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Pelvic floor dysfunction
When we think about pelvic floor problems, we generally think about stress incontinence and prolapse. However, the consequences of pelvic floor
dysfunction also include sexual problems, chronic pelvic pain, bladder voiding and bowel evacuation difficulties.
Pelvic floor disorders are very common: they affect 1 in 10 women >20y, and half of women over 80y.
The symptoms associated with pelvic floor dysfunction can be debilitating and limiting, and treatments can have complications and side-effects.
The economic burden of these problems is substantial: urinary incontinence costs the NHS around £818 million/year (BMJ 2022;378:e070186).
In 2021, NICE published guidance on the prevention and non-surgical management of pelvic floor dysfunction (NG210, 2021). While this may seem a
subject area which primarily involves women’s health physiotherapists, our input in primary care is also important because identifying women at risk
of pelvic floor dysfunction early may prevent symptoms developing (which is good for women and the NHS!).
Definitions
The pelvic floor consists of a large, dome-shaped muscle complex which runs from the pubic bone anteriorly to the ischial tuberosities laterally and the
coccyx and sacrum posteriorly.
The role of the pelvic floor is to:
Support the pelvic and lower abdominal contents.
Enable faecal and urinary function and continence.
Contribute to sexual function.
The three most common conditions associated with pelvic floor dysfunction are urinary incontinence, faecal incontinence and pelvic organ
prolapse. There are separate articles on these conditions which give more detail on assessment and management of each.
Risk factors for pelvic floor dysfunction
Modifiable risk factors
BMI >25kg/m2.
Smoking.
Lack of exercise.
Constipation.
Diabetes mellitus (evidence shows that prevalence of pelvic floor dysfunction is higher in women with diabetes, presumably due to
peripheral nerve damage and/or associated obesity).
Non-modifiable risk factors
Increasing age.
Family history of incontinence.
Gynaecological cancer and its treatment.
Gynaecological surgery.
Fibromyalgia.
Chronic respiratory disease/cough.
Multiparity and giving birth >30y.
Traumatic childbirth.
Prevention, assessment and management of pelvic floor dysfunction
Prevention, assessment and management of pelvic floor dysfunction (NICE NG210, 2021)
Prevention is key!
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NICE states that we need to increase awareness of the pelvic floor for all women from the age of 12y, and should provide information and
resources in healthcare and other settings (e.g. schools, antenatal classes etc…).
We should use advise women about:
The importance of pelvic floor muscle training (PFMT) in the prevention and improvement of pelvic floor dysfunction.
Lifestyle risk factors which could exacerbate issues.
The NHS website has information that we can signpost patients to, and other resources are listed at the end of the article.
Assessment of pelvic floor in primary care
We should ask about this when women consult us specifically about symptoms or related issues. Always remember to ask about pelvic
floor issues at any pregnancy-related or postnatal consultations.
Ask about incontinence, voiding and sexual difficulties, prolapse and pain symptoms.
Examination should be led by any specific symptoms voiced (e.g. looking at the vulva and vagina for atrophy, speculum examination to
assess prolapse, or consider a rectal examination if impaction is possible).
Digital assessment can confirm strength of pelvic floor muscle contraction (i.e. asking woman to squeeze examining fingers during
pelvic examination – see the PERFECT assessment below for more details).
Remember, rule out other causes of symptoms (e.g. dipstick urine, look at medication).
Management of pelvic floor dysfunction
Lifestyle
We should advise (all!) women about the importance of:
Physical activity.
A healthy balanced diet (avoiding constipation which can exacerbate pelvic floor problems).
Stopping smoking.
Avoiding being overweight.
Avoiding caffeine if experiencing overactive bladder symptoms.
Pelvic floor muscle training (PFMT)
We should encourage all women to get into the habit of doing PFMT, but especially around pregnancy and if they are symptomatic.
Warn women that it may take weeks or months before they notice a difference in any symptoms.
Behavioural approaches
Offer supported bladder retraining to women with urinary frequency, urgency or mixed incontinence: either by referring to
physiotherapy, or via resources such as those on the Bladder and Bowel Community – bladder retraining and keeping a bladder
diary.
Intravaginal devices and pessaries
Offer pessaries for women with symptomatic pelvic organ prolapse.
Consider trial of intravaginal devices for women with urinary incontinence if other non-surgical options have been unsuccessful (see
below).
What are intravaginal devices?
Intravaginal devices include sponges, bladder neck supports and incontinence pessaries.
Do they work?
