Pelvic floor disorders

Pelvic floor disorders
Other names: Pelvic floor dysfunction
Location of pelvis muscles in a female
SpecialtyGynecology, urology
SymptomsPelvic pain or pressure, pain during sex, incontinence of urine or stool, constipation, pelvic organ prolapse[1]
Usual onsetOlder age[2]
CausesUnclear[1]
Risk factorsOverweight, prior hysterectomy, smoking, having children[2]
TreatmentLifestyle changes, medication, medical devices, surgery[2]
FrequencyCommon (25% of women)[2]

Pelvic floor disorders, also known as pelvic floor dysfunction, is group of conditions believed to occur when pelvic floor muscles are not functioning properly.[1][3] Symptoms may include pelvic pain or pressure, pain during sex, incontinence of urine or stool, constipation, or pelvic organ prolapse.[1]

The cause is generally unclear.[1] Potential factors may include injury to the pelvic floor, sexual abuse, poorly learned evacuation techniques, lower back pain, endometriosis, and certain medications such as calcium channel blockers or antihistamines.[1] Risk factors include being overweight, prior hysterectomy, smoking, and having children.[2] The underlying mechanism may involve increase, decreased, or poorly coordinated muscle activity.[1]

Treatment may include lifestyle changes, medication, medical devices, or surgery.[2] Lifestyle changes may include, exercising and a healthy diet.[2] Medical devices may include pessaries.[2] In women, pelvic floor physical therapy, is often useful.[3]

Pelvic floor disorders are common, affected about 25% of women at some point in time.[2] They affects females more often than males.[1][4] The disorders become more common with age.[2] Pelvic organ prolapse occurs in half of women who have given birth.[5][1] Stigmatization occurs in some cultures and therefore women may not seek care.[2] It is thus recommended that direct screening for urinary problems occur yearly.[2]

Definition

Pelvic floor dysfunction may include any of a group of clinical conditions that includes urinary incontinence, fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction and several chronic pain syndromes, including vulvodynia in women and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men. The three most common and definable conditions encountered are urinary incontinence, anal incontinence and pelvic organ prolapse.

Causes

Mechanistically, the causes of pelvic floor dysfunction are two-fold: widening of the pelvic floor hiatus and descent of pelvic floor below the pubococcygeal line, with specific organ prolapse graded relative to the hiatus.[6] Associations include obesity, menopause, pregnancy and childbirth.[7] Some women may be more likely to developing pelvic floor dysfunction because of an inherited deficiency in their collagen type. Some women may have congenitally weak connective tissue and fascia and are therefore at risk of stress urinary incontinence and pelvic organ prolapse.[8]

By definition, postpartum pelvic floor dysfunction only affects women who have given birth, though pregnancy rather than birth or birth method is thought to be the cause. A study of 184 first-time mothers who delivered by Caesarean section and 100 who delivered vaginally found that there was no significant difference in the prevalence of symptoms 10 months following delivery, suggesting that pregnancy is the cause of incontinence for many women irrespective of their mode of delivery. The study also suggested that the changes which occur to the properties of collagen and other connective tissues during pregnancy may affect pelvic floor function.[9]

Pelvic floor dysfunction can result after pelvic radiation,[10] as well as treatment for gynegological cancers.[11]

Diagnosis

Pelvic floor dysfunction can be diagnosed by history and physical exam, though it is more accurately graded by imaging. Historically, fluoroscopy with defecography and cystography were used, though modern imaging allows the usage of MRI to complement and sometimes replace fluoroscopic assessment of the disorder, allowing for less radiation exposure and increased patient comfort, though an enema is required the evening before the procedure. Instead of contrast, ultrasound gel is used during the procedure with MRI. Both methods assess the pelvic floor at rest and maximum strain using coronal and sagittal views. When grading individual organ prolapse, the rectum, bladder and uterus are individually assessed, with prolapse of the rectum referred to as a rectocele, bladder prolapse through the anterior vaginal wall a cystocele, and small bowel an enterocele.[12]

