Pelvic Floor Disorders
Understanding the signs, symptoms & causes of pelvic floor disorders
What are pelvic floor disorders (PFDs)?
First off, the pelvic floor is made up of a network of muscles and connective tissue that provide both structure and support of the pelvis and connecting joints, assist in urination and defecation and aid in sexual performance. The pelvic floor consists of three layers of muscle — the superficial perineal layer, the deep urogenital diaphragm layer and the pelvic diaphragm, including the levator ani muscle.
Pelvic floor disorders are any disorder affecting the pelvic floor, including urinary incontinence (stress and urgency), overactive bladder, pelvic organ prolapse (POP), and fecal or anal incontinence.1 Urinary incontinece and fecal or anal inconincen are best described as a loss of the body’s ability to control urination, defecation or flatulence. Pelvic organ prolapse is when the bladder, uterus or rectum drops from its normal place in the lower abdomen down into the pelvis.
How common are PFDs?
Pelvic floor disorders are fairly common, with studies showing that 23.7-34% of women have at least one PFD.2,4 Additionally, while 46% of these women had one PFD, 16%-33% of symptomatic women had two or more disorders.3 A study showed that although PFDs are common, only 25% of symptomatic women seek care.4
What are the signs and symptoms of PFD?
- This includes any amount of leaking urine, feces or even gas at any time
- Whether you are leaking when sneezing, laughing, coughing, doing box jumps or any jumping, lifting heavy, and doing double unders, this is a sign of PFD
- Frequent urination (more than 8 times in 24 hours) or urgency are also a sign of PFD
- Pain with sexual intercourse, bowel movements or urination
- This also includes constipation or feeling like you are not able to complete a bowel movement
- Hemorrhoids - internal and external
- Pressure or pain in the lower abdomen and pelvis
- This can include feeling like you have numbness, heaviness, bearing down sensation or bulging near the vagina
- Low back, pelvic, SI and hip pain
- All of the muscles of the body are interconnected. If you are experiencing pain in any of these areas it may actually be referred from the pelvic floor or referring to the pelvic floor
What are the contributors of PFD?
*Note I did not say CAUSE of PFD. I know we all want one cause, and therefore one treatment to cure PFD. Unfortunately, it is not always that easy as it is typically multi-faceted and has more than one contributing factor.*
- A study showed that vaginal delivery increased the odds of pelvic organ prolapse but additional vaginal deliveries did not increase the odds of developing PFD.5,6,7
- Additionally, urinary incontinence is also associated with vaginal childbirth.5,8,9
- The risk of PFD is does not appear to be correlated with caesarean delivery as PFD has not been found to increase with a history of active labor or complete cervical dilation prior to cesarean delivery.6
Assisted Vaginal Birth - Episiotomy, instrumented delivery, etc.
- The use of instruments in delivery is associated with an increased risk of PFD. This includes the use of forceps or vacuum which significantly increases the risk of PFD and specifically POP.
- “Magnetic resonance images provide evidence that show that the pelvic floor regions experiencing the most stretch are at the greatest risk for injury, especially in forceps deliveries.”15 and “risk factors for pelvic floor injury include forceps delivery, episiotomy, prolonged second-stage of labor, and increased fetal size.”16
- Handa found that obesity is not only a risk factor for incontinence but may also accelerate the progression.8
- Another study showed that weight loss from either diet or exercise can experience a “70% reduction in the frequency of total and urge UI episodes” with a 5-10% loss of body weight.18
- A large birth weight has been shown to increase risk of pelvic floor dysfunctions.16,17
Levator ani injury
- Levator ani muscles have been shown to increase with long second stage, anal sphincter tear, and older maternal age.
- A study by Miller showed that at “seven weeks after delivery, 91% of women showed some form of musculoskeletal injury that involved the pubic bone or levator ani muscle: 66% had pubic bone marrow edema; 29% had pubic subcortical fracture; 90% had levator muscle edema, and 41% had low-grade or greater levator ani muscle tear.”10
What about muscle stretching?
During normal pregnancy, the pelvic floor muscles can stretch over 3 times the usual length to allow for the descent of the baby’s head.11,12
A study performed on rats showed that the pelvic floor muscle fiber length increases between 21-37% and the quantity of extracellular collagen matrix increases by 140% in the pelvic floor muscles. The collagen matrix is a normal protein that “may shield the muscle fibers from excessive mechanical strain during delivery by providing a parallel elastic element that limits fiber strain.”14 This study showed that the extracellular matrix remained elevated at 12 weeks postpartum but the fiber length returned to normal.
It’s easy to look at these numbers and think, “holy cow, my pelvic floor just stretched three times the usual length, that can’t be good,” but the body actually does this to help prevent pelvic floor dysfunction by allowing the pelvic floor muscles to open and move in preparation for the baby’s arrival. This is one reason that one thing we regularly say at BIRTHFIT is “slow is fast” because it takes time for the body to naturally heal.
