Pelvic floor disorders occur due to weakness or tension in the muscles in this area. In addition to muscle weakness and spasms caused by excessive activity, in some cases, functional impairments occur in the lumbar region, coccyx, and hip joint. The person experiencing pelvic floor problems has restrictions on participation in daily life. In addition, if this situation lasts for a long time, people can become withdrawn and psychologically affected.

What Are the Risk Factors Leading to Pelvic Floor Dysfunction?

The deterioration in the functions of the pelvic floor muscles is manifested by the inability to contract strongly enough due to the weakening of the muscles here or the inability to relax sufficiently (spasm) as a result of excessive activity. The factors that cause this condition to occur are listed as follows:

Bladder/bowel dysfunction
Constipation
Postural disorders
Weight gain
Pregnancy and childbirth
Lifting heavy
Emotional changes and stress
Chronic cough
Old age
Menopause
Genetic factors

Urinary Incontinence

The most common problem among pelvic floor dysfunctions is involuntary urine leakage, defined as urinary incontinence. The most common type, "stress urinary incontinence", is caused by coughing, sneezing, or other physical strains. Urgency urinary incontinence develops with the increase of intra-bladder pressure due to excessive contraction of the bladder muscle along with the feeling of sudden urgency. Urinary incontinence called “mixed type” occurs when stress and urgency urinary incontinence types come together.

Pelvic Organ Prolapses

The pelvic organs (bladder, uterus, and intestines) located in the pelvis may hang down through the vagina due to the weakness of the tissues that support them. On the anterior wall of the vagina, sagging of the bladder (cystocele) and urethra (urethrocele), and on the posterior wall of the vagina, sagging of the small intestine (enterocele), the end of the large intestine (rectocele), the uterus and the top of the vagina can be observed.

A woman can experience one or several sagging cases at the same time. The process of experiencing these sagging cases usually starts with the first birth, and physiological processes, developments due to menopause, and genetic factors are effective in experiencing sagging. In addition, strain during defecation and obesity are among the risk factors. Patients often complain of a feeling of pressure and heaviness in the pelvic floor area. If the problem progresses, complete prolapse of the vagina may occur. In pelvic organ prolapse, both preventive treatment without surgery and pelvic floor rehabilitation can be used to prevent recurrences after surgery. In this way, the muscles are strengthened and their normal anatomical positions are maintained.

Pelvic Pain

Endometriosis, pelvic inflammatory disease, infection, adhesions after surgery, disorders in the pelvic vessels, and many diseases can cause pelvic pain. In addition, irritable bowel syndrome is among the most common causes. In addition, pelvic pain may occur as a result of ilioinguinal nerve compression, levator ani syndrome, coccydynia, interstitial cystitis, vulval vestibulitis/vulvodynia, and musculoskeletal system disorders. Pelvic floor rehabilitation is applied in chronic pelvic pain lasting longer than 6 months in order to reduce pain, improve function and eliminate musculoskeletal system disorders.

Anorectal Region Dysfunctions

The last 10-12 cm long rectum region of the anus and large intestine is defined as the "anorectal region". Some disorders in this region can also be treated with pelvic floor physiotherapy.

Stool and gas incontinence: It is the involuntary leakage of stool and gas. In order for the muscles to work effectively and in a synchronized manner again, muscle training is performed with or without a device. Delay maneuvers are also taught for sudden leakages.

Constipation: It is the inability to empty the intestines due to the inability of the pelvic floor muscles to fully relax during defecation. The purpose of pelvic floor training in case of constipation is to increase intestinal motility and teach effective defecation without straining. Pelvic floor muscles are relaxed by using abdominal and pelvic floor massage, correct toilet position, and biofeedback devices. At the same time, nutritional habits are questioned and necessary arrangements are made.

Sexual Dysfunctions

In cases of loss of normal sensation and/or function during intercourse, problems such as low libido, problems in sexual arousal, inability to reach orgasm, and dyspareunia (pain during sexual intercourse) may occur. Some of the sexual problems due to weakness or excessive activation in the pelvic floor muscles are listed as follows.

Vaginismus: It is a spasm-induced problem in the muscles around the vagina during sexual intercourse or against any external stimulus such as tampons and speculum. It occurs due to excessive activation of the pelvic floor muscles.

Dyspareunia: It is the persistent pain experienced during intercourse. It occurs due to excessive activation of the pelvic floor muscles.

Interstitial cystitis (painful bladder syndrome): Although it is thought to be a problem only with the bladder, interstitial cystitis is also a condition that occurs due to excessive activation of the pelvic floor.

Endometriosis: It is a condition in which tissue similar to the inner wall of the uterus is formed outside the uterus and therefore causes a painful process. Endometriosis causes chronic pain due to excessive activation of the pelvic floor.