To assess the degree of dysfunction, three measurements must be taken into account. First, an anatomic landmark known as the pubococcygeal line must be determined, which is a straight line connecting the inferior margin of the pubic symphysis at the midline with the junction of the first and second coccygeal elements on a sagittal image. After this, the location of the puborectalis muscle sling is assessed, and a perpendicular line between the pubococcygeal line and muscle sling is drawn. This provides a measurement of pelvic floor descent, with descent greater than 2 cm being considered mild, and 6 cm being considered severe. Lastly, a line from the pubic symphysis to the puborectalis muscle sling is drawn, which is a measurement of the pelvic floor hiatus. Measurements of greater than 6 cm are considered mild, and greater than 10 cm severe. The degree of organ prolapse is assessed relative to the hiatus. The grading of organ prolapse relative to the hiatus is more strict, with any descent being considered abnormal, and greater than 4 cm being considered severe.[6]

Treatment

There are several approaches to treatment of pelvic floor dysfunction, and often several approaches are used in combination.

Lifestyle

Treatment for pelvic floor dysfunction, especially the symptom of urinary incontinence, is essential, but so is prevention. Patients are usually encouraged to change their lifestyles; interventions such as reducing body weight, limiting the use of stimulants, quitting smoking, limiting strenuous efforts, preventing constipation and increasing physical activity can help prevent pelvic floor dysfunction.[13] For those that already have diagnosed pelvic floor dysfunction, symptoms can be eased by physical activity, especially abdominal exercises and pelvic floor exercises (Kegels) that strengthen the pelvic floor. Symptoms of urinary incontinence can also be reduced by making dietary changes such as limiting intake of acidic and spicy foods, alcohol and caffeine.[14]

Medication

Overactive bladder can be treated with medications, including those in the class of antimuscarinics and beta 3 agonists. Antimuscarinics are the most commonly used, however, beta 3 agonists can be used for those that are unable to take antimuscarinics due to side effects or other reasons.[15]

Physical therapy

Pelvic floor muscle (PFM) training is vital for treating different types of pelvic floor dysfunction. Two common problems are uterine prolapse and urinary incontinence both of which stem from muscle weakness. Pelvic floor muscle therapy is the first-line of treatment for urinary incontinence and thus should be considered before more invasive procedures such as surgery.[16] Being able to control the pelvic floor muscles is vital for a well functioning pelvic floor. Without the ability to control the pelvic floor muscles, pelvic floor training cannot be done successfully. Pelvic floor muscle therapy strengthens the muscles of the pelvic floor through repeated contractions of varying strength.[16] Through vaginal palpation exams and the use of biofeedback, the tightening, lifting, and squeezing actions of these muscles can be determined. Biofeedback can be used to treat urinary incontinence as it records contractions of the pelvic floor muscles and can help patients become aware of the use of their muscles.[13] PFM training can also increase female sexual satisfaction by improving sexual function and the ability to orgasm.[17]

In addition, abdominal muscle training has been shown to improve pelvic floor muscle function.[18] By increasing abdominal muscle strength and control, a person may have an easier time activating the pelvic floor muscles in sync with the abdominal muscles. Many physiotherapists are specially trained to address the muscle weaknesses associated with pelvic floor dysfunction and can effectively treat pelvic floor dysfunction through strengthening exercises.[19] Overall, physical therapy can significantly improve the quality of life of those with pelvic floor dysfunction by relieving symptoms.

Devices

A pessary is a plastic or silicone device that may be used for women with pelvic organ prolapse. This treatment is useful for individuals who do not want to have surgery or are unable to have surgery due risk of the procedure. Some pessaries have a knob that can also treat urinary incontinence. To be effective, pessaries must be fit by a medical provider and the largest device that fits comfortably should be used.[20]

Surgery

Surgery is performed when desired by the patient or when less invasive treatments, such as lifestyle modification and physical therapy, are not effective.[21] There are various procedures used to address prolapse. Cystoceles are treated with a surgical procedure known as a Burch colposuspension, with the goal of suspending the prolapsed urethra so that the urethrovesical junction and proximal urethra are replaced in the pelvic cavity. Uterine prolapse is treated with hysterectomy and uterosacral suspension. With enteroceles, the prolapsed small bowel is elevated into the pelvis cavity and the rectovaginal fascia is reapproximated. Rectoceles, in which the anterior wall of the rectum protrudes into the posterior wall of the vagina, require posterior colporrhaphy, also known as repair of the vaginal wall.[22] Though pelvic floor dysfunction is more common in women, there are also proven methods to assist men. In severe cases of pelvic floor dysfunction causing urinary incontinence, a radical prostatectomy followed by postoperative pelvic floor muscle therapy is an option.[23]

Epidemiology

The condition is widespread, affecting up to 50 percent of women at some point in their lifetime.[6] About 11 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse by age 80.[24] 30 percent of those undergoing surgery will have at least two surgeries in trying to correct the problem.

