Pelvic Floor Dysfunction

What is pelvic floor dysfunction (PFD)?

The pelvic floor is a group of muscles that attach to the front, back, and sides of the pelvic bone and sacrum (the large fused bone at the bottom of your spine, just above the tailbone). Like a sling or hammock, these muscles support the organs in the pelvis, including the bladder, uterus or prostate, and rectum. These muscles also wrap around your urethra, vagina (in women), and rectum. Contracting and relaxing these muscles helps to control bowel and bladder functions. These muscles must relax to allow for urination and bowel movements, and women must be able to relax these muscles during sexual intercourse. Many people with IC have problems with this group of muscles and develop a condition called pelvic floor dysfunction (PFD). In IC patients, PFD is usually related to too much pelvic muscle tension or "high-tone"-the opposite of the too-relaxed state or "low-tone" that contributes to female stress incontinence. In fact, “Kegel” exercises, which are very frequently used to treat incontinence, may make PFD symptoms worsen. In addition to being tense, these muscles may spasm, resulting from uncoordinated muscle contraction. Sometimes IC patients with PFD can have a combination of muscles that are too-tense and too-relaxed. PFD can cause pelvic pain, poor urinary stream; urinary frequency, urgency, or retention, constipation; and pain with intercourse or sexual stimulation. Treating PFD may be very helpful in reducing symptoms and pain for some IC patients. Most patients see improvement after several weeks of therapy.

How is PFD diagnosed?

If you have IC and a poor urine stream, feel the need to push or bear down to urinate and/or have painful intercourse, you may have PFD. Side effects of certain medications commonly used to treat IC, such as tricyclic antidepressants (Elavil, Tofranil, etc.), Ditropan, and Detrol may worsen PFD symptoms. Please check with your physician if you suspect that your medications may be contributing to these symptoms. PFD can be diagnosed on physical examination by a physician or physical therapist who is specially trained in diagnosing and treating PFD. Using "hands-on" or manual techniques to evaluate the function of the pelvic floor muscles, a physician or physical therapist can assess how you can contract and relax these muscles. Muscle control can also be assessed with certain instruments. If an internal examination is too uncomfortable, electrodes to sense muscle impulses can be used. These electrodes are placed on the perineum (area between the vagina and rectum in woman /testicles and rectum in men) and/or sacrum (a triangular bone at the base of the spine) and a measuring instrument indicates whether you are able to contract and relax the pelvic floor muscles. A more accurate way to measure this is with a perineometer, which is a small, tampon-like sensing device that can be placed directly into the vagina or rectum.

How is PFD treated?

The goal of PFD therapy for IC patients is to relax these muscles and avoid stressing them. Treatment usually combines physical therapy, home exercise, medication, and self-care. It is important to avoid pushing or straining when urinating and to treat any constipation. Relaxing the muscles in the pelvic floor area overall is important, and warm baths or hot tubs twice a day can be helpful. In addition, low doses of muscle relaxants such as Valium (diazepam - 2 mg three times a day) may be helpful. Good posture to keep pressure off your bladder and pelvic organs, and stretching techniques such as yoga, can help patients learn how to avoid tightening and spasms in the pelvic muscles. A combination of these techniques can help to make pelvic floor physical therapy more successful.

Physical therapy for pelvic floor dysfunction may involve any or all of the following techniques depending on a patient’s symptoms.

Stabilizing the external pelvis

Because bones and muscles of your low back, hips, and sacroiliac joint (where your sacrum and upper hip bones meet) can stress your pelvic floor muscles, a physical therapist will first check externally for problems such as muscle spasms and weakness or sacroiliac misalignment. The therapist can then do manual therapy or massage to stabilize your pelvis before doing other treatments.

Manual therapy

A physical therapist trained to treat PFD may insert a finger into the vagina or rectum and massage the muscles and connective tissue directly. A frequently used technique is "Thiele stripping," in which the therapist finds a trigger point by feeling a twitch in the muscle underneath, exercises it using a circular motion, and then puts pressure on it to help relax it, repeating the process until the muscle starts to release. If there is too much discomfort with manual therapy, the physical therapist may start with external massage techniques to help you begin to relax these muscles. Manual therapy takes time and patience, and may require one to three sessions per week, depending on the technique used and your response to treatment. You may feel worse initially. However, improvement is often seen after six to eight weeks.

Direct electrical stimulation

A therapist can also stimulate your pelvic floor muscles directly with electrical stimulation through a small probe that can be inserted into the vagina or rectum. The vaginal probe is slightly larger than a menstrual tampon. The rectal probe is about the diameter of a forefinger. The electrical energy discharged into the muscle can slowly desensitize the nerves in the area or even cause muscle contraction and then relaxation. For those who experience too much discomfort with a probe inserted into the vagina or rectum, surface electrodes can be placed above the pubic bones and/or at the sacrum. Electrical stimulation delivered this way can calm pain and spasms, although it cannot cause your pelvic floor muscle to contract and relax. Different kinds of electrical stimulation devices to ease pain are available for home use, including probes for internal stimulation, or external stimulation using a transcutaneous electrical nerve stimulation (TENS) or similar unit.

Biofeedback

A probe inserted in the vagina or rectum or electrodes placed on the perineum and/or sacrum can sense muscle activity, which can be seen on a computer screen or heard with an audio signal. These visual and audio "clues" allow the patient to learn to contract and, even more importantly, to relax the pelvic floor muscles. Usually, this takes six to eight weeks of therapy. Biofeedback units are also available for home use. Click here to learn more about pelvic floor biofeedback therapy.

Home pelvic floor muscle exercise

Because the main goal of therapy for IC patients is to learn to control and, especially, relax the pelvic floor, therapists will teach you techniques at home to build on the therapies they do in their offices. This usually begins with general relaxation, stretching the leg and back muscles, maintaining good posture, and visualization-part of learning to sense your pelvic floor muscles and to relax them. “Kegel” exercises for the pelvic floor muscles are also used but with the emphasis on control and relaxation rather than strengthening. Biofeedback or electrical stimulation can also be part of a home program. Click here to learn more about pelvic muscle exercises.

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