Pelvic floor dysfunction

The pelvic floor is a structure of muscles and ligaments which play an important role in supporting the organs of the pelvic cavity. Dysfunction of the pelvic floor can result in symptoms such as chronic pain, incontinence of bladder or bowel, sexual function disorders and pelvic organ prolapses. These conditions can have an influence on quality of life. Whilst some disorders need medical and surgical interventions, there are some behavioural, dietary and lifestyle modification which can help the pelvic floor.

What is the pelvic floor?

The pelvic floor is a dome- shaped structure of muscles and ligaments positioned across the bones of the pelvis. It canopies from the pubis to the sacrum/coccyx and ischial tuberosities (the bones you feel when you are sitting).

The muscles of the pelvic floor:

• support the organs within the pelvic cavity – bladder, urethra, anus, rectum, the prostate in males, vagina and uterus in females, and the abdominal contents
• are associated with bowel and bladder control
• contribute to sexual arousal and orgasm
• help stabilize the hips and trunk whilst standing and walking

Pelvic floor dysfunction

Conditions falling under the umbrella term of "pelvic floor dysfunction" can be of a gynaecological, urinary or colorectal nature or a combination of these.

• Gynaecological – involving the vagina and uterus
• Urinary – affecting the urethra and bladder
• Colorectal – affecting the anus and rectum

Changes to structural anatomy can result in either an increase of activity – hypertonicity (non-relaxing), or hypotonicity (weakened/uncoordinated) muscle actions.

What are the causes of Pelvic floor dysfunction?

There are many causes and conditions which are associated with failure of pelvic floor muscles to perform their function. These can include:

Pelvic floor prolapses (PFP) which can include the bladder, uterus or vaginal, bulging herniation of intestines or rectum into the vagina. 

Pelvic floor prolapses can occur due to:

• pregnancy and childbirth
• surgical removal of the uterus
• low oestrogen after menopause
• obesity
• chronic coughing due to respiratory disorders
• sitting for long periods of time
• repeated lifting of weights 
• chronic constipation - straining with bowel movements

Pelvic floor dysfunction can occur for many reasons. Low oestrogen levels, endometriosis, poor toileting techniques from childhood, toilet avoidance (putting-off going to the toilet for voiding or bowel movements), sexual abuse, neuromuscular disease, spinal cord injury, surgical and obstetric trauma.

Pelvic muscle pain may be attributed to poor posture, imbalances of the skeletal frame or gait, vulvodynia and atrophic vaginitis. 

Some conditions may have pelvic pain as a symptom - such as irritable bowel syndrome, endometriosis and interstitial cystitis.

Some medications can also affect the bladder resulting in urinary hesitancy and incontinence.

Common symptoms of pelvic floor dysfunction

• Difficulty in passing urine and incontinence (the involuntary leaking of urine)
• Dyspareunia – pain during or following intercourse
• Constipation or trouble having a bowel motion
• Faecal incontinence (involuntary leakage of bowel)
• Unexplained pelvic pain
• Chronic pain associated with the muscles of the pelvis
• Feelings of heaviness in the pelvis
• Tissue protruding from the vagina or feelings of something falling 
• Erectile dysfunction

Chronic conditions of the pelvic floor can occur due to muscles which are too tight or non-relaxing (hypertonic) or muscles which are too weak (hypotonic).

A weak pelvic floor is often associated with prolapses and urinary incontinence.

A nonrelaxing pelvic floor can be associated with non-specific symptoms, such as pain, problems with defecation, urination and sexual function, which are issue which require relaxation of the muscles and co-ordination of anal and urinary sphincters.

Treatment considerations

Many conditions of pelvic floor dysfunction need the attention of specialist medical professionals. With the causes being so varied the evaluation and treatment need to be tailored to the individual. In some instances, addressing disorders involving the bowel, urinary system, gynaecological, and sexual function may be necessary to achieve results. Keeping this in mind there are some dietary and lifestyle modifications with may help.

Kegel and core strengthening exercises

For the pelvic floor to function effectively, the pelvic muscles need to have strength, endurance and co-ordination.

The pelvic floor muscles can be pictured as a hammock or basket lying at the base of the pelvis. Contracting these muscles stops the flow or urine. Kegel and core-strengthening exercises support the muscles of the pelvic floor.

To perform the correct core-strengthening exercises it may be necessary to visit a specialist in this area, such as a physiotherapist or exercise physiologist.

