptoms including chronic pain, prostatitis, and sexual dysfunction. (16,19,20)
Urinary incontinence affects 18.3 million American women, while fecal incontinence impacts 10.6 million, and pelvic floor prolapse affects 3.3 million. (21) The incidence of pelvic floor dysfunction and its related symptoms are expected to increase markedly (35-64%) in future years. (21-23)
Vaginal childbirth is the primary risk factor for pelvic floor dysfunction. More than 90% of women demonstrate some form of pelvic floor injury following vaginal childbirth. (24) A single vaginal delivery increases the likelihood of prolapse ninefold; however, subsequent births do not seem to increase the odds substantially. (25) Delivery-associated risk multipliers include a prolonged second stage of labor, anal sphincter tear, and older maternal age. (24,26) Other contributors to pelvic floor dysfunction include prior surgery, physical or emotional trauma, sexual abuse, obesity, improper performance of Kegel exercises, quickly returning to heavy physical activity postpartum, constipation, a genetic predisposition for weak connective tissue or fascia, nerve damage, pathology (i.e., endometriosis, fibroids, pelvic inflammatory disease, ovarian cysts, ovarian remnant syndrome, vaginitis, hernia, prostatitis, etc.) hormonal changes, and menopause. (27,28)
Significant or repeated trauma can lead to progressive deterioration of the muscles and connective tissues, resulting in prolapse of internal organs. (21) Between 41- 50% of women over the age of 40 show some degree of pelvic organ prolapse. (3) Approximately 5-20% of females will undergo surgery for pelvic organ prolapse. (5,29,30) Between 20-30% of these women will require a repeat operation in the years that follow. (31-33)
Pelvic floor dysfunction presents as a complex clinical picture with a spectrum of potential symptoms, including pain, urinary urgency or incontinence, fecal urgency or incontinence, sexual dysfunction, and pelvic organ prolapse. (2,14,34) Urinary incontinence affects 2/3 of those with pelvic floor dysfunction. (21) However, pelvic pain is the most likely presenting complaint in physical medicine clinics.
When evaluating any pelvic pain, manual therapists should seek to compassionately uncover any potentially related complaints, including bladder or bowel incontinence or GI/GU dysfunction. (18,35) Educating patients and their referring providers about the relevance of this line of questioning may be necessary. (36) The intake history should include a pertinent review of systems, including prior medical and obstetric histories. (37)
The myofascial symptoms of pelvic pain are often described as deep and achy, while rectal and clitoral pain can be sharp and piercing. (38,39) Vaginal symptoms may be described as burning. (38) Myofascial pain frequently affects the perineum, vagina, urethra, and rectum. (40) Referred pain may spread to the suprapubic region, lower abdomen, back, buttocks, and thorax. (40,41) Pelvic floor dysfunction may produce testicular pain in males. (41) Some patients may complain of urinary hesitancy, frequency, or even painful burning. (40,41) A report of chronic bloating is possible. (42) Symptoms are often provoked by urinary voiding, fecal defecation, menses, intercourse, and prolonged walking or sitting. (38,41,43) A sensation of incomplete defecation is not uncommon and may be due to a shortened puborectalis muscle encroaching on the anorectal angle. (38)
Like any other muscle dysfunction syndrome, management hinges on identifying hypotonicity vs. hypertonicity as the primary culprit. Hypertonicity more commonly occurs in high-impact athletes such as runners, cyclists, weight lifters, etc. Hypotonicity often follows pregnancy and childbirth. However, clinicians should remember that diagnostic stereotypes are inherently unpredictable and should be viewed with caution.
