This article explains pelvic floor anatomy, functions, and common disorders. It highlights both conservative and surgical management approaches for effective care.

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Anatomy

The puborectalis muscle forms a sling around the junction where the rectum meets the anus, helping to maintain the angle between them. This action is key to controlling bowel movements and preventing accidental leakage. The pubococcygeus and iliococcygeus muscles work together to lift and support the pelvic organs. Among these, the pubococcygeus is the innermost muscle, creating an opening known as the levator hiatus, which allows the passage of the urethra, vagina, and anus.

The front part of the pelvic floor includes two main muscles: the bulbospongiosus and ischiocavernosus, which provide support near the surface. At the back of the pelvic floor, the external anal sphincter forms the outermost layer, aiding in bowel control. The transverse perineal muscles run horizontally across the middle area of the pelvic floor, joining with the bulbospongiosus and external anal sphincter at a central point called the perineal body.

The pelvic floor structures are mainly supplied by the sacral nerves S3 and S4, with the pudendal nerve playing a key role. Blood supply predominantly comes from the parietal branches of the internal iliac artery.

The muscles of the pelvic floor serve three primary functions:

1. Support: They provide structural support to pelvic organs such as the bladder, urethra, prostate (in males), vagina, uterus (in females), anus, and rectum, while also supporting other abdominal contents.
2. Continence: They assist in controlling the release of urine and faeces, contributing to urinary and faecal continence.
3. Sexual Function: These muscles are involved in sexual activities, aiding in arousal and orgasm [1].

The pelvic floor muscles are comparable to trampolines in that they can move up and down. This occurs during breathing and is much easier to imagine if we see our body as a cylinder. When we breathe in, our internal organs get gently pushed down. To make space and avoid pressure, our pelvic floor and abdominal muscles relax and stretch outward. It's like the base and sides of a cylinder expanding to accommodate the organs.

When we breathe out, the diaphragm moves back to its original position, and the abdominal and pelvic floor muscles return to their normal state. A common issue some people face is holding their breath during activities like lifting heavy objects or during bowel movements. This can put extra strain on the pelvic floor muscles, potentially leading to weakness or problems in that area [2].

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Causes and risk factors

1. Childbirth: Childbirth, particularly vaginal delivery, is a leading cause of pelvic floor muscle weakening. The risk increases significantly when instruments like forceps or vacuum devices are used to assist during delivery. During childbirth, the levator ani muscle and the tissues of the birth canal undergo extreme stretching—more than three times their original length—to accommodate the passage of the baby. This excessive stretching places immense strain on the pelvic floor muscles and surrounding structures[3].

2. Aging: Loss of muscle tone and elasticity with age.

3. Multiparity: Vaginal deliveries stretch and strain the pelvic floor muscles, ligaments, and connective tissues. With each childbirth, this repetitive trauma weakens the support structures of the pelvic organs. Congenital and acquired weakness of the muscles and fascia: This is associated with hypermobile joints.

4. Obesity: Increased intra-abdominal pressure.

5. Chronic Straining: Due to constipation or heavy lifting, chronic cough.

6. Surgery or Trauma

Hysterectomy or pelvic surgeries can disrupt support structures.

7. Hormonal Changes

 As women approach menopause, the decline in estrogen levels leads to changes in the pelvic region. Estrogen helps keep the pelvic floor muscles and tissues strong and elastic, but with lower estrogen, the lining of the urethra can thin, increasing the risk of urinary incontinence. Estrogen also supports connective tissues that hold the pelvic organs in place. As estrogen decreases, these tissues become more fragile, raising the likelihood of pelvic organ prolapse and other pelvic floor disorders. The loss of collagen and elastin further weakens the pelvic floor, making it less resistant to pressure.

8. Race

Women from certain racial backgrounds, such as white or Latina, may be more prone to developing specific types of pelvic floor disorders.

9. Health Conditions 

Conditions like IBS, endometriosis, and interstitial cystitis can lead to pelvic floor pain or discomfort.

10. Neurological disorders, such as Parkinson's disease, can affect the pelvic floor because the nervous system is essential for its proper function. Conditions like Multiple Sclerosis, Parkinson's, and Stroke can disrupt the nervous system, leading to issues with urination, bowel control, and other symptoms related to pelvic floor dysfunction [4].

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The most common pelvic floor diseases include:

• Pelvic Organ Prolapse (POP)
• Bladder dysfunction
• Bowel Dysfunction

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A. Pelvic Organ Prolapse (POP)

The terminology used to describe this condition varies depending on the specific organs involved in the herniation. They are mentioned below:

• Uterine prolapse: The uterus and cervix descend into the vagina or outside the vaginal opening (introitus).
• Apical prolapse

1. Vault prolapse: After a hysterectomy, the vaginal apex (top of the vagina) descends.
2. Uterine prolapse: The uterus and cervix, or just the cervix descend.

