Pelvic Floor Dysfunction

The pelvic floor muscles lie across the base of your pelvis to help keep the pelvic organs – bladder, uterus and bowel – in the correct position. The muscles are held in place by ligaments that support the organs, especially when there is an increase of pressure in the abdomen that occurs with lifting, bending, carrying and straining. This is called intra-abdominal pressure and when it increases the pelvic floor and abdominal muscles brace so that the internal organs such as the uterus and bladder are not pushed downwards. The pelvic floor muscles work to help keep the bladder and bowel openings closed to prevent unwanted leakage (incontinence) and they relax to allow easy bladder and bowel emptying. Good pelvic floor muscles can help with sex by improving the vaginal sensation and your ability to grip.

Up to two-thirds of all women experience a problem with their pelvic floor muscles at some time during their life. The most common problems are leaking with activity, sneezing or coughing (stress urinary incontinence) and pelvic organ prolapse (a feeling of something coming down in the vagina). All the bladder, bowel and sexual functions require good pelvic floor muscles. Effective pelvic floor muscles in pregnancy will reduce the risk of postnatal stress urinary incontinence (SUI).

Pelvic floor dysfunction is more than often not serious; exercises can help recovery considerably. As the pelvic floor muscles aid with toileting, it is not unusual to experience stress incontinence or urgency/frequency. This should be addressed but does not necessarily mean you have a prolapse or that it will progress to a more severe pelvic floor disorder.

Pelvic floor disorders can result in faecal and urinary issues relating to control. They can also result in prolapses. If you feel you have any associated signs or symptoms relating to this you should contact your GP urgently.

• Pregnancy – during and after.
• Being very overweight.
• Menopause – during and after.
• A period of constipation or if constipation is persistent.

Pelvic floor dysfunction is a very common problem ⁽¹⁾. Approximately 67% of women will experience one of the main symptoms related to pelvic floor dysfunction at some point in their life ⁽⁴⁾. Pelvic floor dysfunction can also affect men.

If you are experiencing any of the symptoms of pelvic floor dysfunction then a consultation with your GP or medical professional should be your first step ^{(2, 3)}. They will typically ask you a series of questions, and look to understand your symptoms and how they are affecting you. Tests can then be carried out to explore further. These can include:

• Cystoscopy – test to examine the insides of the bladder to look for problems, such as bladder stones, tumours or inflammation.
• Urinalysis – urine test to detect if you have a bladder infection, kidney problems or diabetes.
• Urodynamics – test to evaluate how the bladder and urethra are working.
• Anal manometry – test to evaluate the strength of the anal sphincter muscles.
• Colonoscopy or sigmoidoscopy – procedure to examine the inside of the colon or the sigmoid (the part of the bowel near the rectum) to look for signs of disease or inflammation that may be causing symptoms.

Lifting – always try to avoid unnecessary strain on your pelvic floor muscles. If you have to lift in your job or daily routine, get advice about safe lifting and equipment to help.

The knack – tighten your pelvic floor muscles before any activity which involves a rise in intra-abdominal pressure – coughing, sneezing, lifting, carrying, bending – even laughing sometimes!

Constipation – get help from your doctor if you tend to strain on the toilet. Make sure that your diet has enough fibre and that you drink at least 1.5 litres of fluid per day.

Bladder problems – do not reduce your fluid intake to try and reduce the frequency as it may make your urine stronger which can cause more irritation of the bladder. Avoid fizzy and caffeinated drinks. To help with the urgency of needing to go to the toilet, sit down if you can, use your pelvic floor muscles to help the bladder relax and wait until the strong urge passes.

Toileting position – using a step or stool under your feet while on the toilet helps create a squatting position which will reduce pressure into your rectum when passing a stool. This will reduce pressure on the ligaments and muscles in this area. It is also important to ensure you always sit and relax on the toilet and not get in a habit of hovering as this does not allow your pelvic floor to relax completely while you empty your bladder.

Relaxation – it is just as important to have pelvic floor muscles that can relax as it is for them to be strong. Increased stress can cause changes to your posture and breathing and this can put more tension in all our muscles, our pelvic floor included. Practising some mindfulness techniques can help to improve our breathing techniques, as well as relax our muscles.

There are many apps available online that can help with this. You can also find out more about simple relaxation methods in our booklet on the ‘Mitchell Method of Relaxation’.

• Weight – if you are overweight, try to lose weight. Even quite small changes in weight can help with your symptoms. Seek help from your doctor if you have tried but not succeeded with weight loss.
• Exercise – if you find that you have stress urinary incontinence with exercise, try a low impact activity such as Pilates/walking/swimming. You might need to avoid very high impact exercises which involve jumping, heavy weights or prolonged increases in intra-abdominal pressure, e.g. double leg lifts, (until your symptoms have been assessed).
• Smoking – try to give up if you can. Your doctor might be able to refer you to a smoking cessation group.

For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a women’s/men’s health specialist physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage.

As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain-relieving treatments to support symptom relief and recovery. Whilst recovering, you might benefit from a further assessment to ensure you are making progress and to establish an appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.

Treatments such as acupuncture, manual therapy, maternity belt prescription or mobility aid prescription may also provide relief, but they are not recommended as stand-alone treatments (2). If your pain is severe then regular pain relief might be needed (5). Your GP can discuss options with you.

1. https://www.nice.org.uk/guidance/GID-NG10123/documents/draft-scope
2. Pelvic floor exercises – NHS www.nhs.uk
3. Pelvic Obstetric and Gynaecological Physiotherapy: Pelvic floor exercises for women: https://thepogp.co.uk/Resources/115/pelvic_floor_muscle_exercises_for_women
4. NHS Squeezy app: https://www.nhs.uk/apps-library/squeezy/