Patients with hypertonic pelvic floors frequently report constipation, straining, and pain with intercourse or sexual stimulation, whereas patients with hypotonic pelvic floors complain more often of fecal or gas incontinence, or prolapse. (44) Urinary urgency or incontinence can be a sign of either dysfunction. (45) However, pelvic floor symptoms do not consistently correlate with physical exam findings (1); thus, confirmatory hands-on assessment is irreplaceable. (27)
Manual therapists should carefully consider whether they are the best-suited clinician for the hands-on assessment. Before embarking on any palpatory evaluation of the pelvic floor, examiners must weigh many factors, including scope of practice, training, informed consent, patient expectations, gender preferences, and liability issues. A specialty-trained pelvic floor physical therapist is the most common type of practitioner to perform an internal pelvic floor evaluation. (82)
Palpation of the pelvic floor can differentiate hypertonicity vs. hypotonicity and identify trigger points, which are common culprits for myofascial pain syndrome. The most frequently affected pelvic floor muscles include the pubovaginalis, puborectalis, iliococcygeus, coccygeus, anal sphincter, and obturator internus. (40)
Palpation of a supine patient could employ an around-the-clock pattern to identify tenderness or hypersensitive taut bands in the ischiocavernosus (1:00 and 11:00), bulbocavernosus (2:00 and 10:00), superficial transverse perineal muscles (3:00 and 9:00), anterior levator ani (4:00 and 8:00), and posterior levator ani (5:00 and 7:00). (46) Digital palpation can also confirm muscle function since self-perceived contractions are predictably unreliable. (44) Clinicians should assess for more distant myofascial involvement in the hips, legs, and torso.
Clinicians should screen for functional deficits that may perpetuate pelvic muscular discomfort, particularly hip abductor weakness, lower crossed syndrome, spinal instability, or dysfunctional breathing. (47,48)
Vaginal or anal manometry uses an inserted pressure sensor to quantify muscle contractility. (37,44) Manometry and dynamometry may be more reliable objective mechanisms to measure strength and contraction. (49) Not surprisingly, EMG assessment of patients with pelvic floor dysfunction demonstrates decreased activity and difficulty performing voluntary contraction of the affected muscles. (50) Real-time diagnostic ultrasound may help rule out soft tissue pathology and is also a reliable mechanism for assessing pelvic muscle contraction. (51) Advanced imaging, including MRI, may be necessary to narrow the broad list of differential diagnoses for pelvic pain. (2) MRI provides superior anatomic assessment of the regional structures, including ligaments, muscles and pelvic organs. Additionally, any underlying organic pathology potentially responsible for pelvic dysfunction can be more easily identified with MRI when compared to other modalities. More recently, the use of dynamic sequencing techniques provides an accurate means for identifying pelvic floor weakness, especially when multiple compartments are involved. (86)
Clinicians must recognize that pelvic pain frequently originates from pathology involving the gastrointestinal and genitourinary systems. (35,52) The differential diagnosis for pelvic pain includes urinary tract infection, endometriosis, fibroids, cysts, interstitial cystitis, prostate issues, colorectal lesions. (41,53,54)
Management of pelvic floor dysfunction can prove challenging, as evidenced by the fact that more than 40% of patients suffer from symptoms for more than five years. (3) If left untreated, the problem can be a significant deterrent to intimacy, work, and social functions. (18) The associated symptoms can lead to depression, isolation, and anxiety. (3)
Conservative management of pelvic floor dysfunction consists of myofascial techniques, rehabilitation exercise, and lifestyle advice. Proper management often requires a coordinated multi-disciplinary team to resolve all components, including any underlying comorbidities. (1)
Pelvic floor rehabilitation must be specifically tailored to the patient’s needs. (55) Patients with weak or hypotonic vaginal and anal muscles may benefit from Kegel-type exercises, whereas those with hypertonicity might be better served by techniques like manual therapy, scar tissue manipulation, modalities (ultrasound, e-stim), massage, dilators, breathing re-training, cognitive behavioral therapy, and meditation. (42,44)
Kegel exercises remain the most popular choice of rehab for patients with pelvic floor weakness. Kegel exercises meet the three-main principles of effective muscle training: overload (perform more work than usual), specificity (replicate functional demands), and reversibility (ongoing training required to sustain benefit). (28,56) However, Kegel exercises may worsen cases of hypertonicity and should only be applied when internal palpation has proved necessity and that the exercises are being performed appropriately. (36)
Patients may perform Kegel exercises in any position; however, most find greatest ease while sitting. Patients performing Kegel exercises contract the muscles that stop or slow urination by imagining that they are squeezing and lifting a tampon or marble. (57,58) Similar contractions can be repeated for the anal muscles. Kegel exercises can be performed via both short 1-2 second contractions and longer 10-20 second holds. There is no consensus on the frequency of performing pelvic floor strengthening exercises, and recommendations range between 5 and 200 repetitions per day. (59,60) Some experts advocate for 30 successive short-hold repetitions to the point of fatigue. (27)
Proper instruction and exercise monitoring are essential, as most women with pelvic floor dysfunction have an inaccurate self-perception of pelvic floor muscle contraction. (61) Many patients will often incorrectly bear down, performing a Valsalva maneuver instead of a Kegel.
