Wave, March / April 2014
Dr. Kelli Berzuk is a pelvic floor physiotherapist and Director of the Incontinence & Pelvic Pain Clinic (IPPC). In 2011, she received an award from the Winnipeg-based Women's Health Research Foundation of Canada to support her research in the area of pelvic floor dysfunction. She took time out to talk about the issue to Wave.
What is the pelvic floor?
The medical term "pelvic floor" encompasses the pelvic area of the body and includes anatomical structures such as the bony pelvis, the pelvic organs (bladder, bowel and, in women, the uterus), as well as nerves, blood vessels, ligaments and muscle.
What is the pelvic floor muscle?
The pelvic floor muscle is part of the pelvic floor. It is a multi-layered muscular sling that fills the interior bowl of the pelvis, forming its base, inserting into the pubic bones and the tailbone.
The pelvic floor muscle wraps around the urethral and rectal openings and, additionally, the vagina in women. Because of its anatomical position, it plays a role in proper bladder, bowel and sexual function, childbirth, support to the pelvic organs, postural support and core stabilization of the trunk. The pelvic floor muscle also plays a role in assisting the diaphragm during respiration.
What is pelvic floor dysfunction?
Pelvic floor dysfunction, or PFD, refers to disorders found within the pelvic floor. Bladder and bowel dysfunction, sexual dysfunction, pelvic pain, pelvic organ prolapse (descent of the organs) and pelvic floor muscle dysfunction are all forms of PFD. In fact, those experiencing one type of PFD are prone to developing other forms of PFD. As a result, it is important to identify and address early symptoms before the vicious cycle begins.
What is the connection between the pelvic floor muscle and PFD?
Research suggests that the pelvic floor muscle plays a role in the high prevalence of co-occurring PFD, as it connects all of the pelvic organs and directly affects the function of each.
In 2008, a study completed in the Netherlands found the pelvic floor muscle to be dysfunctional in 77.2 per cent of patients with bladder, bowel and sexual dysfunction. It is thought that changing behaviour to compensate for dysfunction in one pelvic organ often leads to dysfunction within the pelvic floor muscle itself, potentially affecting the function of neighbouring organs. For example, straining to defecate due to constipation leads to injury of the pelvic floor muscle that may, over time, negatively affect bladder and/or sexual function. Another example is chronic pelvic pain, which may originate in one pelvic organ before other organs become painful and dysfunctional.
The International Pelvic Pain Society explains that chronic tensing of the pelvic floor muscle as a protective or support mechanism in response to prolonged pelvic pain leads to subsequent injury to the muscle. For this reason, what may begin with uterine pain, perhaps with a diagnosis of endometriosis, may eventually lead to bowel dysfunction and/ or bladder dysfunction with corresponding pain in these organs, and even referred pain in surrounding areas.
What causes PFD?
Because there are multiple forms of PFD, the causes are various and numerous. Also, issues can arise within the organs themselves as a primary source (for example, interstitial cystitis of the bladder, endometriosis of the uterus and irritable bowel disease of the bowel), or the pelvic organs can be afflicted secondarily via pelvic floor muscle dysfunction if the muscle has been injured (for example, a tear during childbirth).
Anything that irritates the bladder, bowel, or uterus, or injures the pelvic floor muscle can produce or exacerbate PFD symptoms.
What are the symptoms of PFD?
The symptoms of PFD range from bothersome to debilitating and can involve any or all of the pelvic organs. For example, common symptoms of bladder and bowel dysfunction include incontinence, urgency, incomplete emptying or needing to use the washroom too often or not often enough. When the pelvic floor muscle or the pelvic organs are not functioning properly, they can also lead to pain in the region.
The following is a list of questions that may help you to identify symptoms of PFD or warning signs that your pelvic floor, or specifically the pelvic floor muscle, needs some attention and possibly treatment:
- Do you refrain from laughing wholeheartedly because of fear of loss of bladder control?
- Do you use the washroom more than nine times per day and more than one time per night?
- Do you feel unexpected and strong urgency with voiding and bowel movements?
- Do you worry that you may not be able to hold back this urgency?
- Do you use the washroom 'just in case' even if you don't feel the need to void?
- Do you unintentionally pass gas?
- Do you strain to empty your bowels or push to empty your bladder?
- Do you feel weak in your perineal area or in your pelvic floor muscle?
- Do you feel heaviness in your perineum, especially by the end of the day or after doing a lot of standing or lifting?
- Do you have difficulty keeping a tampon inserted?
What are some of the risk factors?
Some risk factors associated with PFD are:
- Diet filled with bladder- or bowel-irritating foods and beverages, smoking, dehydration
- Certain medications, radiation and chemotherapy
- Chemicals, dyes or friction from clothing that is irritating to the perineum
- Family history of PFD
- Childhood bed wetting
- Certain medical conditions such as diabetes and multiple sclerosis
- Hormonal changes associated with menopause
- Increased weight/increased BMI
- Chronic urinary tract or yeast infections
- Pregnancy, vaginal delivery, forceps, episiotomy, perineal tearing
- Chronic straining to defecate
- Poor voiding and defecation biomechanics (such as hovering over the toilet seat) or patterns (such as voiding or defecating too often or not frequently enough)
Is pelvic floor muscle health important in overall health?
As many PFD triggers revolve around the pelvic floor muscle, it is critical to ensure that this muscle remains healthy and that it can properly contract and relax as needed. If the pelvic floor muscle does not effectively contract or have the endurance to maintain this contracted state, then bladder or bowel incontinence may arise. Equally important, if the pelvic floor muscle does not properly relax, then bladder and bowel emptying becomes compromised leading to issues such as urinary tract infections and chronic constipation, as well as problems with pelvic pain and sexual dysfunction.