What can I do about it?
While pelvic floor disorders are common, they are not normal and should not be minimized or ignored. If you are experiencing any sign or symptom of pelvic floor dysfunction, please reach out to a women’s health physical therapist near you. Not sure where to start? Check out these resources to find a local women’s health physical therapist near you:
- Hallock JL, Handa VL. The epidemiology of pelvic floor disorders and childbirth: an update. Obstetrics and gynecology clinics of North America. 2016;43(1):1-13. doi:10.1016/j.ogc.2015.10.008.
- Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ, Prevalence of symptomatic pelvic floor disorders in US women. Pelvic Floor Disorders Network. JAMA. 2008 Sep 17; 300(11):1311-6.
- Gyhagen M, Åkervall S, Milsom. Clustering of pelvic floor disorders 20 years after one vaginal or one cesarean birth. Int Urogynecol J. 2015 Aug; 26(8):1115-21.
- Rortveit G, Subak LL, Thom DH, et al. Urinary Incontinence, Fecal Incontinence and Pelvic Organ Prolapse in a Population-Based, Racially Diverse Cohort. Female Pelvic Medicine & Reconstructive Surgery. 2010;16(5):278–283.
- Quiroz L, Muñoz A, Shippey SH, Gutman RE, Handa VL. Vaginal Parity and Pelvic Organ Prolapse. J Reprod Med. 2011;55(3–4):93–98.
- Handa VL, Blomquist JL, Knoepp LR, Hoskey KA, McDermott KC, Muñoz A. Pelvic Floor Disorders 5–10 Years After Vaginal or Cesarean Childbirth. Obstetrics & Gynecology. 2011 Sep;:1.
- Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG: Int J O&G. 2012;120(2):152–160.
- Handa VL, Pierce CB, Muñoz A, Blomquist JL. Longitudinal changes in overactive bladder and stress incontinence among parous women. Neurourol Urodyn. 2014;34(4):356–361.
- Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. A comparison of the long-term consequences of vaginal delivery versus caesarean section on the prevalence, severity and bothersomeness of urinary incontinence subtypes: a national cohort study in primiparous women. BJOG: Int J O&G. 2013;120:1548–1555.
- Miller, J., Low, K.L., Zielinski, R., Smith, A., DeLancey, J., and Brandon, C. Evaluating maternal recovery from labor and delivery: bone and levator ani injuries. Am J Obstet Gynecol. 2015; 213: 188.e1–188.e11
- Hoyte, L., Damaser, M.S., Warfield, S.K. et al. Quantity and distribution of levator ani stretch during simulated vaginal childbirth. Am J Obstet Gynecol. 2008; 199: 198.e1–198.e5
- Lien, K.C., Mooney, B., DeLancey, J.O., and Ashton-Miller, J.A. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol. 2004; 103: 31–40
- Alperin, M., Lawley, D.M., Esparza, M.C., and Lieber, R.L. Pregnancy induced adaptations in the intrinsic structure of rat pelvic floor muscles. Am J Obstet Gynecol. 2015; 213: 191.e1–191.e7
- New directions in understanding how the pelvic floor prepares for and recovers from vaginal delivery. Nygaard, Ingrid. American Journal of Obstetrics & Gynecology , Volume 213 , Issue 2 , 121 - 122
- Ashton-Miller JA, Delancey JO. On the biomechanics of vaginal birth and common sequelae. Annu Rev Biomed Eng. 2009;11:163–176. PubMed PMID: 19591614. eng.
- Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470–8. doi: 10.1016/0029-7844(96)00151-2.
- Dietz HP, Wilson PD. Childbirth and pelvic floor trauma. Best Pract Res Clin Obstet Gynaecol. 2005;19:913–24.
- Wing RR, Creasman JM, West DS, et al. Improving Urinary Incontinence in Overweight and Obese Women Through Modest Weight Loss. Obstetrics & Gynecology. 2010;116(2, Part 1):284–292.
- Bump RC, Norton P. Epidemiology and Natural History of Pelvic Floor Dysfunction. Obstetrics and Gynecology Clinics of NA. 1998;25(4):723–746
The information by Dr. Lauren Keller of Elemental Chiropractic, Inc. is provided for general information only and should in no way be considered as a substitute for medical advice or information about any particular condition. While every effort has been made to ensure that the information is accurate, Dr. Lauren Keller nor Elemental Chiropractic, Inc. make no warranties or representations as to its accuracy and accept no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. If you have any specific questions about any medical matter or think you may be suffering from any medical conditions, you should consult your doctor or other professional healthcare provider. You should never delay seeking medical advice, disregard medical advice, or discontinue medical treatment because of information on this website.