PELVIC FLOOR DISORDERS
It’s more common than you think — and there are effective treatments available.
Many people don’t feel comfortable talking about personal topics like pelvic floor disorders and symptoms such as incontinence. But these are actually very common medical problems that can be treated successfully. Millions of people have the same issues, but many don’t seek treatment and compromise their quality of life. Treatment can have a dramatic effect on pelvic floor dysfunction
Pelvic floor dysfunction refers to a wide range of issues that occur when muscles of the pelvic floor are weak, tight, or there is an impairment of the sacroiliac joint, lower back, coccyx, or hip joints. Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain. Many times, the underlying cause of pelvic pain is difficult to determine.
Pelvic floor dysfunction may include any of a group of clinical conditions that include urinary incontinence, fecal incontinence, pelvic organ prolapse, sensory and emptying abnormalities of the lower urinary tract, defecatory dysfunction, sexual dysfunction and several chronic pain syndromes, including vulvodynia. The three most common and definable conditions encountered clinically are urinary incontinence, anal incontinence, and pelvic organ prolapse.
It is estimated that at least one-third of adult women are affected by at least one of these conditions. Furthermore, statistics show that 30 to 40 percent of women suffer from some degree of incontinence in their lifetime and that almost 10 percent of women will undergo surgery for urinary incontinence or pelvic organ prolapse. 30 percent of those undergoing surgery will have at least two surgeries in trying to correct the problem
What is pelvic floor dysfunction?
For most people, having a bowel movement is a seemingly automatic function. For some individuals, the process of evacuating stool may be difficult. Symptoms of pelvic floor dysfunction include constipation and the sensation of incomplete emptying of the rectum when having a bowel movement. Incomplete emptying may result in the individual feeling the need to attempt a bowel movement several times within a short period of time. Some times use of digital help during the evacuation for support of the pelvic floor. Residual stool left in the rectum may slowly seep out of the rectum leading to reports of bowel incontinence.
Constipation is not about frequency (or infrequency) of bowel movements, but rather chronic constipation is a “symptom complex.”
The process of defecation (having a bowel movement) requires the coordinated effort of different muscles. The pelvic floor is made up of several muscles that support the rectum like a hammock. When an individual wants to have a bowel movement the pelvic floor muscles are supposed to relax allowing the rectum to empty. While the pelvic floor muscles are relaxing, muscles of the abdomen contract to help push the stool out of the rectum. Individuals with pelvic floor dysfunction have a tendency to contract instead of relax the pelvic floor muscles. When this happens during an attempted bowel movement, these individuals are effectively pushing against an unyielding muscular wall.
Chronic constipation may be associated with normal or slow stool transit time, functional defecation disorder (dyssynergic defecation) or a combination of both. With slow-transit constipation, there is a prolonged delay in the transit of stool through the colon. Dyssynergic or outlet obstruction (also called pelvic floor dyssynergia) is characterized by either difficulty or inability to expel the stool. With pelvic floor dysfunction (dyssynergic defecation), the muscles of the lower pelvis that surround the rectum (the pelvic floor muscles) do not work normally. A third type of constipation occurs with irritable bowel syndrome (IBS) where constipation alternates with bouts of diarrhea.
How is pelvic floor dysfunction diagnosed?
The diagnosis of pelvic floor disorder starts with a careful history regarding an individual’s symptoms, medical problems and a history of physical or emotional trauma that may be contributing to their problem. Next the physician examines the patient to identify any physical abnormality. A dynamic MRI and a defecating proctogram are studies commonly used to demonstrate the functional problem in a person with pelvic floor dysfunction. During this study, the patient is given an enema of a thick liquid that can be detected with x-ray.
A special x-ray video records the movement of the pelvic floor muscles and the rectum while the individual attempts to empty the liquid from the rectum. Normally the pelvic floor relaxes allowing the rectum to straighten and the liquid to pass out of the rectum. This study will demonstrate if the pelvic floor muscles are not relaxing appropriately and preventing passage of the liquid.
These tests are also useful to show if the rectum is folding in on itself (internal rectal prolapse). Many women have outpouching of the rectum known as a rectocele. A rectocele is a bulging of the front wall of the rectum into the back wall of the vagina. Rectoceles are usually due to thinning of the rectovaginal septum (the tissue between the rectum and vagina) and weakening of the pelvic floor muscles. This is a very common defect; however, most women do not have symptoms. There can also be other pelvic organs that bulge into the vagina, leading to similar symptoms as rectocele, including the bladder (i.e., cystocele) and the small intestines (i.e. enterocele).
Usually, a rectocele does not affect the passage of stool. In some instances, however, stool may become trapped in a rectocele causing symptoms of incomplete evacuation. The defecating proctogram or dynamic MRI helps to identify if the liquid is getting trapped in a rectocele when the individual is trying to empty the rectum.
How is pelvic floor dysfunction treated?
Pelvic floor dysfunction due to non-relaxation of the pelvic floor muscles may be treated with a specialized physical therapy known as biofeedback. With biofeedback, a therapist helps to improve a person’s rectal sensation and pelvic floor muscle coordination. There are various effective techniques used in biofeedback. Some therapists train patients by teaching them to expel a small balloon placed in the rectum. Another technique uses a small probe placed in the rectum or vagina or electrodes placed on the surface of the skin around the opening to the rectum (anus) and on the abdominal wall. These instruments detect when a muscle is contracting or relaxing and provide visual feedback of the muscle action. This visual feedback helps the individual to understand the muscle movement and aids in improving muscle coordination. Approximately 75% of individuals with pelvic floor dysfunction experience significant improvement with biofeedback.
It is very important to have a good bowel regimen in order to avoid constipation and straining with bowel movements. A high fiber diet, consisting of 25-30 grams of fiber daily, will help with this goal. This may be achieved with a fiber supplement, high fiber cereal, or high fiber bars. In addition to augmenting fiber intake, increased water intake (typically 6-8 glasses daily) is also highly recommended. This will allow for softer stools that do not require significant straining with bowel movements, thereby reducing your risk for having a bulge associated with a rectocele. The surgical management of rectoceles should only be considered when symptoms continue despite the use of medical management and are significant enough that they interfere with activities of daily living. There are abdominal, rectal, and vaginal surgeries that can be performed for rectoceles.
Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. The weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men. There are many different ways to surgically correct rectal prolapse.
Abdominal or rectal surgery may be suggested. An abdominal repair may be approached laparoscopically in selected patients. The decision to recommend an abdominal or rectal surgery takes into account many factors, including age, physical condition, the extent of prolapse and the results of various tests.
If a patient has pelvic health issue, don’t hesitate to learn more about treatment options, seek out an expert evaluation, at our center, we have state-of-the-art technology for physiologic testing and a multidisciplinary approach to patients with complex pelvic floor disorder.