The need for keeping muscles healthy for the prevention of injury is a philosophy that is easily understood and universally accepted. So, too, is the importance of proper rehabilitation in the recovery process when injuries unfortunately occur.
However, the pelvic floor muscle seems to be a muscle that often eludes this generally accepted principle, both for prevention of injury as well as the necessity for rehabilitation, even with the most extreme of injury such as muscle tear that sometimes occurs during childbirth. This muscle has responsibilities to uphold, and neglect and injury can lead to devastating effects on the function of that muscle and the body as a whole.
How many women are affected by PFD and how aware are they about pelvic floor health?
PFD symptoms affect millions of women in Canada, with negative social, occupational, physical, sexual, psychological, relationship and financial impacts. Yet many women have a low level of general knowledge about pelvic floor health.
I recently completed a research study that evaluated the presence of PFD symptoms within a presumably healthy group of women (ages 18 to 65) working in an office setting.
Of the 145 participants that completed the study, 81 per cent of the female participants reported symptoms of bladder dysfunction, 77 per cent noted bowel dysfunction, 66 per cent were identified with sexual dysfunction, 59 per cent displayed symptoms of pelvic organ prolapse, and 52 per cent experienced symptoms of pelvic pain. Additionally, 87 per cent of these volunteers reported symptoms in multiple forms of PFD and 25 per cent reported symptoms in each of the five categories studied.
Additionally, study participants' knowledge level related to pelvic floor health was measured. At the onset of the study, pelvic floor health knowledge levels were very low and this was matched with high levels of PFD symptoms.
Furthermore, many participants failed to recognize the presence of their own PFD symptoms and, therefore, had no reason to seek medical attention or alter daily behaviours known to be harmful to pelvic floor health. Few people have, or seek, the tools to prevent or correct PFD, and behaviours that unintentionally exacerbate symptoms and promote co-occurrence of PFD are commonplace in this field of medicine.
If a woman suspects she has PFD, what should she do?
If a woman suspects that she may have PFD, or if any of the warning signs listed feel familiar, she should speak with her doctor about these symptoms. Do not let embarrassment stop you from seeking medical attention as there are many treatment options available to you and if you do nothing to correct the problems, unfortunately, most often the symptoms increase and other forms of PFD may develop.
For those women who are not experiencing any signs or symptoms of PFD, take steps to ensure that you are knowledgeable on what you should be doing, or avoiding, to prevent issues. Be pro-active in confirming that you are not consuming bladder- or bowel-irritating foods and beverages, understand that there are proper biomechanics and patterns when it comes to voiding and defecating, and make sure that you are keeping your pelvic floor muscle healthy and fit.
If you are unsure how to do your pelvic floor muscle exercises, worry that you may be doing them incorrectly, or simply don't know what they are, please seek the advice of a qualified pelvic floor physiotherapist for assessment and to customize a home exercise program specific for your muscle.
How is pelvic floor dysfunction diagnosed and treated?
As there are many different forms of PFD, there are numerous medical disciplines available for diagnosis and each have different diagnostic tools for analysis. Some examples are physical examination, urodynamic testing, ultrasound and other imaging, scopes, and biofeedback. Patients should begin discussing their symptoms and concerns with their family doctor so that they can determine if a referral is indicated and to which specialty. Gynecologists, urologists, uro-gynecologists, gastroenterologists and colorectal specialists are some of the medical specialists that you may be referred to for assessment, depending on your symptoms.
To evaluate the health of the pelvic floor muscle, your doctor may refer you to a pelvic floor physiotherapist. A physiotherapist with post-graduate education in pelvic floor health, including vaginal and rectal examinations, would complete an internal physical examination to determine the health of your pelvic floor muscle. During this assessment, pelvic floor muscle strength, endurance, responsiveness, co-ordination, ability to effectively relax, presence of myofascial trigger points, scar tissue or tension in the muscle are some elements investigated to determine the overall health of the muscle.
Many medical treatment options are available including pelvic floor physiotherapy, medication and surgery, and sometimes, a combination of approaches is appropriate. Pelvic floor physiotherapy may include pelvic floor muscle exercise and relaxation techniques, education on dietary factors and toileting patterns and biomechanics, soft tissue massage and manual therapy techniques, as well as acupuncture, neuromuscular nerve stimulation, computerized EMG biofeedback and laser therapy. When medical intervention is indicated, the American Urogynecologic Society notes that conservative management such as pelvic floor physiotherapy should be a first-line defence strategy followed by more invasive medical interventions such as pharmaceutical and surgical approaches.
How successful are treatments for PFD?
According to the American Urogynecologic Society (AUGS), PFD is experienced by as many as one out of three women, and 80 to 90 per cent of these women note significant improvement if they seek medical help. AUGS encourages medical providers to start the conversation around PFD, as symptoms too easily go unidentified. Because women who seek medical attention respond so well to treatment, PFD should not be viewed as a normal experience, a part of aging, or an acceptable consequence to childbirth, as often simple behavioural adjustments and exercise are all that is needed to reverse symptoms when treated early. Women need to take action in the prevention and correction of PFD through healthy living and diet, good toileting habits and commitment to proper pelvic floor muscle exercise.
While PFD is highly prevalent and has been shown to produce physical and psychological symptoms ranging from embarrassing to debilitating, it is important to recognize that much can be done to remedy these conditions. Often ensuring good pelvic floor muscle health improves or corrects PFD. As well, a healthy diet and lifestyle, combined with diligence in proper pelvic floor muscle strengthening, may prevent PFD from arising. Since all women are at risk of PFD, especially those who have had, or plan to experience childbirth, taking a pro-active approach to ensuring a healthy pelvic floor muscle is the key to prevention of PFD.