References

  1. 1 2 3 4 5 6 7 8 9 Grimes, WR; Stratton, M (January 2020). "Pelvic Floor Dysfunction". PMID 32644672. {{cite journal}}: Cite journal requires |journal= (help)
  2. 1 2 3 4 5 6 7 8 9 10 11 12 Good, MM; Solomon, ER (September 2019). "Pelvic Floor Disorders". Obstetrics and gynecology clinics of North America. 46 (3): 527–540. doi:10.1016/j.ogc.2019.04.010. PMID 31378293.
  3. 1 2 Wallace, SL; Miller, LD; Mishra, K (December 2019). "Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women". Current opinion in obstetrics & gynecology. 31 (6): 485–493. doi:10.1097/GCO.0000000000000584. PMID 31609735.
  4. ↑ Lakhoo, J; Khatri, G; Elsayed, RF; Chernyak, V; Olpin, J; Steiner, A; Tammisetti, VS; Sundaram, KM; Arora, SS (November 2019). "MRI of the Male Pelvic Floor". Radiographics : a review publication of the Radiological Society of North America, Inc. 39 (7): 2003–2022. doi:10.1148/rg.2019190064. PMID 31697623.
  5. ↑ Hagen S, Stark D (2011). "Conservative prevention and management of pelvic organ prolapse in women". Cochrane Database Syst Rev. 12 (12): CD003882. doi:10.1002/14651858.CD003882.pub4. PMID 22161382.
  6. 1 2 3 Boyadzhyan, L; Raman, S. S.; Raz, S (2008). "Role of static and dynamic MR imaging in surgical pelvic floor dysfunction". RadioGraphics. 28 (4): 949–67. doi:10.1148/rg.284075139. PMID 18635623.
  7. ↑ "Abbey Hospitals Gynaecology and Vaginal Repair information". Archived from the original on 2011-09-07. Retrieved 2020-09-04.
  8. ↑ "Pelvic Floor Dysfunction Expanded Version | ASCRS". www.fascrs.org. Archived from the original on 2017-12-03. Retrieved 2017-12-02.
  9. ↑ Lal, M; h Mann, C; Callender, R; Radley, S (2003). "Does cesarean delivery prevent anal incontinence?". Obstetrics and Gynecology. 101 (2): 305–12. doi:10.1016/s0029-7844(02)02716-3. PMID 12576254. S2CID 25647029.
  10. ↑ Bernard, Stéphanie; Ouellet, Marie-Pier; Moffet, Hélène; Roy, Jean-Sébastien; Dumoulin, Chantale (April 2016). "Effects of radiation therapy on the structure and function of the pelvic floor muscles of patients with cancer in the pelvic area: a systematic review". Journal of Cancer Survivorship. 10 (2): 351–362. doi:10.1007/s11764-015-0481-8. hdl:1866/16374. ISSN 1932-2259. PMID 26314412. S2CID 13563337.
  11. ↑ Ramaseshan, Aparna S.; Felton, Jessica; Roque, Dana; Rao, Gautam; Shipper, Andrea G.; Sanses, Tatiana V. D. (2017-09-19). "Pelvic floor disorders in women with gynecologic malignancies: a systematic review". International Urogynecology Journal. 29 (4): 459–476. doi:10.1007/s00192-017-3467-4. ISSN 0937-3462. PMC 7329191. PMID 28929201.
  12. ↑ El Sayed, R. F.; El Mashed, S; Farag, A; Morsy, M. M.; Abdel Azim, M. S. (2008). "Pelvic floor dysfunction: Assessment with combined analysis of static and dynamic MR imaging findings". Radiology. 248 (2): 518–30. doi:10.1148/radiol.2482070974. PMID 18574134. S2CID 5491294. Archived from the original on 2021-08-28. Retrieved 2020-09-04.
