Pelvic Floor Dysfunction

What the pelvic floor does

The pelvic floor is a hammock of muscles and connective tissue stretching from the pubic bone to the tailbone. It:

• supports the bladder, bowel and uterus or prostate
• keeps the openings of the urethra and anus closed (continence)
• relaxes to allow urination and bowel movements
• contributes to sexual function and core stability

Problems arise when these muscles cannot contract or relax at the right time.

Types and symptoms

Weak (underactive) pelvic floor

• leaking urine with coughing, sneezing, laughing or exercise (stress urinary incontinence)
• leaking stool or gas (fecal incontinence)
• a heavy, dragging feeling or bulge in the vagina from pelvic organ prolapse
• reduced sensation during sex

Tight (overactive or non-relaxing) pelvic floor

• chronic constipation with straining, a feeling of blockage, and incomplete emptying (dyssynergic defecation)
• needing to push on the vagina or perineum to empty the bowel
• slow urine stream, hesitancy, frequency or urgency
• pain in the pelvis, lower back, hips, genitals, rectum or tailbone
• painful sex, or difficulty with tampon insertion or pelvic exams (vaginismus)
• in men, pelvic pain, pain after ejaculation and urinary symptoms, often diagnosed as chronic prostatitis/chronic pelvic pain syndrome

Some people have both weak and tight features.

Causes and risk factors

• pregnancy and vaginal childbirth, especially large babies, forceps delivery or tears
• menopause and lower estrogen
• aging
• chronic constipation and straining
• chronic cough, obesity and heavy lifting
• pelvic surgery or radiation (hysterectomy, prostatectomy)
• pelvic injury
• habitually holding urine or stool
• anxiety and stress, which promote muscle tension
• nerve conditions such as diabetes, MS or spinal problems

Diagnosis

• History: bladder, bowel and sexual symptoms; childbirth and surgical history; a bladder or bowel diary.
• Examination: internal vaginal or rectal assessment of muscle strength, tone, tenderness and coordination; checking for prolapse.
• Tests: urine test, post-void residual scan, urodynamics for complex bladder symptoms, anorectal manometry and balloon expulsion test for bowel symptoms, defecography and pelvic ultrasound or MRI in selected cases.

Treatment

Pelvic floor physical therapy

A specialist pelvic health physical therapist is the cornerstone of treatment:

• for weak muscles: supervised pelvic floor muscle training (Kegel exercises), done correctly and consistently for at least 3 months
• for tight muscles: relaxation training, breathing, stretching, manual therapy and trigger point release. Kegels can make tight pelvic floors worse.
• biofeedback: sensors show muscle activity on a screen to retrain coordination; highly effective for dyssynergic defecation

Lifestyle and habits

• avoid straining: use a footstool on the toilet, take time, and keep stools soft with fiber and fluids
• treat chronic cough and maintain a healthy weight
• bladder training for urgency
• limit bladder irritants such as caffeine
• lift with good technique

Devices and medicines

• vaginal pessaries to support prolapse or reduce leaking
• vaginal estrogen after menopause
• medicines for overactive bladder
• laxatives for constipation
• muscle relaxants or pain medicines for some pelvic pain

Procedures and surgery

• urethral bulking or sling surgery for stress incontinence
• prolapse repair
• sacral nerve stimulation for bladder or bowel control
• botulinum toxin injections into tight pelvic floor muscles in selected cases

Prevention

Pelvic floor exercises during and after pregnancy, avoiding chronic straining, staying active and maintaining a healthy weight reduce the risk.

Frequently asked questions

What are the symptoms of pelvic floor dysfunction?

Symptoms include leaking urine or stool, frequent or urgent urination, constipation with straining or incomplete emptying, a vaginal bulge or heaviness, pelvic or low back pain, and pain during sex.

What is a tight pelvic floor?

A tight or overactive pelvic floor is when the muscles stay contracted and cannot relax properly. It can cause constipation, straining, slow urination, pelvic pain and painful sex. Relaxation-based physical therapy, rather than Kegels, is the main treatment.

Can men have pelvic floor dysfunction?

Yes. Men can develop pelvic floor problems after prostate surgery, with chronic constipation, or with chronic pelvic pain syndrome. Symptoms include leaking urine, pelvic pain, pain with ejaculation and urinary difficulties.

How long does pelvic floor therapy take to work?

Many people notice improvement within 6 to 12 weeks of regular therapy and home exercises. Continuing exercises long term helps maintain results.