Pelvic Floor Dysfunction

Pelvic floor is a group of muscles and connective tissues that work together to support the organs in the pelvis including the anus and rectum, bladder, uterus and vagina. Improper functioning of the pelvic floor may affect your ability to defecate and/or urinate normally, and may cause pelvic pain at rest and/or during sexual intercourse. While the condition is not life-threatening and symptoms may be subtle, it often negatively impacts a patient's quality of life.

Types and symptoms of pelvic floor dysfunction

You may think of symptoms as a reflection of the "activity" of the pelvic floor and its effect on the organ it supports. When the pelvic floor muscle is in spasm (contracts involuntarily) especially for a long period, you may experience pain, soreness or stiffness in the pelvis or perineum area (similar to a cramp in your lower leg). Sometimes pain may be related to specific structure such as a nerve. Pain is the main symptom in the following pelvic pain syndrome:

Levator syndrome - abnormal spasms of pelvic floor muscles causing prolonged often dull ache, soreness or pressure in the pelvis and around the anorectum.
Proctalgia fugax - short spasms of rectal wall or pelvic muscle causing sudden rectal pain that last seconds to minutes.
Coccygodynia - pain of the tailbone (coccyx), often due to trauma or inflammation of unknown cause.
Pudendal neuralgia - pain related to the pudendal nerve (a nerve that runs along the pelvic floor) being entrapped or stretched, causing sharp shooting or burning pain.

Normal defecation requires proper relaxation of the pelvic floor muscle and the anal sphincter muscle. When the pelvic floor is in spasm, or unable to relax or coordinate due to other causes (such as nerve problem or a learned behavior), the anal canal is constricted and you may have difficulty emptying stool, feeling like you have to strain or push against a closed door. Incomplete emptying of stool may cause pelvic fullness or bloating sensation. This occurs in:

Anismus - related to nonrelaxation of or paradoxical contraction of the puborectalis muscle, a sling of pelvic floor muscle around the anal sphincter

When the pelvic floor is weak, it will not be able to support the pelvic organ and the pelvic organs sink downward by gravity (prolapse). Weakness may be due to aging, previous trauma (including childbirth), nerve dysfunction, etc. You may feel a sensation of heaviness in the pelvis. The bulge of the prolapsing organ (such as rectum) itself may cause symptoms such as swelling, pain, bleeding or mucus discharge. As the pelvic support weakens, the normal angle of the anal canal to the rectum changes as well, resulting in a "kink". The swollen bulge itself or the kink may prevent stool from emptying completely. A rectum prolapsing through the anus may stretch the anal sphincter and weakens it further, causing fecal seepage or incontinence. This pelvic floor weakness occurs in the following:

Rectal prolapse - when full-thickness of the rectum prolapses down; the rectum may prolapse only down onto the lower rectum itself or the anal canal and stays internally, or it may prolapse externally out of the anus
Pelvic organ prolapase - when the bladder and/or uterus prolapses into the vagina
Rectocele - when the front wall of rectum prolapses into the back wall of vagina
Perineal descent - when the pelvic floor bulges down with straining

Diagnosis of pelvic floor dysfunction

Pelvic floor dysfunction is diagnosed by a detail history and physical exam, including anorectal and pelvic/vaginal exam. Sometimes additional testing may be needed. These tests include:

Anorectal manometry
Balloon expulsion testing
MRI defecography
Endoanal / endorectal ultrasound
Pudendal nerve testing
Colonic transit study

Pelvic floor dysfunction is very complex and the patient often finds it embarassing and hard to explain. Many practitioners are unfamiliar with the condition. It is important to see a proctologist like Dr. Choi for accurate diagnosis and treatment.

Treatment of pelvic floor dysfunction

Except for rectal prolapse and large symptomatic rectocele that will require surgery, treatment of other pelvic floor dysfunction is nonsurgical. Treatment may include analgesic or anti-inflammatory medication (oral, topical or injection) for pelvic pain syndromes, pelvic floor physical therapy (with or without biofeedback) to help relax pelvic floor muscle and improve muscle coordination, bowel regimen and dietary changes to optimize stool consistency, and correction of improper bowel habits. It may take weeks to months or longer for symtpoms to improve, and sometimes symptoms may not go away completely or may relapse. However with patience and persistence, most patients experience significant improvement of symptoms and quality of life.