  13. 1 2 Kopańska M, Torices S, Czech J, Koziara W, Toborek M, Dobrek Ł (2020-06-25). "Urinary incontinence in women: biofeedback as an innovative treatment method". Therapeutic Advances in Urology. 12: 1756287220934359. doi:10.1177/1756287220934359. PMC 7325537. PMID 32647538.
  14. ↑ Grimes WR, Stratton M (2021). "Pelvic Floor Dysfunction". StatPearls. Treasure Island (FL): StatPearls Publishing. PMID 32644672. Archived from the original on 2021-12-27. Retrieved 2021-09-17.
  15. ↑ Hong MK, Ding DC (2019-10-01). "Current Treatments for Female Pelvic Floor Dysfunctions". Gynecology and Minimally Invasive Therapy. 8 (4): 143–148. doi:10.4103/GMIT.GMIT_7_19. PMC 6849106. PMID 31741838.
  16. 1 2 Arnouk A, De E, Rehfuss A, Cappadocia C, Dickson S, Lian F (June 2017). "Physical, Complementary, and Alternative Medicine in the Treatment of Pelvic Floor Disorders". Current Urology Reports. 18 (6): 47. doi:10.1007/s11934-017-0694-7. PMID 28585105. S2CID 5230186.
  17. ↑ Verbeek M, Hayward L (October 2019). "Pelvic Floor Dysfunction And Its Effect On Quality Of Sexual Life". Sexual Medicine Reviews. 7 (4): 559–564. doi:10.1016/j.sxmr.2019.05.007. PMID 31351916.
  18. ↑ Mateus-Vasconcelos EC, Ribeiro AM, Antônio FI, Brito LG, Ferreira CH (June 2018). "Physiotherapy methods to facilitate pelvic floor muscle contraction: A systematic review". Physiotherapy Theory and Practice. 34 (6): 420–432. doi:10.1080/09593985.2017.1419520. PMID 29278967. S2CID 3885851.
  19. ↑ Vesentini G, El Dib R, Righesso LA, Piculo F, Marini G, Ferraz GA, et al. (2019). "Pelvic floor and abdominal muscle cocontraction in women with and without pelvic floor dysfunction: a systematic review and meta-analysis". Clinics. 74: e1319. doi:10.6061/clinics/2019/e1319. PMC 6862713. PMID 31778432.
  20. ↑ Jones KA, Harmanli O (2010). "Pessary use in pelvic organ prolapse and urinary incontinence". Reviews in Obstetrics & Gynecology. 3 (1): 3–9. PMC 2876320. PMID 20508777.
  21. ↑ Conway CK, White SE, Russell R, Sentilles C, Clark-Patterson GL, Miller KS, et al. (2020-12-21). "Pelvic Organ Prolapse: A Review of In Vitro Testing of Pelvic Support Mechanisms". The Ochsner Journal. 20 (4): 410–418. doi:10.31486/toj.19.0089. PMC 7755550. PMID 33408579.
  22. ↑ "Pelvic Floor Dysfunction Expanded Version | ASCRS". www.fascrs.org. Archived from the original on 2017-12-03. Retrieved 2017-12-02.
  23. ↑ Strączyńska A, Weber-Rajek M, Strojek K, Piekorz Z, Styczyńska H, Goch A, Radzimińska A (2019-11-12). "The Impact Of Pelvic Floor Muscle Training On Urinary Incontinence In Men After Radical Prostatectomy (RP) - A Systematic Review". Clinical Interventions in Aging. 14: 1997–2005. doi:10.2147/cia.s228222. PMC 6858802. PMID 31814714.
  24. ↑ Fialkow, M. F.; Newton, K. M.; Lentz, G. M.; Weiss, N. S. (2008-03-01). "Lifetime risk of surgical management for pelvic organ prolapse or urinary incontinence". International Urogynecology Journal. 19 (3): 437–440. doi:10.1007/s00192-007-0459-9. ISSN 0937-3462. PMID 17896064. S2CID 10995869.
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