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Summary

Pelvic floor disorder (PFD): a group of conditions that affect the pelvic floor muscles, ligaments, and connective tissue; includes urinary incontinence (UI; eg, stress, urge, mixed), pelvic organ prolapse (POP), bowel control issues (eg, fecal incontinence [FI], gas loss, constipation, difficulty evacuating, obstructive defecation), fistula (less common), and myofascial pelvic floor dysfunction (less common)

Epidemiology: per the National Health and Nutritional Examination survey, 25% of women have ≥1 PFD; individuals with POP may experience UI with or without FI; UI is most common (17%), followed by FI and POP (least common); Wu et al (2011) determined that the surgical rates for UI and POP will increase by 47.2% over the next 40 yr; Subak et al (2001) showed the rising annual direct costs of POP surgeries

Urinary incontinence

Stress UI: classic type; urine leaks while coughing, sneezing, laughing, or jumping; prevalence ranges from 25% to 45%, depending on the amount of leakage; an anatomic issue resulting from loss of urethral support from behind the pubic bone; treatment is similar to POP; baseline treatment is pelvic floor physical therapy (PFPT) or Kegel exercises; vaginal support devices (eg, pessary) and surgery are other options

Overactive bladder (OAB; ie, urge incontinence): impacts 1 in 6 women; incidence increases with age; the negative neural signal from the brain to the bladder is lost, allowing the bladder to contract without brain control; patients have urinary urgency, frequency, and OAB wet (UI and leakage associated with urinary urge; some patients may experience this without feeling an urge); treatment can be done at home and involves behavioral modifications (ie, training the bladder not to feel full at a smaller volume and reducing the frequency of bathroom visits)

Mixed UI: common; combines symptoms of OAB and stress UI; asking patients the appropriate questions is crucial; initially treat the predominant type of UI, but treat both types; focus treatment on the most bothersome symptoms (typically urgency and frequency)

Pelvic organ prolapse: involves loss of pelvic floor support with dropping pelvic organs; herniation through the pelvic floor is bothersome; Nygaard et al (2004) found that some degree of prolapse is nearly ubiquitous (97.7%) in elderly women, based on the POP Quantification System; staging of pelvic support may not necessarily correlate with symptoms; symptoms develop when the prolapse is ≤1 cm from the hymen, causing sensory and neurologic alterations (innervation is more autonomic above the level of the hymen and becomes more somatic at and below the hymen); symptoms include, eg, pressure, bulging, tissue protrusion, urinary symptoms (including difficulty emptying), bowel symptoms, sexual dysfunction, and significantly affect quality of life; ≤33% of patients are depressed or embarrassed and do not discuss POP with providers, family, or caregivers; POP is not physically painful

Meister et al (2019): 85% of women reported some degree of pelvic floor muscle pain on examination (10% reported mild pain, 25% reported severe symptoms, and the rest had moderate symptoms); the degree of reported pain did not correlate with POP symptoms; subjective symptoms included, eg, abdominal pressure, pelvic pressure, pain, sensation of incomplete emptying; objective symptoms included, eg, seeing and feeling a bulge, protrusion of tissue, need to replace the tissue to completely evacuate for urination and defecation; severe muscle pain correlated with subjective symptoms (especially pressure) but not with objective symptoms

Myofascial pelvic floor dysfunction: requires a multidisciplinary approach; hypertonic or hypotonic muscles cause dysfunction; short, tight, and tender pelvic floor muscles with myofascial trigger points cause local and referred pain; can alter physiologic function; obstructed defecation — surgical treatment of rectocele may not provide resolution; puborectalis muscle appears very tight, and relaxation is needed to allow stretching at the anorectal angle and complete defecation; gastrointestinal and colorectal consultation may help; not surgically managed; pelvic floor dyssynergia — performing the Valsalva maneuver during urination or defecation causes paradoxical muscle contraction; train patients to avoid straining; irritative voiding dysfunction — ie, lower urinary tract symptoms; patients report dysuria; cultures for, eg, Neisseria gonorrhoeae, Chlamydia trachomatis, Ureaplasma urealyticum, Mycoplasma genitalium, Mycoplasma hominis, are negative; patients usually have tight pelvic floor muscles (including the obturator internus); significantly improves with PFPT; associated with interstitial cystitis/painful bladder syndrome

Treatment: provide patient education through handouts and weblinks for POP and bladder retraining; counseling sessions are usually too time-consuming to be feasible

Pessary: vaginal support device that can help treat stress incontinence and POP; one study found that a diameter of 65 mm (size 4) is most commonly used; a fitting kit can be helpful

Pelvic floor physical therapy: a program of functional retraining to improve pelvic floor muscle strength, endurance, power, and relaxation in patients with pelvic floor dysfunction; modalities include myofascial release, strengthening exercises, and biofeedback with or without electrical stimulation; there is good evidence to support the effectiveness of PFPT, and it is noninvasive; Li et al (2016) showed improvement in objective POP stage and a greater number of women who reported prolapse improvement; Tu et al (2005) found that 60% to 80% of women reported reduction in pelvic pain following PFPT; Dumoulin et al (2017) found that patients receiving guided PFPT for stress UI were 8 times more likely to report a cure than patients receiving standard care (ie, Kegel exercises at home), likely secondary to adherence to PFPT; Wallace et al (2019) found strong evidence for benefit with hypertonic and hypotonic PFDs, but the evidence for perioperative PFPT was weak, compared with surgery alone

Questions and answers: a trial of 8 sessions of PFPT is recommended as initial treatment; pelvic pain and trauma — a high correlation exists between chronic pelvic pain, myofascial pelvic pain, and trauma; limited studies do not reveal significant improvement from vaginal pain suppositories (eg, gabapentin, baclofen, diazepam); use of electrical stimulation — studies do not reveal significant pelvic floor strengthening following biofeedback with electrical stimulation; in-office percutaneous tibial nerve stimulation and at-home transcutaneous electrical nerve stimulation successfully treat OAB