Kegel exercises are easy exercises to perform and can be done anytime you are standing, sitting or laying down. Best performed with an empty bladder. The muscles to exercise can be identified by stopping and starting the flow of urine whilst on the toilet. After identification, exercises should not be performed whilst urinating. 

• Tighten your pelvic floor muscles. Hold tight and count 3 to 5 seconds.
• Relax the muscles and count 3 to 5 seconds.
• Repeat 10 times, 3 times a day 

Avoid tightening muscles of the thighs, buttocks or abdomen. Check with your health professional (doctor, physiotherapist) if unsure if you are performing these exercises correctly.  Note: Kegel exercises may not be suitable for hypertonic conditions.

Myofascial release

This is a physical therapy involving joint mobilization, deep pressure massage and stretching techniques, combined with relaxation and breathing exercise. It may be beneficial for chronic pelvic pain such as endometriosis.

Biofeedback

This is a neuromuscular technique training the muscle of the pelvic floor through contraction and relaxation. The use of intra-anal, intra-vaginal or surface electrodes provide visual and/or auditory responses to actions performed.

Lifestyle

Diet modification can help with urinary frequency and incontinence. Foods to avoid include those high in concentrated sugar and artificial sweeteners, acidic foods (citrus, oranges) and spicy foods and caffeine-containing drinks (cola, coffee and tea).

Weight reduction - Carrying extra weight can put pressure on the pelvic muscles. Losing weight can help with stress incontinence. 

Quit smoking - smokers are at greater risk of incontinence. Smokers will often develop a chronic cough which can put pressure on the pelvic muscles and eventually cause them to weaken and lead to stress incontinence. 

Answering the call of nature. Don't avoid or put-off going to the toilet when the need arises. 

Maintain good posture 

Supplement with Magnesium

Magnesium is a mineral important for muscle relaxation and can help with muscle cramps, including the muscles of the pelvic floor. Magnesium is a natural calcium-channel blocker (needed for muscle action), and inhibits the release of acetylcholine (responsible for nerve impulses), at the synapse (the end of a nerve) thus calming-down over-stimulated muscles (associated with urge-incontinence).

Magnesium can prevent constipation by relaxing the muscles of the intestine supporting a regular muscle action. Magnesium also draws water into the bowel to soften the stool which prevents over-straining during bowel actions (which tightens the pelvic floor muscles and anal sphincter).

Herbal medicine considerations

Herbal medicine can offer pain and spasm relief. It may be necessary to talk with a naturopath or herbalist for the most appropriate prescription. Some suggestions include:

Pain relief – California poppy (Eschscholzia californica) and Jamaican dogwood (Piscidea piscipula).

Antispasmodics (relieves spasms of the urinary tract) – Yarrow (Achillea millefolium), Cramp bark (Viburnum opulus) and kava kava (Piper methysticum). 

References

1. Pelvic Floor Dysfunction https://www.ncbi.nlm.nih.gov/books/NBK559246/
2. The impact of pelvic floor muscle training on the quality of life of women with urinary incontinence: a systematic literature review https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962309/
3. Relating Chronic Pelvic Pain and Endometriosis to Signs of Sensitization and Myofascial Pain and Dysfunction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5585080/
4. Physical, Complementary, and Alternative Medicine in the Treatment of Pelvic Floor Disorders https://pubmed.ncbi.nlm.nih.gov/28585105/
5. https://journals.lww.com/jwhpt/Fulltext/2021/07000/Exercise_Interventions_to_Improve_Pelvic_Floor.4.aspx?WT.mc_id=HPxADx20100319xMP
6. The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain https://www.sciencedirect.com/science/article/abs/pii/S2050052115000025?via=ihub
7. The status of pelvic floor muscle training for women https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2997838/
8. Recognition and Management of Nonrelaxing Pelvic Floor Dysfunction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498251/
9. Pelvic Floor Dysfunction https://my.clevelandclinic.org/health/diseases/14459-pelvic-floor-dysfunction
10. Romm, Aviva; 2010; Botanical Medicine of Women’s Health, Churchill Livingstone Elsevier, USA
11. Signaling in Muscle Contraction https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4315934/
12. Magnesium Oxide in Constipation https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7911806/
13. https://www.health.gov.au/resources/publications/pelvic-floor-muscle-training-for-women
14. https://www.health.gov.au/resources/publications/pelvic-floor-muscle-training-for-men