Pelvic Floor Dysfunction | Confusing diagnosis can lead to confusing and improper treatment
- In this article, we will discuss new research and what doctors are recommending moving forward in the treatment of Pelvic Floor Dysfunction in women.
- We will also explore how regenerative medicine treatments may provide an unfound answer to the problems of bowel movement dysfunction, urinary incontinence, unexplained back and pelvic pain and other symptoms attributed to Pelvic Floor Dysfunction in cases where conventional treatment has failed.
We see many patients in our clinics who have been diagnosed with pelvic floor dysfunction or chronic myofascial pelvic pain. Before we discuss the differential in diagnosis, lets look at some of the challenges we have seen affecting these patients and likely you the reader.
A woman will sit on our examination table, sometimes fighting back emotion and pain as the act of sitting can be causing her discomfort. When we ask her when did this pain start, she may respond:
- “It started while I was pregnant”
- “It started right after child birth”
- “One day I coughed really hard.”
- “One day I sneezed really hard.”
- An older patient will tell us she does not know when it started but it has been been getting worse, age related problems may be a cause.
- Sometimes we will see a patient who is obese, obesity can be a factor.
- Sometimes we will see a patient who is a endometrial or cervical cancer survivor. Radiation treatment can be a factor.
- Sometimes we will see a patient after pelvic area surgery or hysterectomy. The surgery may have caused problems.
- Sometimes we will see a woman who is under emotional stress.
When we ask what are the symptoms that are causing the distress, they may have a long list that could include:
- Pelvic pain or pressure that is chronic and generally severe.
- Chronic constipation and discomfort with bowel movement
- Chronic lower back pain
- Genital pain
- Rectal pain
- Vulvodynia (chronic pain in the vulva)
- Coccydynia (tailbone pain)
- Hip impairment
- Pain with sitting
- Painful intercourse
- Sleep disturbances
- Spasms of the muscles of the pelvic floor commonly result in urological issues such as:
- poor urine stream
- urinary frequency and urgency
- urge incontinence.
The surgery option
In May 2017, 13 radiologists from 8 institutions representing five different nations wrote in the medical journal European Radiology, (1) that there is a need to develop recommendations that can be used as guidance for a standardized approach regarding the diagnosis and grading of pelvic floor dysfunction. The standardized approach being surgery. Here is the reasoning behind this study:
- “Imaging of the female pelvic floor is of rising interest due to an aging population, harboring an increasing incidence of pelvic floor disorders and the rising need for comprehensive diagnosis and treatment.”
The stress component of pelvic floor dysfunction
A patient may recount something in her current or recent situation that has caused her a lot of stress, anxiety, and depression. She is a woman filled with worry and despair. This woman will explain that suddenly and maybe without warning she began to suffer from the well know symptoms of pelvic floor dysfunction.
That these symptoms, especially the urinary problems, came upon her so quickly and so severely, caused her great concern. Enough so that she made more than one trip to the the urgent care center or her doctor to get prescriptions or treatment for urinary tract infections.
Even when there is no evidence of urinary tract infection, the patient will tell us that they were prescribed antibiotics and that they did not help anyway.
Confusing diagnosis can lead to confusing and improper treatment
We are going to cover the symptoms above and continue describing some of the challenges our patients faced in treating their Pelvic Floor Dysfunction, but before we do, let’s discuss the problems of confusion.
Pelvic Floor Dysfunction in our society
It is estimated that nearly 25% of women suffer from pelvic floor dysfunction. (1) That means 1 in 4 women are currently dealing with this condition right now. Most common causes are childbirth, trauma, obesity, history of previous pelvic surgery, and nerve damage. While this condition is most common in women, men can also suffer from pelvic floor dysfunction that may be from trauma or exercise-induced.
What is Pelvic Floor Dysfunction?
The pelvis consists of three paired bones: the ilium, ischium, and pubis that interconnect and meet 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 stabilizing joints of the pelvis and are held together by ligaments and the pubic symphysis, which is a disc.
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 (bladder, intestines, and uterus) during contraction and relaxation. These pelvic floor muscles attach to the pubis (anterior) and coccyx (posterior) and work to stabilize the pelvis. If functioning properly, they can help prevent urinary and fecal incontinence.
The sacrotuberous, sacrococcygeal and sacroiliac ligaments are vital to providing stability in the “back portion” of the pelvic rim upon which the muscles attach. The pubic symphysis provides stability in the “front portion” of the pelvic rim, onto which muscles also attach. If these supporting ligaments of the pelvis become injured or stretched out, joint instability can result. This means that the pelvic bones become unstable because its primary stabilizers (ligaments) are too weak or lax to properly hold them in place. The same can happen if the pubic symphysis becomes stretched out or sprained.
Subsequently, if the pelvic floor muscles are trying to contract and the pelvis is unstable, muscle spasms will occur. This can also happen if the pelvic floor musculature is trying to stabilize the pelvis – these muscles can spasm trying to provide stability but can be very painful and contribute to pelvic floor dysfunction.
It is important to mention that the hips can also contribute to pelvic floor dysfunction, as the hip joint is partly made up by the pelvis. Any laxity of the pubis, sacroiliac joint, or surrounding ligaments can increase strain on the hip, leading to hip injury. The reverse is true as well – hip injuries can increase forces on the pelvic floor, leading to pelvic pain.
When an individual experiences pelvic floor muscle spasms, the pain is excruciating, and any activity that puts pressure on the pelvis, the involved organs, and the pelvic floor ligaments can easily make the symptoms worse.
