Pelvic Floor Dysfunction
New research is not only suggesting a high risk of Pelvic Floor Dysfunction in women who give childbirth and suffer from obesity, but also in high-level female athletes.
This is what researchers from Brazil had to say: The pelvic floor provides support to all pelvic organs, as well as appropriately closure/opening mechanism of the urethra, vagina, and anus. Therefore, it is likely that female athletes involved in high-impact and in strong-effort activities are at risk for the occurrence of urinary incontinence (UI).
In their study the doctors investigated the occurrence of UI and other PF dysfunctions (PFD) [anal incontinence (AI), symptoms of constipation, dyspareunia (difficult or painful intercourse), vaginal laxity, and pelvic organ prolapse] in 67 amateur athletes compared with a group 96 of nonathletes. The conclusions?
- Athletes are at higher risk to develop urinary incontinence, loss of gas, and sexual dysfunctions, either practicing high-impact or strong-effort activities. Thus, pelvic floor must be considered as an entity and addressed as well. Also, women involved in long-term high-impact and strengthening sports should be advised of the impact of such activities on pelvic floor function and offered preventive PFD strategies as well.1
Recent research has appeared that can help the patient understand Pelvic Floor Dysfunction symptoms like those above and help guide them on treatment and healing courses.
Recently, doctors found that in treating Pelvic Floor Dysfunction, knowledge of what Pelvic Floor Dysfunction is helped the patient’s symptoms and quality of life.
This may sound strange, in that knowledge of how to treat a problems would lead to better results but Pelvic Floor Dysfunction knowledge is limited and is often confused with problems of urinary and bowel incontinence.
Here is what those doctors did: They conducted a “blind” study (not telling the patients what type of education or treatment they were getting). The purpose was to evaluate pelvic floor knowledge and the presence of Pelvic Floor Dysfunction in women office workers. The effects of receiving pelvic floor muscle health education on pelvic floor knowledge and Pelvic Floor Dysfunction were also evaluated.
The women who received pelvic floor muscle exercise education and Pelvic Floor Dysfunction education intervention showed highly significant improvements in pelvic floor knowledge compared with the control group who were not told what the study was all about.
The doctors concluded that an increase in knowledge/awareness following education was significantly associated with an increase in quality of life and a decrease in Pelvic Floor Dysfunction symptoms.2
The Obesity connection
As with many problems of chronic pain, obesity plays a major role. In a recent study doctors acknowledge that obesity is associated with a high prevalence of pelvic floor disorders. Patients with obesity have wide ranging symptoms from urinary, bowel and sexual dysfunction problems as well as uterovaginal collapse. Urinary incontinence, fecal incontinence and sexual dysfunction are more prevalent in patients with obesity.
Uterovaginal prolapse is also more common than in the non-obese population. Weight loss plays a major role in the improvement of these symptoms in such patients. The treatment of symptoms leads to an improvement in their quality of life. However, surgical treatment of these symptoms may be accompanied by an increased risk of complications in obese patients. A better understanding of the mechanism of obesity-associated pelvic floor dysfunction is essential.3
What is Pelvic Floor Dysfunction?
The pelvis consists of three paired bones: the ilium, ischium, and pubis that interconnect and form the innominate bones, meeting in the midline at the pubic symphysis anteriorly and the sacrum posteriorly. The midline joint anteriorly is called the pubic symphysis joint and posteriorly the sacroiliac joint. These are the two joints of the pelvis.
The pelvic floor is composed of muscles and fascia that form a sling from the pubic bone to the tailbone and functions to support the pelvic organs, contraction, and relaxation. The organs include the bladder, the intestines, and the uterus. Their function is critical for urinary and fecal continence and sexual intercourse. The pelvic floor stabilizes the connecting joints of the pelvis.
The pelvic floor muscles attach to the pubis and coccyx. The pubic bones are held together by ligaments and the pubic symphysis. The pubic symphysis is a disc. This disc and the supporting ligaments can be torn or sprained, resulting in pelvic instability. If the pelvic floor muscles are trying to contract and the pelvis is unstable, muscle spasms will occur. The sacrotuberous, sacrococcygeal and sacroiliac ligaments are vital to providing stability in the “back portion” of the pelvic rim upon which the muscles attach.
Pelvic floor dysfunction can be defined as spasm or a lack of coordination of the pelvic floor musculature. In pelvic floor dysfunction, the musculature is sometimes weak and sometimes tight. There also may be an impairment of the sacroiliac joint, the low back, the coccyx, and/or the hip joints. The pelvic organs respond with increased or decreased sensitivity, which results in a wide range of symptoms. Pelvic floor dysfunction is a very disabling condition.
Pelvic floor dysfunction is most common, but not exclusively limited to women of reproductive age, as other women, men and children can suffer from the condition as well.
