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Pelvic Floor Dysfunction

Pelvic Health Physiotherapy

Please seek immediate medical attention if you experience any of the following symptoms:

  • Severe abdominal pain
  • Blood visible in the urine
  • Bleeding from the back passage
  • Bleeding from your vagina or front opening if you are post menopausal
  • Sudden/ significant changes in your bladder sensation AND/ OR control (e.g. reduced awareness of needing to empty, difficulties emptying)
  • Sudden/ significant changes in your anal or bowel sensation AND/ OR control (e.g. constant OR reduced awareness you need to empty or loss of control)
  • If you have had a significant trauma to the spine or pelvis
  • Stool or urine coming out of your vagina or front opening

See your GP if you experiencing any of the following symptoms:

  • Persistent constipation
  • Persistent or recurrent urinary tract infection symptoms (pain on passing urine, urgency, frequency, getting up to pee overnight a lot)
  • Any symptoms of vaginal infection (new, bloody OR foul smelling discharge)
  • Itchy or red or broken genital skin
  • Vaginal dryness in Perimenopause/ menopause
  • Minor injury to the back or pelvis

A Pharmacist may be able to assist you with these problems in the first instance:

  • Urinary tract infection
  • Constipation
  • Thrush/ Bacterial Vaginitis
  • Mild Vaginal dryness

Pelvic floor dysfunction (PFD) is an umbrella term for the conditions listed below; these conditions are common but not ‘normal’ and can be very bothersome for some people. There are many treatment options available which are often successful.

The following information includes lots of hints, tips and guidance on self management and accessing further help; this is also helpful information if you are currently waiting to be seen by the team.

PFD can include:

Pelvic Organ Prolapse (POP)

There are 4 types of vaginal prolapse and you can have more than one. When health professionals examine you they will take a note of the type and severity of the prolapse using a grading system from ‘mild’ to ‘severe’. However, the true significance of the prolapse is dependent on your symptoms and how much it bothers you.

  • Anterior wall prolapse (previously known as a ‘Cystocele’ or ‘Bladder Prolapse’) – this is when the front vaginal wall bulges down into or out of the vagina
  • Posterior Wall prolapse (previously known as a ‘Rectocele’) – this is when the back vaginal wall bulges down into or out of the vagina. This is not to be confused with a rectal prolapse where the rectum itself comes out of the anus
  • Uterine decent (cervical prolapse)– this is when the uterus moves down into or out of the vaginal canal
  • Urethral prolapse (Urethrocele)– This is when the tube from the bladder bulges down

It is also possible that you may have more than one. Please read this Prolapse information leaflet and Pelvic organ prolapse for more information.

See the treatment options list below

If these measures alone do not improve your symptoms there are other options such as pessary fitting and surgery.

  • Pessaries are devices made from medical grade silicone or plastic that is worn inside the vaginal canal; they act as internal ‘scaffolding’ to support the vaginal walls up. How a pessary is used depends on the type of pessary fitted; some stay in place for a period of time (usually 4-6 months); some get removed, cleaned and replaced each day by the wearer.
  • Pessaries for Prolapse | POGP

Urinary Incontinence (UI)

There are 2 types of Urinary incontinence and it is common to get a mix of both problems.

Stress urinary Incontinence (SUI) –Abdominal pressure is constantly changing during movement and it is particularly high during coughing, sneezing, laughing, large movements and exercise. When your abdominal pressure increases, urine will be forced out of the bladder if the urethral muscle and pelvic floor muscles are not strong enough to balance that pressure. If you have had vaginal births or often strain to move your bowels these structures may already be overstretched and if you are overweight your abdominal pressure will also be higher during simple movements like getting off a chair. Both may exacerbate your symptoms.

Urge incontinence (‘Over active bladder’ Irritable bladder’ and ‘detrusor overactivity’). This is caused by a miscommunication between the bladder and brain causing the detrusor muscle in the bladder wall to squeeze more strongly and more often than it needs to.