Anorgasmia – dysorgasmia: It is the problem of not being able to reach orgasm or having difficulty in reaching orgasm observed in women. It may occur due to pelvic floor muscle dysfunction. In the treatment, it is aimed to strengthen the pelvic floor muscles and accelerate the regional blood flow.

Erectile dysfunction (impotence): It is the condition of not reaching enough erection to enable sexual intercourse or the premature termination of erection. It may occur due to weakness of the pelvic floor muscles.

Premature ejaculation: It is the situation where the sexual intercourse ends in a very short time and the orgasm cannot be controlled. It may develop due to the weakness of the pelvic floor muscles.

Delayed ejaculation: It is the situation where ejaculation is experienced late and partially or is not experienced at all during sexual intercourse. It may develop due to excessive activation of the pelvic floor muscles.

Pelvic Floor Problems in Adults

In young adults, especially in women, muscle weakness in the pelvic floor due to pregnancy and childbirth and urinary incontinence problems are very commonly observed. At the same time, the constant contraction of the muscles due to holding urine for a long time also causes constipation, especially in working people.

İleri yaş grup hastalarda ise, kadınlarda menopoz sonrası azalan östrojen seviyesi ile pelvik taban kaslarında meydana gelen zayıflık idrar kaçırma ve pelvik organ sarkmalarına sebep olmaktadır. Erkeklerde ise özellikle prostat cerrahileri sonrasında idrar kaçırma ve dışkı kaçırma problemi ile çok sık karşılaşılmaktadır.

Pregnancy

During pregnancy, women may face many problems. Problems such as low back pain, pelvic joint disorders, pelvic pain, constipation, and bladder/bowel dysfunction also affect the pelvic floor.

Weakening of the pelvic floor muscles can cause urinary incontinence in pregnant women, especially in the third trimester. This can occur most often when coughing, sneezing, laughing, or walking. Although it improves after childbirth, sometimes muscle weakness can make the problem of urinary incontinence more pronounced at later ages.

Pelvic floor exercises help strengthen these muscles and support the pelvic organs, thus protecting against common problems such as urinary incontinence and pelvic organ prolapse. Doing regular pelvic floor exercises during pregnancy facilitates childbirth. Since it increases circulation, it accelerates the healing of tears, episiotomy scars, or hemorrhoids, if any, that may occur during childbirth. Exercise should be done to heal the damage to the pelvic floor muscles that remain under stress during pregnancy and to avoid problems in the future.

Menopause

With the decrease in estrogen in the body during menopause, the pelvic floor muscles begin to weaken. This situation leads to urinary and fecal incontinence, constipation, pelvic organ prolapse, changes in sexual functions, and deterioration of the relationship between bladder, bowel, and pelvic floor in women. The problems that arise cause a decrease in the quality of life of the person. The menopause period, in which many changes are experienced in women, is also important in terms of pelvic floor muscles. Because the problems experienced affect the quality of life of women negatively.

Pelvic Floor Problems in Children

Urinary incontinence can be mentioned when a child who is at least 5 years old leaks urine at least once a month and for 3 months in a row. Depending on pelvic floor problems in children, problems such as bladder/bowel dysfunction, overactive bladder, urinary incontinence with sudden urgency, lazy bladder, delayed urination, neurogenic bladder, constipation, and fecal incontinence can be observed.
It is treated with a urotherapy approach when there is no underlying pathological condition determined by various urological tests. Urotherapy includes methods such as patient information, behavioral adjustments, bladder diaries, biofeedback and electrical stimulation, pelvic floor exercises, neuromodulation, and catheterization.

How Are Pelvic Floor Disorders Diagnosed?

At the end of the examination of the patients to be carried out by the gynecology, urology, general surgery, pediatric surgery, and gastroenterology departments, it is necessary to make sure that there is no underlying infection or disease. After examination and tests based on complaints, patients are referred to pelvic floor rehabilitation as a first-line treatment option.

First of all, a detailed history is obtained from the patients and the problems underlying their complaints are tried to be understood. During the evaluations, pelvic floor muscle tests, whether there is sagging in the pelvic organs, and the anatomical positions of the organs are examined. Weakness or overactivity of the pelvic floor muscles is determined. However, it is added to the treatment by taking into account the accompanying orthopedic problems.

Treatment of Pelvic Floor Disorders

What is the General Treatment Approach?

The most important element in the treatment of pelvic floor disorders is patient training. The patient, who is informed about what the pelvic floor is and how the problems occur, participates in the treatment more effectively and actively. These treatments are a process that should be planned individually with a holistic approach. For this purpose, treatments include approaches such as personalized exercise programs, bladder training, biofeedback, electrical stimulation, and lifestyle changes.

How Long Does Pelvic Floor Muscle Training Take?

The rehabilitation process may vary depending on the underlying problem, personal characteristics, and compliance with the treatment. At this point, patients need to increase their awareness of the pelvic floor, continue their exercises regularly, and make it a lifestyle.

This content was prepared by Yeditepe University Hospitals Medical Editorial Board.

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