• Anterior vaginal wall prolapse (Anterior compartment)

1. Cystocele: The bladder bulges into the upper two-thirds of the anterior vaginal wall.
2. Urethrocele: The urethra bulges into the lower third of the anterior vaginal wall.

• Posterior vaginal wall prolapse (Posterior compartment)

1. Enterocele: The peritoneum of the pouch of Douglas, with or without intestinal loops, bulges into the upper third of the posterior vaginal wall.
2. Rectocele: The rectum bulges into the middle third of the posterior vaginal wall.

• Procidentia: Descent of apical, anterior and posterior compartments through the introitus, including the uterine body and fundus.
• Total Vaginal Vault Prolapse: The entire vagina turns inside out and protrudes, typically after a hysterectomy [5].

Symptoms

1. Mass descending per vaginum: A noticeable mass or bulge descending through the vaginal opening, which may occur on straining or even at rest.

2. Fullness in the vagina: A feeling of heaviness or pressure in the vaginal area, often described as a sensation of "something falling out."

3. Vaginal discharge or bleeding: A decubitus ulcer develops on the cervix when it protrudes beyond the vaginal introitus, leading to venous stasis, congestion, and oedema. This condition may result in a mucoid vaginal discharge, which can sometimes be tinged with blood. Trauma to the ulcer can further exacerbate the condition, causing active bleeding.

4. Low backache: A dull ache or discomfort in the lower back, which may be aggravated by prolonged standing or physical activity.

5. Urinary symptoms:

• Sensation of incomplete bladder emptying
• Increased urinary frequency and urgency
• Dysuria
• Stress urinary incontinence (leakage of urine during coughing, sneezing, or straining)
• Retention or the need to manually reduce the prolapse to void

6. Bowel symptoms:

• Constipation or a feeling of incomplete rectal emptying.
• Need for splinting or applying pressure to facilitate defecation.
• Straining during bowel movements.

7. Sexual symptoms: Decreased sexual satisfaction, discomfort, or pain during intercourse (dyspareunia), often due to vaginal laxity or associated tenderness.

8. Asymptomatic: In some cases, the prolapse may be incidental and detected during routine gynaecological examinations.Top of FormBottom of Form

Diagnosis

1. To evaluate pelvic organ prolapse, it is essential to take a comprehensive medical history and conduct a detailed clinical examination to assess the severity of the condition and identify any related symptoms. Examination of the chest and abdomen is necessary to exclude factors that increase intra-abdominal pressure.
2. Pelvic organ prolapse (POP) is traditionally categorised into first, second, and third degrees and procidentia. Anterior and posterior wall prolapses are further divided into cystocele, urethrocele, enterocele, rectocele and deficient perineum, depending on the level of prolapse.
3. However, the International Continence Society (ICS) has developed and recommended a quantification system known as the POP-Q system. So, the prolapse should be graded according to the POP-Q system. The strength of the levator ani muscle should be assessed, and the presence of stress incontinence or decubitus ulcers should be noted.
4. In addition to basic investigations, a pessary test is advised to detect hidden stress incontinence associated with prolapse. A Pap smear is crucial for cervical cancer screening.
5. Further cytological studies, such as colposcopy and biopsy, may be performed if malignancy is suspected. Additionally, a pelvic ultrasound helps identify any coexisting pathology, such as fibroids or ovarian masses, that could influence treatment planning

Treatment

1. The conservative management of pelvic organ prolapse (POP) includes lifestyle changes, pelvic floor strengthening exercises, the use of vaginal pessaries and estrogen creams.
2. Surgery is generally the preferred treatment unless contraindicated or if the prolapse is mild. For anterior or posterior vaginal wall prolapses, specific reconstructive procedures are performed, often employing site-specific repairs.
3. The decision to preserve the uterus and the choice of surgical approach depend on factors such as the patient's age, parity, the cause and type of prolapse, and any associated conditions.
4. Vaginal vault prolapse can be corrected through vaginal, abdominal, or laparoscopic procedures. Synthetic and biological meshes have been utilised to support surgical repair.

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B. Bladder dysfunction

Common bladder-related manifestations include:

1. Stress urinary incontinence (SUI):
SUI is characterised by involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, or physical exertion. This occurs due to compromised support of the urethra and bladder neck from weakened pelvic floor muscles and fascial structures.

2. Urge urinary incontinence (overactive bladder): Characterised by a sudden and intense urge to urinate, often accompanied by involuntary leakage. It is frequently associated with detrusor overactivity or altered bladder innervation secondary to pelvic floor dysfunction.

3. Urinary retention and overflow incontinence: When pelvic floor dysfunction impairs bladder emptying, it can result in urinary retention. This can lead to overflow incontinence, where urine dribbles continuously due to an overfilled bladder.