  • This may make you feel like you desperately need the toilet (urgency).
  • You may go regularly and pass only small amounts of urine (frequency).
  • You may also wake several times overnight to empty your bladder (Nocturia).
  • This may also lead to not making it to the toilet in time and getting a leak of urine (urge incontinence); these leaks can be small dribbles or full ‘floods’.

See the treatment options list below

  • If these measures alone do not improve your symptoms there are other options such as medication trials or surgery.
  • It is also important to care for the skin of the vulva; urinary incontinence and pad use can cause or exacerbate skin conditions
  • Skin conditions of the vulva | RCOG

Anal Incontinence (AI)

Anal incontinence can be loss of control of stools (‘faecal’) but also of wind (‘flatal’); both problems can respond well to combination of pelvic floor muscle exercises and bowel care.

See the treatment options list below

Consistency of the stool is really important. If the stool is hard or difficult to pass it causes difficultly emptying the rectum fully; this can result in small leaks following bowel movements known as ‘post defecatory smearing’. If the stool is too loose it is very difficult to maintain control even with very good pelvic floor muscles.

Sexual Dysfunction

Sexual dysfunction can present in several ways; for some, pain is the only or dominant symptom. However, issues with desire, arousal, erections, and orgasm all also fall under this umbrella. If you are having problems with sexual function it is important that a holistic approach is taken and you see the correct health professionals. Please see your GP in the first instance. Here are some resources that may help.

Risk Factors

A question the team often gets asked by individuals is “Why has this happened to me?” When considering the answer to that question it is useful to think about risk factors and focus on the ones you can change. Many people blame themselves for developing PFD but you can see from the list below, the common risk factors are not always within your control and it is often a combination of factors that lead to PFD.

Treatment Options

Pelvic Floor Muscle Training (PFMT)

*Please read this section if you are having any type of PFD

The pelvic floor has a lot to do; it has to be strong and have stamina…. but it also needs to be able to coordinate an intricate pattern of movement, timing and reflexes to maintain your continence and support the organs above. In some cases the muscles are weak because they are tight and cannot move enough. This can cause problems such as incontinence but may result in sexual dysfunction such as pain during intercourse, during a smear test or while using tampons.

Remember that to function properly, muscle needs to be able to contract and shorten, but it also needs to be able to lengthen and relax. So when you are doing your pelvic floor muscle exercises please remember that the squeeze is important, but the release phase of the movement is equally important.

Maintaining a program of exercises can be the hardest part of PFMT so consider using a diary or the Squeezy phone app to help remind you and record your progress.

Devices that may help with PFMT

*Please read this section if you are having any difficultly doing PFMT

There are so many devices available that knowing which one may be of benefit to you can be difficult. Most of the devices to assist in rehabilitation of the pelvic floor can be split into 3 types…

  • Electrical stimulators – This can be very useful for someone has little to no ability to contract their pelvic floor. A small electrical current is delivered to the nerves and muscles of the pelvic floor by a small internal probe causing a contraction response, with time and repeated use the muscle strengthens and stamina builds.
  • Biofeedback machine – A biofeedback machine doesn’t do anything to you, instead it shows you what you are doing by giving feedback; it will show you if are doing your exercises correctly. Depending on the machine, it may do this by lighting up, beeping, vibrating or even show you a picture that moves in response to your contractions. This allows you to monitor your progress and assists with improving your pelvic floor exercise technique by helping you ‘see’ the movement.
  • Weighted devices – also known as vaginal weights, Kegel weights or vaginal cones. These weighted devices will add resistance to your pelvic floor exercises to make them more challenging and assist with strengthening. Most come with a variety of weights and sizes. To begin with you would start with the lightest/ largest weight and progress as your strength develops to a smaller/ heavier weight.

General exercise to help the Pelvic floor

*Please read this section if you are having any type of PFD

Research shows us that PFMT can be very helpful with PFD but it also tells us that PFMT is more effective if used in combination with global movement and strengthening exercises. It’s important not to forget about all the associated anatomy that works closely with the pelvic floor. Having strong and mobile hips, abdominal muscles and feet is really important when rehabilitating your Pelvic Floor.

