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Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) refers to any disorder involving the muscles and organs of the pelvic floor.

The bony pelvis encompasses the lower part of the colon, the urinary bladder and urethra, the female genital organs, the muscles that support the lower back, lower extremities, and pelvic organs, and all the tissue, nerves, and blood vessels that innervate and support these organs.

The pelvic floor is the system of muscles, ligaments, fascia and connective tissue that support the pelvic organs. The muscles that make up the pelvic floor, the levator ani muscle group, obturator internus, coccygeus, and piriformis, attach to the bony pelvis and act as a hammock to support the bladder and urethra, vagina and genital organs, and rectum.

The muscles of the pelvic floor serve to support the organs both physically and functionally. There is also a more superficial layer thought to be more involved with sexual function. 

The nerve supply of the pelvic floor muscles is from the sacral nerves S2-S4 and travels from the sacrum through the pudendal nerve. Most of the nerve innervation is slow twitch which helps the muscles maintain a constant tone. There are also fast twitch nerve fibers which help the muscles contract more quickly as needed. The pelvic floor muscles have three main functions: support, continence, and sexual function.

PFD refers to problems that occur when the muscles don’t work together properly leading to changes in function as well as pelvic pain.

PFD can occur when muscles of the pelvic floor are either overactive or underactive. Inability to hold urine or have coordinated bowel movements can be a sign of underactivity.

Overactivity or spasms may occur for many reasons. When muscles contract for long periods of time they can become pain generators. They can also put pressure on nerves and blood vessels. This increases the pain signals that are sent back to the brain through the nervous system. Signals sent back out may be associated with additional muscle contraction allowing the cycle to spiral out of control and the pain to become chronic.

Myofascial Pelvic Pain Syndrome

Myofascial Pelvic Pain Syndrome refers to pain in the muscles of the pelvic floor that is attributed to PFD. Sometimes it is called proctalgia fugax, coccygodynia, levator ani syndrome, pain in the muscles, or myalgia, can develop in three ways.

It may be caused by a direct injury to a muscle, a viscera-muscular reflex, or primary dysfunction in which muscles do not act in a coordinated manner. Direct injury may result from trauma, childbirth, or surgery.

Painful spasms of the muscles of the pelvic floor can occur because of musculoskeletal changes that occur with posture changes or low back pain.

Conversely, tension and pain in the pelvic floor can be the cause of mobility problems in the bony pelvis and sacroiliac joint.

PFD is often associated with other conditions that cause chronic pelvic pain. Conditions like interstitial cystitis (IC), irritable bowel syndrome (IBS) and endometriosis, for example, stimulate the nervous system which sends signals to the pelvic floor to contract. Chronic stimulation of the nervous system can cause the muscles to contract continuously. Muscle spasm and painful trigger points that occur in response to other organ problems are a type of problem caused by a viscera-muscular reflex.

Almost 90 percent of women with IC have pain in the muscles of the pelvic floor in conjunction with PFD, and at least half of women diagnosed with IC have IBS. About 85 percent of women with chronic pelvic pain have muscular spasm of the pelvic floor or postural changes.

Symptoms

  • Aching, heaviness, or burning
  • Cyclic or continuous  pain
  • Worsening symptoms around the time of menses
  • Pain with vaginal penetration 
  • Pain with orgasm   
  • Deep pelvic pain with intercourse
  • Prior surgery for prolapse
  • Difficulty starting or stopping stream of urine
  • Urine leaking with cough, sneeze, or straining
  • Pain attributed to uterine cramping or ovarian cysts
  • Pain with bowel movements
  • Chronic constipation or difficulty evacuating
  • Pain with sitting for any length of time
  • Feeling of sitting on a golf ball
     

Associated conditions in women

Gynecologic

  • Dysmenorrhea
  • Ovarian cysts
  • Endometriosis
  • Pelvic congestion syndrome
  • Pelvic inflammatory disease
  • Vulvodynia
  • Provoked vestibulodynia or vulvar vestibulitis syndrome

Urologic

  • Interstitial cystitis
  • Recurrent urinary tract or bladder infections
  • Kidney stones      

Gastrointestinal

  • Inflammatory bowel disease
  • Irritable bowel syndrome
  • Chronic constipation
  • Diverticulitis
  • Colon cancer
  • Hemorrhoids

Psychological

  • Depression
  • Anxiety
  • Personality disorder
  • History of physical or sexual abuse

Musculoskeletal or neurologic

  • Fibromyalgia
  • Myofascial abdominal wall pain
  • Piriformis syndrome
  • Poor posture

Work-up

The diagnoses of pelvic floor dysfunction and pelvic floor tension myalgia are often overlooked. Complete evaluation of pelvic organs and the pelvic floor should be undertaken with a complete medical, surgical, and personal history, a thorough physical exam, and appropriate diagnostic testing depending on specific symptoms. Part of the evaluation includes a comprehensive exam of the pelvic floor musculature.

Treatment options

Treat all associated conditions

Medications

  • Analgesics
  • Anti-inflammatory medication
  • Muscle relaxants
  • Anti-depressants or anti-seizure medications

Physical therapy

  • Exercises
  • Biofeedback
  • Direct massage

Trigger point injections

  • Anesthetics with or without steroids
  • Botulinum toxin

Neurostimulation

  • TENS unit
  • Implanted neuromodulation

Adjunct treatment options

  • Acupuncture
  • Massage therapy 

Resources

International Pelvic Pain Society

Sources

Howard FM: Introduction. Pelvic pain—Diagnosis and Treatment.Edited by Howard FM, Perry CP, Carter JE, El-Minawi AM. Philadelphia: Lippincott Williams &Wilkins; 2000:477-492.

Karlovsky ME and Moldwin RM Pelvic Floor Dysfunction a treatment update. New treatment modalitis take advantage of the maturing relationship between pelvic floor dysfunction and chronic pelvic pain . accessed 2/5/2012

Montenegro MLLS,Vasconcelos ECLM, Candido dos Reis FJ, Nogueira AA, Poli-Neto OB. Physical therapy in the management of women with chronic pelvic pain. Medscape. Accessed 2/4/2012.

Peters KM, Carrico DJ, Kalinowski SE, IbrahimIA, DioknoAC. Prevalence of pelvic floor dysfunction in patients with interstitial cystitis. Urology. 2007 Jul:70(1):16-8. Accessed 2/5/2012.

Srinivasan AK, Kaye JD, Moldwin R. Myofascial dysfunction associated with chronic pelvic floor pain: management strategies. Current Pain and Headache Reports. 2007. 11:359-364. Accessed 2/4/2012.

Uptodate.com/contents/clinical-manifestations-abd-diagnosis-of-myofascial-pain-syndrome-in-women. Accessed 2/4/2012. Elkadry e and Myonihan NK. Last update 6/2/2009.

Won HR and Abbott J. Optimal management of chronic cyclical pelvic pain: an evidence-based and pragmatic approach. Int J Women’s Health. 2010 Aug(2):263-277.