If a Kegel has been deemed appropriate, manual monitoring by the clinician or internal self-assessment by the patient can confirm a proper lift and squeeze technique. Vaginal or anal electromyography and biofeedback are alternate means of monitoring muscular activity. (37) Compared to manual monitoring, biofeedback devices may enhance the effectiveness of Kegel exercises. (79-81)
One of the quandaries for prescribing Kegel exercises is that a hands-on pelvic exam is essential, however, very few practitioners are qualified and willing to provide that service. Fortunately, core and eccentric pelvic floor training exercises are alternatives to Kegel exercises that may benefit patients with either hypertonicity and hypotonicity.
Movement and balance exercises can be performed in the seated or supine position. Rehab should target the inner core muscles including the pelvic floor and transverse abdominis. Options could include pelvic tilt, pelvic clock, and V-sit exercises. Dynamic stability exercises for the inner core can be performed on a rocker-type board to promote movement of the pelvis in all planes. (85)
The dynamic neuromuscular stabilization bear position allows patients to manage intra-abdominal pressure with the pelvic floor in an elevated position while limiting the tendency to bear down. This allows for eccentric control of the pelvic floor and simultaneous pressurization of the core canister. (36)
Patients with pelvic floor dysfunction often present with paradoxical breathing patterns, so instruction of proper diaphragmatic breathing is crucial. Proper diaphragmatic breathing helps to improve pelvic floor relaxation and allows better coordinated function for overall canister stability. (36)
Pelvic floor muscle training performed for three months can lead to significant quality of life improvements. (62) Women who perform pelvic floor muscle training are five times more likely to report resolution of urinary incontinence. (58) Kegel exercises, when appropriate, have been shown to improve sexual function in both genders (59), including symptoms of erectile dysfunction in men. (16,19)
Similar to the earlier concerns about hands-on palpation, manual therapy procedures deserve a careful appraisal of appropriateness. Myofascial release has shown benefit for pelvic myofascial pain syndrome, particularly in hypertonic patients. (38,63,73) Dry needling, where allowed, may be a helpful technique for reducing myofascial involvement. (83) Studies on Pulsed Electromagnetic Field therapy (PEMF) applied over the sacral nerve roots have shown merit for managing urinary incontinence. (75-77) Extracorporeal Shockwave Therapy (ESWT) is another potentially helpful modality for pelvic floor dysfunction. (78) HVLA manipulation of the pelvis and lumbosacral region has been shown to affect the strength and tone of pelvic floor muscles (27) Acupuncture may be helpful. (42)
Concurrent general aerobic training may enhance outcomes for pelvic floor rehab. (55,64) Regular aerobic exercise may also help maintain improvements achieved through pelvic muscle training. (42) Incorporating Pilates and yoga may be useful adjuncts. (65)
Patient education is a crucial component of recovery. (26) Clinicians must provide a potent rationale and motivation for home exercise. Patients may be taught controlled fluid intake and timed urination skills, although some patients may not respond to bladder training. (36) The natural tendency to avoid fluids can lead to dehydration and subsequent muscle dysfunction. Patients must understand the importance of diet, including limiting caffeine, alcohol, artificial sweeteners, and inflammatory or gas-producing foods. (66) Stress management may be appropriate for some cases. Most importantly, providers must provide an environment of support, empathy, and compassion so that patients are comfortable discussing their concerns.
Pharmacologic considerations include medication for overactive bladder and hormonal deficits. (67,68) Trigger point injections, including Botox®, may help ease the pain of myofascial trigger points. Pudendal nerve blocks or pudendal neuromodulation are considerations. (42) Surgery, including mesh slings, which have come under strong scrutiny in recent years (74) may be necessary when other more conservative measures fail. (69,70)
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