What are the main pelvic floor dysfunctions and how to treat them

First let's answer the question, what precisely makes up the pelvic floor? Try imagining it as a sling or a hammock made up of muscles and connective tissue that hold your bladder, bowel, and reproductive organs in place. Its responsibilities include pelvic girdle stability, continence, voiding/defecation, and sexuality. Because it consists of so many different parts and is vital for so many functions, there are quite a few things that can go wrong. We call this “constellation of symptoms and anatomic changes” pelvic floor dysfunctions.

The type of dysfunction is dependent on two factors: the functional changes in the muscles and the location.

Let’s start with the functional changes. When the pelvic floor muscles have increased activity it’s called hypertonicity. This means that the muscles can’t relax as well as they should. If there’s decreased activity, it’s called hypotonicity. Hypotonic muscles are weak or injured and have trouble holding up the organs. Lastly, some pelvic floor dysfunctions are caused by a lack of coordination of the pelvic floor muscles. This could be caused by bad habits learned during childhood.

The symptoms will also depend on the location. There are four possibilities:

Anterior - the urethra and bladder
Middle - the vagina and uterus
Posterior - the anus and rectum
General - pain or discomfort felt throughout the pelvis

The most common pelvic floor dysfunctions are urinary incontinence, fecal incontinence, and pelvic organ prolapse. But let’s take a closer look at dysfunctions related to which organs are affected:

Urologic

Difficult urination: hesitancy or delay in the urinary stream
Cystocele: bulging or herniation of the bladder into the vagina
Urethrocele: bulging of the urethra into the vagina
Urinary incontinence: involuntary leakage of urine

Gynecologic

Dyspareunia: pain during or after sex
Uterine prolapse: herniation of the uterus through the vagina
Vaginal prolapse: herniation of the vaginal apex beyond the introitus
Enterocele: bulging or herniation of the intestines into the vagina
Rectocele: bulging or herniation of the rectum into the vagina

Colorectal

Constipation: paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation
Fecal incontinence: involuntary leakage of stool
Rectal prolapse: prolapse of the rectal walls that might protrude through the anus

General

Pelvic pain: chronic pain lasting more than three to six months, unrelated to other defined conditions
Levator spasm or Proctalgia fugax: pain related to the levator ani muscles

Treatment varies depending on which type of pelvic floor dysfunction you have. That’s why it’s extremely important to be diagnosed by a doctor, rather than self-diagnosing yourself with the help of Dr. Google. It’s also important not to wait! You might feel uncomfortable at the thought of going to the doctor about your symptoms, but there are some great treatments, and putting it off until later could only make matters worse.

Once a proper diagnosis is made, treatment will often be multifactorial and tailored to your specific needs. Here are 5 possible treatments ranging from simple habit changes to surgical intervention:

Lifestyle modifications
Medications
Manipulation
Invasive procedure
Surgery

1- Lifestyle Modifications

As usual, diet and exercise make the top of the list. The avoidance of certain foods and drinks and the cessation of smoking can help against urinary frequency and incontinence, anorectal symptoms, or fecal incontinence. A high-fiber diet could help with constipation. A 3-5% weight reduction can decrease urinary incontinence episodes by about 50% as well as improve or prevent prolapse symptoms. After getting your diagnosis, ask your doctor about which foods to avoid and to discuss your healthy body weight.

Exercises are very dependent upon which type of pelvic floor dysfunction you have. For example, Pelvic floor exercises and Kegel exercises could do wonders for urinary incontinence and prolapse symptoms, but are strongly advised against for people with hypertonic, or non-relaxing pelvic floor dysfunction. It’s important to discuss this with your doctor or physical therapist. For more information, read about Kegel exercises for pelvic floor dysfunction.

2- Medications

Another reason to seek help from a healthcare professional is that there may be a pharmaceutical option for your symptoms. For example, topical vaginal estrogen might be prescribed for an overactive bladder, vaginal thinning, and painful sex. On the other hand, certain medications may be causing or contributing to incontinence symptoms. Be open with your doctor about which medications you are taking and ask about treatment possibilities.

3- Manipulation

Depending on which type of pelvic floor dysfunction you have, there are a multitude of ways to ease symptoms manually. The first is physical therapy. Using exercise, massage, and other techniques, a pelvic floor physical therapist is vital in treating pelvic floor dysfunctions. You might get recommended for constipation education classes, pelvic floor retraining exercises or behavior modification.

A pessary is a device inserted into the vagina to ease stress urinary incontinence and prolapse symptoms.

Patient splinting is the act of using your fingers to assist voiding and defecation.

Lastly, biofeedback is a neuromuscular technique for training proper pelvic floor muscle contraction and relaxation form. Using a device, your doctor or therapist can analyze your contractions and work with you to strengthen, relax, or coordinate your contractions based on your needs.

4- Invasive Procedures

Injection of botulinum toxin A for an overactive bladder, sacral nerve stimulation for urinary or fecal incontinence, and pain management using trigger point injections are some examples of invasive treatment options.

5- Surgery

If non-operative measures aren’t working for prolapse symptoms, then surgery could be an option. There is also a procedure called a “mid-urethral sling” for urinary incontinence.

Pelvic floor dysfunctions may be common but that does not make them normal!

Though there are quite a few ways the pelvic floor can malfunction, there are also many treatment options. If you think you might have any of the conditions listed above, find some help. There’s no need to live with discomfort or pain. If you don’t have any of the conditions above but are concerned about the future, read about ways to prevent prolapse and how to do Kegel exercises.

Article written by

Dama Awadallah, Medical Doctor

Research assistant for the Mary S. Easton Center for Disease Research

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References :

Grimes WR, Stratton M. Pelvic Floor Dysfunction. [Updated 2021 Jul 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559246/
https://www.mayoclinic.org/medical-professionals/physical-medicine-rehabilitation/news/treating-patients-with-pelvic-floor-dysfunction/mac-20431390
https://www.healthline.com/health/pelvic-floor-dysfunction#outlook
https://www.nichd.nih.gov/health/topics/pelvicfloor