Here are some links to Forth Valley Council leisure facilities, the NHS fitness Studio and a Pilates Leaflet produced by the POGP.

There is also the added bonus that exercises to assist with PFMT will have a greater health benefit by also helping with mood, pain relief, weight loss, sleep and digestion.

The tissues of your body (Bones/ muscles/ ligaments/ tendons/ organs/fascia) all need nutrition and hydration to be healthy, this also helps you get maximum benefit from any activity and exercise that you do

Bladder Health

*Please read this section if you are having any type of PFD

Below are some links to healthy bladder habits including bladder drill and fluid modification

Bowel Health

*Please read this section if you are having any type of PFD

The bowels themselves can cause difficulties AND have a significant influence on the bladder function, difficultly emptying can also be the cause of prolapse, follow the links to information regarding bowel care.

Weight management

*Please read this section if your BMI is over 25

The Musculoskeletal system is vulnerable to extra weight; especially the pelvic floor as it is the only horizontal muscle group in the body. BMI calculations can be an unreliable measure for health as you fall into the ‘overweight’ category even if you are very fit and active. If your BMI is 25-29.9 a waist to height ratio may be more helpful in determining if weight loss would be of benefit to you. This is done by dividing your waist circumference measurement by your height measurement- the aim is for your result to be under 0.5.

If your BMI is over 30, research has shown your pelvic floor is at risk and you are far more likely to have PFD.

Treating symptoms of perimenopause/menopause

*Please read this section if you are having any changes to your menstrual cycle or over 40 years old

Hormones have a huge role in your pelvic health; changes in perimenopause and menopause can significantly influence you bladder, bowel and sexual function. This can be particularly problematic if the tissues of your genitalia do not have enough oestrogen. This was previously known as vaginal atrophy and currently known as Genito-urinary syndrome, the tissues may feel dry or sore or maybe feel ok but look a bit dry or darker in colour or red.

Genitourinary syndrome can exacerbate prolapse, bladder and sexual dysfunction symptoms so it is always worth speaking to your doctor about options such as Hormone replacement therapy, moisturisers and topical oestrogen replacement.

How to be referred to a specialist physio

  • It is important that your GP has the opportunity to discuss your symptoms, examine you and do some provisional checks.
  • You can discuss referral to a specialist Pelvic Health Physiotherapist with your GP and if appropriate they will refer you.
  • There is also the Bladder and Bowel Service (BABS), Pessary clinic, Urology, Colorectal and Urogynaecology services available in Forth Valley. Your GP may recommend that one of these services is more appropriate.
  • The Pelvic Health Physiotherapy team aim to provide a holistic approach which is respectful and inclusive.

What does a Pelvic Health Physiotherapy Assessment involve?

Many people are unsure of what to expect when attending physiotherapy for assessment of a pelvic floor dysfunction problem; for some it can even prevent them seeking help.

At the first appointment the physiotherapist will take a detailed history. This will include questions about your symptoms and what aggravates and eases them. They will also ask about when and how your symptoms started, previous treatment, past medical history, general health and lifestyle. It is also standard practice in pelvic health to screen for associated issues; this means you will be asked about your bladder, bowel and sexual function including any history of trauma.

It can be daunting to have conversations about personal and intimate topics; please be reassured that the pelvic health physiotherapists are sensitive to this and will do their upmost to put you at ease. The spaces used are private and confidentiality is maintained at all times; nothing you say will be discussed without your permission and you are welcome to bring someone with you for support if you wish.

Once a history has been taken, you may also be asked if you are happy to have a vaginal or rectal examination to assess the function of your pelvic floor muscles. This is always completed by a physiotherapist who has received specific specialist training and will talk you through each step of the examination; they will be sensitive to any concerns and do their best to put you at ease.  You can also ask for the examination to be stopped at any time, decline this examination completely or ask to have it on another day. This will not affect your treatment options.

When an assessment has been completed the physiotherapist will discuss their findings with you and your treatment options; together you can then decide on a treatment plan.

In an Emergency call 999 for health advice and reassurance call NHS24 on 111.
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