Symptoms of Pelvic Floor Dysfunction
Spasms of the muscles of the pelvic floor commonly result in urological issues such as poor urine stream, urinary frequency and urgency, and urge incontinence. Pelvic pain or pressure is frequent and is generally severe. Other common symptoms include chronic constipation, lower back pain, genital pain, rectal pain, vulvodynia, erectile dysfunction, pain with sitting, painful intercourse, discomfort with bowel movement, and sleep disturbance.
When an individual experiences muscle spasms, the pain is excruciating, and any activity that puts pressure on the pelvis, the involved organs, and the pelvic floor ligaments is going to make the symptoms worse.
Treatment of Pelvic Floor Dysfunction
Treatment will vary depending on the cause of the condition. Many times, the underlying cause is not determined. Physical therapy is frequently recommended. Doctors have shown that physical therapy can assist with symptoms including urinary incontinence and sexual function.4
Kegel exercises may be encouraged to strengthen the pelvic floor. Other treatments include external and internal soft tissue mobilization, myofascial and trigger point release, visceral manipulation, connective tissue manipulation, deep tissue massage, biofeedback, transcutaneous electrical nerve stimulation (TENS), heat and cold therapy, muscle strengthening, relaxation and reeducation, exercises, stretching, postural education, nerve blocks, and epidurals.
These treatments may offer some relief to the sufferers of pelvic floor dysfunction, but when the underlying problem is an unstable pelvis, they do not mend the actual source of the problem, and therefore do not bring permanent relief. Sufferers continue to live with PFD trying to “control” the symptoms, but the symptoms still decrease their enjoyment of life.
Pelvic Floor ligaments and soft tissue injury and damage
Pelvic floor dysfunction may occur after pregnancy or childbirth. Other causes may be an undiagnosed infection, poor posture from chronic low back or sacroiliac problems, trauma from a fall or other injury, or a post-surgical issue. There may be referral or trigger points from other areas, such as internal organs which cause tenderness in the pelvic floor. Conditions such as endometriosis can also lead to pelvic floor pain.
If pelvic floor pain lingers and no known source is found, injured, loose or weak ligaments and instability of the pelvis should be considered. In pelvic floor dysfunction, the musculature is in spasm and muscles that are constantly contracting or in spasm will generate pain. But why are the muscles in spasm? One basic principle people forget about muscle spasms is that muscle spasms will occur when a muscle contracts against an unstable base. When the muscle contracts against a stable base, it is possible to get maximum force from that muscle, and the likelihood of muscle injury is minimal. When the muscle contracts against bone that is moving and unstable, minimal muscle force can be achieved and the likelihood of injury is great.
Numerous ligaments surround the pelvis and help to keep it stabilized. When these ligaments become weak, they are unable to maintain pelvic stability and can cause pain. Injury to the pubic symphysis, pubic ligaments or any of the ligaments that stabilize the lower back (especially sacroiliac joint) would cause the pelvic floor muscles to be contracting continually against an unstable base. This would mean every time we urinated, defecated, held our breath or had sex, the muscles would try to generate force attached to structures that are moving. The pelvic floor would be unable to function correctly.
Injury to the pelvic floor ligaments would result in the pelvic bones moving excessively. In such a scenario, pelvic floor muscle spasm has to occur. Treatments such as massage therapy, exercises and re-education would only have temporary benefit. They would address the muscle spasm part of the problem but not the cause of the muscle spasms.
Prolotherapy for Pelvic Floor Dysfunction
Prolotherapy to the injured ligaments induces a mild “healing” inflammatory reaction, which stimulates the repair of the injured or lax ligaments. Prolotherapy injections to the weakened pelvic floor ligaments will cause an increase of blood supply and regenerative cells to the area. A natural healing cascade is put in motion resulting in the deposition of new collagen at the weakened areas. This new collagen strengthens the ligaments. Once the ligaments are of normal strength, the pelvic floor musculature can contract with maximum force against a stable base. Thus, the muscle spasms stop. The chronic pelvic floor pain, low back pain, genital pain and bowel/bladder symptoms stop because the muscle tone in the pelvic floor gets back to normal. Then the person can exercise and be active.
1. Almeida MB, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scand J Med Sci Sports. 2015 Sep 15. doi: 10.1111/sms.12546. [Epub ahead of print]
2. Berzuk K, Shay B. Effect of increasing awareness of pelvic floor muscle function on pelvic floor dysfunction: a randomized controlled trial. Int Urogynecol J. 2015 Jan 9. [Epub ahead of print]
3. Ramalingam K, Monga A. Obesity and pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2015 Feb 19. pii: S1521-6934(15)00021-8. doi: 10.1016/j.bpobgyn.2015.02.002. [Epub ahead of print]
4. Sacomori C, Cardoso FL. Predictors of Improvement in Sexual Function of Women with Urinary Incontinence After Treatment with Pelvic Floor Exercises: A Secondary Analysis. J Sex Med. 2015 Jan 13. doi: 10.1111/jsm.12814. [Epub ahead of print]