Mercy's Dr. Mark Ellerkmann Explains Pelvic Floor Disorders

More than one-third of the 129 million women in the U.S. suffer from a pelvic floor dysfunction, according to the National Institutes of Health (NIH). Symptoms include constipation, a feeling of needing to have several bowel movements during a short period of time, painful urination, lower back pain that can’t be explained by other causes and pain during intercourse. In an interview with U.S. News & World Report, R. Mark Ellerkmann, MD, FACOG, Directory of Urogynecology, Institute for Gynecologic Care at Mercy Medical Center, explains what pelvic floor dysfunction is and provides advice on how to diagnose and treat it.

One out of four women (25%) 20 years or older suffer with PFDs. Most women are noted to have more than one PFD—the most common being pelvic organ prolapse, urinary incontinence and fecal incontinence.  Other PFDs include problems with urination and defecation (moving one’s bowels), pelvic pain and sexual dysfunction/painful intercourse.
 
Pelvic floor disorders (PFDs) are a group of conditions that affect the pelvic floor. Most mammals have a pelvis. The pelvis or pelvic girdle is made from three fused bones: the ilium, ischium and pubis bones. The pelvic bones form a connection point for the legs and sacrum or lower part of the spinal column. In humans, the pelvis is much shorter and wider than other mammals because it holds organs such as the bladder, the uterus, the prostate (in males) and the bowel including the rectum. The female pelvis is wider to accommodate childbirth.

In addition to the bony pelvis, the pelvic floor includes the muscles, ligaments and connective tissue in the lowest part of the pelvis. These structures, along with the bones of the pelvis help to support internal organs, including the bowel, bladder, uterus, vagina, and rectum. The pelvic floor prevents these organs from falling down or out of your body through an opening called the genital hiatus. The pelvic floor also helps the organs function properly.

Pelvic floor disorders are commonly due to pelvic muscles that have become weak or traumatized. Tears in the connective tissues or muscles of the pelvis (pelvic diaphragm) and injury to the nerves supplying these muscles can result in laxity, pain and dysfunction. A damaged pelvic floor cannot continue to provide the support that your organs need to work effectively. As the pelvic floor weakens, normal functioning of the bowel, bladder, uterus, vagina, and rectum can be affected.

There are many causes of pelvic floor dysfunction. A few of these causes include vaginal childbirth, repetitive straining (think chronic constipation, chronic coughing, or occupations requiring heavy lifting and straining), pelvic trauma, nerve injury, possible genetics and other health issues that can affect nerve function including diabetes, prior back surgery, spinal stenosis, stroke, Parkinson’s disease and Multiple Sclerosis. Some of the reasons women develop PFDs are better understood than other reasons.  For example, vaginal childbirth assisted with forceps or vacuum has been shown to increase the risk for pelvic organ prolapse—one of the most common types of pelvic floor dysfunction.

Risk Factors for PFD

Childbirth can contribute to the development of PFDs, because it can put excessive strain on the pelvic floor during delivery. Vaginal births double the rate of pelvic floor disorders compared to Cesarean deliveries or women who never gave birth. It also appears that the larger the baby and the longer a women pushes may play a role in injury the pelvic floor to some degree.

Menopause can contribute to weakening and thinning of tissues. With menopause, there is a decrease in circulating estrogen. Pelvic tissues such as the bladder and the vagina are very rich in estrogen receptors; without estrogen stimulation, they can become weak and thin, in turn contributing to conditions such as pelvic organ prolapse and urinary incontinence and painful intercourse.

Age affects the strength of all muscles, including those of the pelvic floor. As muscles become less strong, tissues can sage and pelvic organ prolapse can result.

Genetics seem to play a role, although the exact genetic link is not yet known. It appears that a women whose mother or sister has an underlying PFD may be at higher risk of developing one herself.

Race has been shown to influence the incidence of some PFDs. For example, Caucasian women are more likely to develop pelvic organ prolapse and urinary stress incontinence (leakage with activity).

Modifiable risk factors include weight, diet and smoking. 

Overweight or obese women are at an increased risk of developing POP and urinary incontinence.
 
Constipation often occurs when there is not enough fiber or water in a woman’s diet, bowel movements are more likely to be hard or irregular. Certain foods also can irritate the bladder, making women feel like they have to urinate. Bladder irritants include caffeine, chocolate, artificial sweeteners, spicy foods, carbonated beverages and alcohol.
Women who smoke increase their risk of developing POP and UI.
 
Treatments

Treatments are specific to the type of PFD.

The most common types of PFDs include pelvic organ prolapse, urinary incontinence and fecal incontinence. Sexual dysfunction, trouble urinating and moving one’s bowels are also common.
 
Women who experience any of these problems should seek out a urogynecologist. A urogynecologist has additional fellowship training to appropriately address these problems.  The American Urogynecological Society (AUGS) website has a directory of all the urogynecologists in the country.

Pelvic organ prolapse, or POP, is the dropping of the pelvic organs caused by the loss of normal support of the vagina. POP occurs when there is weakness or damage to the normal support of the pelvic floor. The pelvic floor holds up the pelvic organs, including the vagina, cervix, uterus, bladder, urethra, intestines and rectum. If the muscles of the pelvic floor and layers of connective tissue, which are called fascia, become weakened, stretched, or are torn the pelvic organs may fall downward. The organs drop down from where they should be and can cause trouble. In severe cases, women may feel or see tissue coming out of the opening of their vagina. Typically, the tissue coming out is from a prolapsing cervix and uterus or the walls of the vagina.

Treatment options for POP can include the use of vaginal pessaries (non-surgical) or a number of different surgical approaches including vaginal and laparoscopic approaches.

Urinary Incontinence: There are different types of urinary incontinence (UI) in women. The most common types of women's incontinence are stress urinary incontinence (SUI) and urge incontinence, also called overactive bladder (OAB). Many women often have symptoms found in more than one category (i.e., mixed incontinence).

Treatments for overactive bladder (urinary urgency, frequency, urge related leakage, getting up at night to void) can include conservative, behavior and dietary strategies; medications; bladder Botox and neuromodulation (InterStim therapy). Treatments for stress or activity-related urinary incontinence can include modest weight loss for women who are overweight, pelvic floor exercises/pelvic floor physical therapy and surgery including minimally invasive sling operations which have been shown to be highly effective and safe in correcting SUI.

--R. Mark Ellerkmann, M.D., FACOG