4. Pelvic organ prolapse and bladder dysfunction: Prolapse of the bladder (cystocele) into the vaginal wall can disrupt normal bladder function, causing incomplete emptying, frequent urination, or a feeling of fullness.

Diagnosis

Evaluation of bladder dysfunction consists of urine microscopy and culture, postvoid residual urine measurements, cystometry and urodynamic studies

Treatment options

1. The initial management of stress urinary incontinence often involves non-surgical approaches such as using pessaries, performing pelvic floor exercises, and making lifestyle adjustments like weight management, dietary modifications, and avoiding bladder irritants such as caffeine. Medications like imipramine and duloxetine may also be prescribed.
2. If surgery is required, it can be performed using vaginal, laparoscopic, abdominal, or combined methods. Historically, Burch colposuspension was the preferred surgical treatment, but newer techniques like tension-free vaginal tape (TVT) and trans obturator tape (TOT) procedures are now more commonly used.
3. For urge incontinence and overactive bladder, treatment typically includes bladder training, psychotherapy, and medications such as oxybutynin, dicyclomine, tolterodine, or trospium. Other advanced options include intravesical botulinum toxin injections, augmentation cystoplasty, or detrusor muscle myectomy[5].

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C. Bowel dysfunction

Diagnosis

1. Anorectal manometry: Anorectal manometry is a diagnostic test used to evaluate the function of the anal sphincters, rectal sensation, and rectoanal reflexes. It involves a catheter with sensors that measures resting anal sphincter pressure, reflecting internal anal sphincter activity, and squeeze pressure, which assesses external anal sphincter strength in four quadrants: anterior, right, left, and posterior. This 10-minute test requires no bowel preparation and provides valuable insights into neuromuscular coordination in the anorectal region.

2. Endoanal ultrasound: A small 10-MHz transducer that rotates 360° is inserted into the anal canal and withdrawn while images of both the internal and the external anal sphincters are obtained, helping evaluate anal sphincters integrity [6].

3. Anorectal electromyography (EMG): It is a diagnostic test used to evaluate potential damage to the pudendal nerve, such as from stretch injuries caused by prolonged labour. It works by measuring how well the anal sphincter responds to electrical stimulation, providing insights into the nerve and muscle function in the anorectal region.

4. Laboratory investigations: Blood, stool, and urine tests can detect infections, inflammation, or conditions like inflammatory bowel disease that contribute to faecal incontinence.

5. Magnetic resonance imaging (MRI): MRI uses strong magnetic fields and radio waves to produce detailed images of the anorectal area and surrounding pelvic organs, identifying abnormalities like fistulas or pelvic floor disorders [7].

Nonsurgical treatments for faecal incontinence

1. Bowel training: Developing a routine for bowel movements at specific times can aid in regaining control.
2. Dietary adjustments: Increasing dietary fibre can alleviate constipation while avoiding trigger foods can reduce diarrhoea. Staying hydrated by drinking plenty of water is also recommended.
3. Medications: Treatments may include anti-diarrheal agents, stool softeners, or laxatives to regulate stool consistency and minimise accidents. Medications can also address underlying conditions like irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).
4. Pelvic floor exercises: Strengthening the pelvic floor muscles can improve bowel control.
5. Biofeedback training: Also known as pelvic floor rehabilitation, this non-invasive treatment is designed for patients with faecal incontinence (FI) who have not achieved sufficient improvement through dietary changes, medications, counselling, or other supportive approaches.
6. A well-rounded biofeedback program focuses on enhancing sensation, coordination, and strength of the pelvic floor. It also offers guidance and practical advice on diet, bowel habits, behaviour modifications, and skincare to support overall management [8].

Surgical treatments for faecal incontinence

Faecal incontinence surgery is considered when medical treatments fail, focusing on improving sphincter function and correcting structural issues.

Types of surgery:

1. Sphincteroplasty: Repairs isolated sphincter injuries, typically using interrupted sutures to overlap sphincter ends. Success rates are 50%-80%, depending on nerve damage, and the procedure is often performed by colorectal or gynac surgeons.
2. Prolapse Surgery: Treats rectal or hemorrhoidal prolapse, which can weaken sphincters. Hemorrhoidectomy or rectal prolapse repair (abdominal or perineal) often restores continence, though long-standing prolapse may require additional sphincter repair.

Sphincter replacement:

1. Gracilisplasty: Uses the gracilis muscle as a sling, enhanced with electrodes for controlled contraction. Limited to specialised centres.
2. Artificial Sphincter: A silicone cuff with a pump system provides continence but carries risks of infection and device wear.
3. Sacral Nerve Stimulation: Electrically stimulates sacral nerves, improving symptoms.
4. Faecal Diversion: End colostomy, often laparoscopic, is a last resort for elderly or severe cases, though mucus leakage may persist [6].

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Nikita is an Assistant Professor in the OBGY department at SMMCHRI in Chennai.