Pelvic floor assessment
What is the pelvic floor?
The pelvic floor is a group of muscles and ligaments that are attached to the bottom rim of the bones of the pelvis. These muscles and ligaments form a trampoline-like structure that supports the bladder, uterus, and bowel. There are three openings in the pelvic floor in women that the urethra (urine outlet), vagina, and anus pass through. The pelvic floor muscles wrap tightly around these structures so that bladder, uterus, and bowel, which normally rest on the top of the pelvic floor, cannot slip down through the openings. Although the urethra and anus have their own muscles to keep them closed until we are ready to pass urine or empty our bowels, the muscles of the pelvic floor provide extra assistance. So, when the pelvic floor is not working properly people have difficulty controlling the release of urine, faeces, and wind.
What is pelvic floor dysfunction?
Pelvic floor dysfunction encompasses pelvic organ prolapse, urinary incontinence and voiding problems, obstructed defaecation and faecal incontinence, and sexual dysfunction.
The causes of pelvic floor dysfunction are not completely understood but it does seem that vaginal childbirth plays a major role. Large babies and forceps deliveries may be particularly important factors. Chronic constipation and being overweight also seem to predispose some women to vaginal prolapse, and studies have shown that the overall incidence increases with ageing.
Pelvic Organ Prolapse
This is downwards movement of one or more of the pelvic organs into the vagina, sometimes even protruding out through the vagina. The main pelvic organs are the bladder, uterus, and the small and large bowel. Women with pelvic organ prolapse sometimes describe a feeling of a lump or bulge in the vagina, a dragging sensation, vaginal looseness, or occasionally discomfort during sex.
Urinary incontinence and voiding problems
Urinary incontinence means leakage of urine and is a very common symptom in women after childbirth. Stress incontinence is the most common type of incontinence in women with pelvic floor dysfunction, and refers to leakage of urine during activities such as laughing, sneezing, running and lifting. Many women experience this on rare occasions, but for some women it can happen many times every day.
Obstructed defaecation and faecal incontinence
Obstructed defaecation occurs when the passage of faeces is obstructed by prolapse of the bowel. This causes symptoms such as chronic constipation, needing to strain when opening bowels, or a feeling of incomplete bowel emptying. Faecal incontinence refers to uncontrollable leakage of faeces or wind which can be very distressing, and will result in social isolation for some women.
Most women with mild to moderate vaginal prolapse will be able to continue to have a normal sex-life, although some women describe reduced sexual pleasure. A common concern is vaginal looseness, but in reality partners are unlikely to be able to feel or see a mild to moderate prolapse, and most will be unaware of it during sex. Women with a more severe prolapse might find sex uncomfortable, but in general it is safe for women with a prolapse to have sex, and sex will not worsen a prolapse.
Difficulty passing urine
Recurrent urinary tract infections
Vaginal prolapse, or sensation of a ‘lump’ in the vagina
Difficulty in emptying bowels
How can ultrasound help?
3D pelvic floor ultrasound is a dynamic imaging technique that allows us to look into the female pelvis and visualise the relationship between the pelvic organs and the pelvic floor in real-time. It provides information about the structure and function of the pelvic floor and documents the position of the bladder, urethra, uterus and rectum relative to the pelvic floor both at rest and when ‘pushing down’. It identifies the presence and extent of pelvic organ prolapse, and can detect other changes in the pelvic floor which may increase the risk of pelvic organ prolapse developing. The scan is not painful and is performed by resting an ultrasound probe on the external part of the vagina. It takes about 30 minutes.
Until recently this type of assessment was only performed in Melbourne by some specialists in urogynaecology. Recently Dr Andrew Edwards went interstate to learn this new technique from Prof Peter Dietz, a pioneer in the assessment of the pelvic floor. The assessment can now be requested by a GP who can then organise further management.
Many women with pelvic floor dysfunction have little or no symptoms and therefore may not require treatment. But if symptoms are problematic or bothersome there are a number of treatments that can be considered. It is important to discuss potential treatments with your doctor or physiotherapist. Treatment usually begins with relatively simple and non-invasive treatments such as pelvic floor exercises, in combination with management of other problems, such as constipation and being overweight. It is important to perform pelvic floor exercises properly to get the maximum benefit, and the best way to learn to do them properly is to see an experienced pelvic floor physiotherapist. Pelvic floor exercises work by strengthening the muscles of the pelvic floor and can be extremely effective. If symptoms persist you might need to see a specialist to discuss other options including vaginal pessaries and various surgical techniques.