Cochrane looked at the efficacy of mechanical devices to prevent female urinary incontinence. It found limited evidence which was
insufficient in comparing the different devices with each other, and with other forms of treatment (CD001756,2014).
Should we recommend them?
NICE considers that, despite the lack of supportive data, use of intravaginal incontinence devices may be beneficial on an individual basis
and may prevent the need for more invasive treatment.
See Continence Product Advisor for more information on (and pictures of!) different products.
When should we refer to a women’s health physiotherapist?
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Refer for a 3-month programme of supervised PFMT:
Women with stress or mixed urinary incontinence.
Pregnant women who have a first-degree relative with pelvic floor dysfunction (this should commence by 20 weeks).
Postnatal women who have had an instrumental delivery, an OP presentation or anal sphincter injury.
Referral for a 4-month programme of supervised PFMT:
Women with symptomatic pelvic organ prolapse which does not extend more than 1cm beyond hymen on straining.
Women with faecal incontinence and coexisting pelvic organ prolapse.
The physiotherapist waiting list is very long – how do I teach pelvic floor exercises?!
A Practice Pointer article in the BMJ describes how to assess and train the pelvic floor (BMJ 2022;378:e070186). PFMT should aim to improve
muscle strength, endurance and relaxation.
The PERFECT assessment
In primary care, we may not feel we have the expertise (or time) to do this ‘perfectly’! But we can use it as a basis to assess pelvic floor function during
digital vaginal examination, and ensure the patient can identify which muscles she needs to contract.
Power – assess maximal contraction strength.
This should be graded 0–5: 0 = absence, 1 = flicker, 2 = weak (increase in tension but no lift/squeeze), 3 = moderate (some degree of life/squeeze), 4
= good (pelvic floor elevation and some resistance), 5 = strong.
Endurance – how long they can hold a maximal contraction – up to 10 seconds.
Repetitions – how many 10-second maximal contractions they can hold (allowing 4 seconds rest between) – up to 10.
Fast – the number of 1-second contractions they can perform in a row – up to 10.
Remember that Every Contraction needs to be Timed.
How to do pelvic floor muscle training (PFMT)
Sit comfortably with knees slightly apart.
Lift and tighten muscles around anus and vagina (as if stopping oneself from passing flatus or urine).
A basic contraction consists of a 1–2 second contraction with 1–2 seconds break in between. The length of contraction can be gradually increased
to 6–10 seconds with 6–10 seconds break.
Do PFMT three times a day and do at least 8–12 contractions each time.
With time, PFMT can be performed while standing and during activity.
Women who experience stress incontinence can learn to contract their pelvic floor in preparation for a leakage-provoking event (this is known as
‘the knack’).
Consider downloading an app such as the NHS ‘squeezy’ app which reminds you to do your PFMT and keeps a record of when you do it!
Should we recommend commercially-available biofeedback tools?
Women may come to us asking about whether to invest in (quite expensive!) pelvic floor toners, or tools to help improve their pelvic muscle muscles
(e.g. Kegel 8 or Elvie).
Evidence looking at the effectiveness of additional therapies in improving pelvic muscle function is inconsistent, but some studies suggest they may
be beneficial in aiding women to learn to effectively contract their pelvic floor. However, there is no evidence that they are more effective than
supervised pelvic floor muscle training.
NICE suggests that for women who are unable to perform an effective pelvic floor muscle contraction, biofeedback techniques, electrical stimulation or
vaginal cones may be considered.
This suggests that, before a woman parts with her money, she may be better seeing a physiotherapist first.
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Pelvic floor dysfunction
Pelvic floor disorders are common – especially as a consequence of pregnancy and as women get older.
Pelvic floor dysfunction can cause urinary and faecal incontinence, pelvic organ prolapse, sexual problems and chronic
pelvic pain.
Encourage all women to get into the habit of doing pelvic floor muscle training every day preventatively.
Refer symptomatic women to a women’s health physiotherapist for supervised pelvic floor muscle training.
Useful resources:
Websites (all resources are hyperlinked for ease of use in Red Whale Knowledge)
NHS – what are pelvic floor exercises? (includes link to instruction video)
Bladder and Bowel Community (useful downloads of bladder diaries and instructions for bladder training)
NHS squeezy app
We make every effort to ensure the information in these articles is accurate and correct at the date of publication, but it is of necessity of a brief and general nature, and this
should not replace your own good clinical judgement, or be regarded as a substitute for taking professional advice in appropriate circumstances. In particular check drug doses,
side-effects and interactions with the British National Formulary. Save insofar as any such liability cannot be excluded at law, we do not accept any liability for loss of any type
caused by reliance on the information in these articles.
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