Understanding pelvic floor disorders: causes symptoms and treatments

There’s an unspoken understanding among women who’ve given birth. It’s the reason some quietly avoid jumping jacks and others subtly cross their legs when laughing or sneezing. And though nearly 40% of women will experience a pelvic floor disorder in their lifetime—whether they’ve given birth or not—talking about sagging pelvic organs, incontinence and weak pelvic muscles still feels a bit taboo. For Roper St. Francis Healthcare urogynecologist Dr. Bernard Taylor, opening the discussion is step one in restoring quality of life and self-esteem to his patients.

Across the Spectrum

“Pelvic floor is a general term to describe muscles that help to support the pelvic organs, such as the bladder, urethra, vaginal walls, uterus and rectum,” explains Dr. Taylor. This important group provides control over our bladder and rectum. When it weakens and fails, accidents happen. Those accidents, called incontinence, can be especially distressing and embarrassing for people trying to go about their daily lives.

Leaking urine—often the first sign of a pelvic floor disorder—can occur with coughing, laughing or a sudden movement such as lifting. “Probably the most common initial presentation is with running and laughing,” he says. But people with active lifestyles aren’t the only ones impacted. “Someone who doesn’t have a very active lifestyle may still notice symptoms while simply standing, walking or coughing. Then there are some who develop conditions related to bladder sensation that results in what’s called urinary urgency and overactive bladder—a sudden urge to go to the bathroom,” Dr. Taylor adds.

From young adults to the elderly, Dr. Taylor’s patients most commonly arrive reporting symptoms of incontinence and prolapse of vaginal pressure. “Imagine not being able to participate in activities with your friends because you’re avoiding having accidental leakage,” he says. “I also have patients who come in after having children with incontinence that’s so destructive they can’t take care of their newborn.” And for his oldest patients, incontinence can lead to isolation and depression. “I’ve had grandmothers who aren’t able to visit their grandchildren because their symptoms are so profound they’re not able to travel any distance from home. Restoring bladder control has allowed patients to resume a normal social and family life,” he states.

“Childbirth is the most common denominator in pelvic floor disorders, but symptoms can occur after surgery, radiation and trauma,” explains the urogynecologist. “Even surgery on the back or spinal cord may result in nerve injury that can affect the muscles around the urethra and base of the bladder.”

These conditions can affect men, as well. “Most men who develop pelvic floor disorders have had surgery of the prostate. Others have neurologic conditions such as a stroke, multiple sclerosis or cerebral palsy,” explains Dr. Taylor.

Some early evidence also points to a genetic link within families, predisposing individuals to these disorders. One particular study, published in 2009 in the American Journal of Human Genetics, identified a gene that may contribute to the development of pelvic floor disorders.

Preventive Measures

While studies have shown that pregnancy and childbirth can stress and damage the pelvic floor no matter the delivery method, don’t rule out having a baby for fear of a pelvic floor disorder. “Avoiding childbirth doesn’t guarantee that a person won’t develop a pelvic floor disorder,” says Dr. Taylor. Just as having children vaginally doesn’t automatically mean that you’ll develop a disorder. “We have no evidence that using C-sections decreases one’s risk to zero.”

Unfortunately, there are few controllable factors when it comes to avoiding a pelvic floor disorder. “The recommendations we provide are the same instructions we’d give anyone wanting to live a healthy lifestyle,” says Dr. Taylor. “Avoid smoking, maintain a healthy weight and keep a regular bowel regimen. Also, be aware of your body’s limitations if you’re participating in high-intensity, heavy-lifting exercise programs. “There is some evidence that the chronic straining and lifting associated with certain popular workout classes can exacerbate pelvic floor weakness in women, accelerating their pelvic floor disorders, specifically incontinence and prolapse. I always advise getting a full examination and making sure you’re healthy before starting any new exercise regimen,” says Dr. Taylor. A pelvic floor physical therapist can also help you modify these exercises as necessary, so that you can continue to participate and enjoy such classes.

“Pelvic floor contractions, which most of us know as Kegels, are certainly a good exercise to maintain pelvic floor strength, but 95 percent of people who come through my door are doing them wrong,” explains Cate Schaffer, a Roper St. Francis Healthcare affiliated pelvic floor physical therapist. “They’re often using their glutes, abs, back or inner thighs instead of just the pelvic floor muscles.” Beyond Kegels, Schaffer recommends dynamic core strengthening exercises such as planks, clams, bird dogs and bridges for boosting pelvic floor strength.

“The tricky thing with pelvic floor health is understanding if a patient’s muscles are too weak or too tight,” says Schaffer. An evaluation by either a doctor or physical therapist can help determine whether strengthening or stretching is needed. “If someone is experiencing pain in their pelvis during intercourse or bowel movements, we’ll work to relax those muscles and identify any trigger points in the pelvis. Then, if they’re still having problems with leakage, urgency or frequency, we add in strength exercises.”

Individualized Treatment

Experiencing symptoms related to pelvic floor dysfunction can be embarrassing for some and is a common reason for delays in seeking evaluation and treatment. Because pelvic floor disorders may involve the bladder, rectum, outer and internal vagina and reproductive organs, many patients are initially seen by a primary care physician, gynecologist, urologist, gastroenterologist or colorectal doctor. A urogynecologist has special training in all organ systems involving the pelvic floor and can provide comprehensive care. Collaboration and consultation with other experts may be required to achieve a successful treatment outcome.

The first step in treatment is to undergo an evaluation including a history and examination. Second, patients often fill out a quality-of-life assessment to determine the impact their condition has on their daily activities and social life. Depending on what the urogynecologist finds, other testing may be necessary to confirm or discount certain diagnoses and focus treatment.

Individual treatment then begins with first-line therapies, including behavior and dietary modification. Some patients may work on muscle strengthening and toning with a pelvic floor physical therapist, while others may see benefit from instituting a bowel regimen to improve chronic constipation affecting their bladder and bowel control. “If not satisfactory, we go on to second-line therapies, which may include medications,” explains Dr. Taylor. “If those therapies aren’t effective or meeting the patient’s desired goals, then we can move on to surgery. Surgeries are focused on alleviating symptoms and improving their quality of life.”

“We are pleased that greater than 90 percent of women for whom we care achieve satisfactory improvement in their conditions, whether they undergo surgical or non-surgical treatments.”

Urogynecology vs. Gynecology
- A gynecologist specializes in the female reproductive system. Women typically see these doctors for routine annual well-woman exams, conditions related to menstrual cycles, Pap smears, infection screening and menopausal care.

- A urogynecologist is a surgical specialist who has completed formal medical training in either gynecology and urology and additional specialized training focused on the treatment of pelvic floor conditions, such as prolapse, incontinence and reconstructive surgery.

- Dr. Taylor recommends that his female patients first see a gynecologist to rule out any underlying causes for their symptoms. “That evaluation helps determine if a patient should be referred to us for further evaluation and/or treatment.”

Common Pelvic Floor Disorders
- Pelvic organ prolapse: A herniation, bulging or sliding of the uterus, vaginal skin supporting the bladder or rectum into the vaginal canal due to weak supportive tissues or muscles.

- Urinary incontinence: Accidental leakage of urine from the bladder; classified as either urethral weakness (stress incontinence), which occurs with increases in abdominal pressure such as sneezing or exercise, or urge (bladder spasm-related) incontinence, which is associated with a strong, sudden need to urinate followed by an involuntary loss of urine.

- Fecal incontinence: Accidental bowel leakage

If you’re experiencing symptoms of a pelvic floor disorder, talk to your primary care doctor or OB/GYN.

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