Pelvic floor dysfunction

Pelvic floor dysfunction (PFD) refers to laxity (low-tone PFD) or tension (high-tone PFD) of the pelvic floor muscles and/or connective tissue. Causes include muscle or nerve damage (e.g., from surgery or trauma), increased intra-abdominal pressure, and genetic conditions. PFD can manifest with urinary or bowel symptoms (e.g., urinary incontinence, constipation), pelvic organ prolapse (POP), sexual dysfunction, a feeling of pressure (e.g., pelvic, rectal), and/or pelvic pain. Diagnosis is based on a focused clinical examination to assess the pelvic floor muscles and adjacent structures (e.g., the rectum). Management includes pelvic floor muscle training and management of associated symptoms (e.g., urinary incontinence).

Pelvic floor muscle laxity or tension can be due to: ^[1][2]

• Muscle or nerve damage (e.g., due to surgery, trauma, chronic straining)
• Increased intra-abdominal pressure (e.g., due to obesity, pregnancy)
• Genetic conditions (e.g., connective tissue disorders, neurological disorders)

• Symptoms of PFD are nonspecific and include: ^[3]
  • Feeling of pressure in the pelvic region or rectum
  • Urinary symptoms, e.g.:
    • Urinary incontinence, urinary urgency
    • Dysuria
  • Defecatory dysfunction
  • Fecal incontinence
  • Lower back pain or pelvic pain
  • Sexual dysfunction (e.g., dyspareunia)
• High-tone PFD more commonly manifests with: ^[4]
  • Chronic constipation with defecatory dysfunction
  • Feeling of incomplete evacuation
  • Dyspareunia
  • Urinary hesitancy, slow stream, and/or straining to void
  • Bladder pain
• Low-tone PFD more commonly manifests with: ^[4]
  • Urinary incontinence
  • POP

Approach ^[4][5]

• PFD is a clinical diagnosis; perform:
  • An external genitalia examination
  • Vaginal examination of the pelvic floor musculature
  • Digital rectal examination ^[4]
  • Musculoskeletal examination of nearby structures (e.g., lumbar spine, pelvis) ^[5]
• Evaluate any associated symptoms (e.g., urinary incontinence).
• If there is diagnostic uncertainty or complexity, refer to a specialist for imaging studies, e.g.: ^[1][2][6]
  • Ultrasound: transperineal or transvaginal
  • MRI: defecography or dynamic movements (e.g., Valsalva maneuver)

Vaginal examination of the pelvic floor musculature ^[5]

• Assess for POP.
• Ask the patient to contract the pelvic floor and assess for normal elevation of the perineum. ^[4]
• Insert a single finger into the vaginal introitus and use the pad of the finger to palpate the surrounding muscles and connective tissue.
• Slowly rotate the finger as though around an imaginary clock to palpate the superficial and deep muscles, bladder, and urethra.
• Ask the patient to contract the pelvic floor muscles around the palpating finger and then relax.
• Signs of high-tone PFD
  • Muscle tightness or thickening
  • Tenderness or pain on palpation
  • Strong contraction
  • Delay or difficulty relaxing the pelvic floor muscles after contracting
• Signs of low-tone PFD
  • POP
  • Weak or no contraction felt on assessment

Before initiation, use a trauma-informed approach and explain the purpose and process of the vaginal examination to all patients. ^[5]

Further assessment

• Obtain further studies guided by associated symptoms.
• Depending on symptom severity, patients may require specialist referral for assessment.

General principles ^[7][8]

• Treatment varies based on the underlying pathophysiology.
  • Low-tone PFD: Treatment focuses on increasing muscle strength.
  • High-tone PFD: Treatment focuses on relaxing the pelvic floor.
• Refer all patients to physical therapy for pelvic floor muscle training.
• Manage any associated symptoms (e.g., urinary incontinence).
• Additional treatments (usually performed by a specialist) may include:
  • Low-tone PFD: surgery
  • High-tone PFD ^[8]
    • Cognitive behavioral therapy
    • Vaginal muscle relaxants (e.g., local benzodiazepines)
    • Trigger point injections
    • Botulinum toxin injections
    • Sacral neuromodulation

Pelvic floor muscle training ^[7]

• Pelvic floor muscle training encompasses techniques to strengthen, relax, and/or improve coordination of the pelvic floor muscles.
• The specific techniques used depend on the patient's symptoms and underlying pathophysiology.
  • Techniques to strengthen the pelvic floor muscles include:
    • Kegel exercises: tightening and relaxing of the pelvic floor muscles ^[9]
    • Electrical stimulation of the pelvic floor muscles
    • Weighted vaginal cones
  • Techniques to help relax the pelvic floor muscles include: ^[8]
    • Myofascial release
    • Trigger point massage
    • Dry needling
• Biofeedback can be used to assess exercise technique. ^[8]

Physical therapy for PFD may also include exercises to strengthen core abdominal and spinal muscles. ^[4][7][8]

Symptom-based management ^[4][8]

• Initiate symptom-based management alongside pelvic floor muscle training.
• Depending on symptom severity, patients may require specialist referral for management.