Most patients with chronic pelvic floor dysfunction feel their quality of life has been greatly affected and find it hard to live with chronic pelvic symptoms. Often times, women with pelvic floor dysfunction post-baby find themselves struggling with the idea of having more children, being intimate with their partners, working, or continuing with their active lifestyle due to their chronic pelvic pain and associated symptoms.
Pelvic Floor Dysfunction following childbirth
The connection between Pelvic Floor Dysfunction and childbirth is seemingly beyond debate. The majority of new studies centers on reducing the risk of Pelvic Floor Dysfunction after vaginal delivery. This followed a wave of studies that examined the long-term effects of a single vaginal and cesarean delivery. Many studies suggest the use of forceps and other childbirth procedures may cause significant damage to the mother resulting in long-term problems.
In fact, the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, released Practice Bulletin No. 165 . The summary is found here: Prevention and Management of Obstetric Lacerations at Vaginal Delivery
In this bulletin, more obvious reasons for Pelvic Floor Dysfunction after childbirth are addressed:
“Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth.”
But is it only lacerations and more easily recognizable injuries during childbirth that are causing the problem? What if the cause of the problem is seemingly invisible?
If pelvic floor pain lingers and no known source is found, injured, loose or weak ligaments and instability of the pelvis should be considered. The numerous ligaments that surround and stabilize the pelvis undergo relaxation due to the hormone relaxin that is secreted during pregnancy. This hormone does just what it says – it relaxes the ligaments in the pelvis to allow the baby to pass through the birth canal. In some cases, the relaxed ligaments may not return to their normal properties and the woman is left with pelvic ligament laxity and instability, which can include the hip(s) in some cases. This can be especially true for women who already have joint hypermobility.
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 contract continually against an unstable base.
In pelvic floor dysfunction, the musculature is in spasm and muscles that are constantly contracting or in spasm will generate pain. Muscles spasm because they are trying to provide stability in an unstable region.
Injury to the ligaments in childbirth or sports injury (see below) and their successful treatment can be the turning point in Pelvic Floor Dysfunction.
Pelvic Floor Dysfunction is a real sports injury
Pelvic floor dysfunction as related to sports injuries can happen in both men and women, though most pelvic floor disorders do affect women. Most pelvic floor sports injuries come from high impact exercises. Though, hip sports injuries could also contribute to the development of pelvic floor dysfunction.
Recently, researchers writing in the Scandinavian Journal of Medicine & Science in Sports pushed to acknowledge that pelvic floor must be considered as an entity. This is what researchers had to say:
The pelvic floor provides support to the pelvic bones and all pelvic organs. Therefore, it is likely that female athletes involved in high-impact and in strong-effort activities are at risk for the occurrence of pelvic floor dysfunction.
In their study, the doctors investigated the occurrence of urinary incontinence and other Pelvic Floor Dysfunction [anal incontinence, 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 pelvic floor dysfunction either practicing high-impact or strong-effort activities.
- The pelvic floor must be considered as an entity and addressed as well.
- 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 Pelvic Floor Dysfunction strategies as well.(2)
Pelvic Floor Dysfunction and Obesity
As with many problems of chronic pain, obesity plays a major role. In a recent study appearing in the medical journal Best Practice & Research. Clinical Obstetrics & Gynaecology, doctors acknowledged 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.
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. (3)
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. In the Journal of Sex Medicine doctors have shown that physical therapy can assist with symptoms including urinary incontinence and sexual function.(5)
Traditional treatments for pelvic floor dysfunction include:
- Kegel exercises may be encouraged to strengthen the pelvic floor.
- external and internal soft tissue mobilization (massage or manipulation)
- myofascial and trigger point release (injections into the muscle to relieve spasms),
- visceral manipulation (abdominal pelvic)
- connective tissue manipulation (stretching the skin, can be seen as a form of neural therapy)
- deep tissue massage,
- transcutaneous electrical nerve stimulation (TENS),
- heat and cold therapy,
- muscle strengthening, relaxation, and re-education,
- postural education,
- nerve blocks,
- and epidurals.
BUT WHAT HAPPENS WHEN ALL OF THESE TREATMENTS FAIL?
These treatments may offer some temporary 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.
Prolotherapy for Pelvic Floor Dysfunction
Clinical observations over the course of decades have shown Prolotherapy treatment to injured ligaments induces a mild “healing” inflammatory reaction, which stimulates the repair of injured or lax ligaments. Prolotherapy injections can strengthen the ligaments and pubic symphysis, increasing stability and relieving muscle spasm and other symptoms in pelvic floor dysfunction.
In those with pelvic floor dysfunction and associated pain in their back, pubis, pelvic floor, genitals, coccyx, and associated symptoms, Prolotherapy can help to strengthen injured or stretched out ligaments, allowing them to reinstate stability to the pelvis and allow tight muscles to relax. Regaining stability in the pelvis can help to get rid of chronic pelvic pain and help patients “get their lives back”. If you are suffering from chronic pelvic floor dysfunction, wouldn’t you like to get back to your normal self?
1. Memon H, Handa V. Vaginal childbirth and pelvic floor disorders. Womens Health (Lond Eng) 2013; May 9(3). [PubMed]
2.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. [Google Scholar]
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. [Google Scholar]
4. El Sayed RF, Alt CD, Maccioni F, Meissnitzer M, Masselli G, Manganaro L, Vinci V, Weishaupt D, ESUR and ESGAR Pelvic Floor Working Group. Magnetic resonance imaging of pelvic floor dysfunction-joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. European radiology. 2017 May 1;27(5):2067-85. [Google Scholar]
5. 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. [Google Scholar]