Pelvic floor pathology includes different symptoms or diseases related to the function of the muscles or ligaments whose mission is to support the abdominal viscera and, at the same time, make way for structures such as the rectum, vagina or urethra, and control evacuatory and sexual functions. Many of these processes are more common in women because childbirth may be among their causal factors.
Pelvic floor alterations may be related to problems such as:
- Anal incontinence or urinary incontinence.
- Rectocele and enterocele
- Rectal prolapse
- Chronic anal or pelvic pain
- Evacuatory difficulty
In certain pelvic floor disorders, patients are unable to relax their sphincters correctly or even contract them more, making evacuation very difficult (anismus) or painful syndromes may appear. Conversely, in other cases, the patient is unable to hold back stool or urine (anal and urinary incontinence) and, finally, lumps called “cystocele” (cystocele, hysterocele, colpocele, rectocele, enterocele…) may also appear in the perineum, resulting respectively from the herniation of viscera, such as the urinary bladder, uterus, vagina, rectum or small intestine, through defects in the pelvic floor.
Main symptoms of pelvic floor pathology
The symptomatology of pelvic floor pathology depends on the specific and concrete problem. Thus, the need to constantly go to the toilet, leakage of feces or urine or having to urinate or defecate urgently to avoid leakage or, on the contrary, difficulty in urinating or defecating, as well as the appearance of a lump in the genitals when straining, the exit of the rectum through the anus or pain in the pelvic area will manifest themselves in the patient. All these reasons should prompt a medical consultation with an expert in surgery and coloproctology.
How to diagnose pelvic floor pathology
Apart from a directed clinical history and a careful examination, as far as the assessment from the coloproctologist’s point of view is concerned, several tests can be performed, such as:
- Anorectal manometry: measures the pressures of both anal sphincters, rectal sensitivity and pelvic floor muscle coordination. It mainly evaluates anal incontinence and constipation.
- Balloon expulsion test: Analyzes the ability to expel a balloon filled with 50ml of liquid placed in the rectum, to rule out alterations in evacuation.
- Endo-anal-endorectal ultrasound: This is used to assess the integrity of the anal sphincters and pelvic floor muscles, as well as the structures around the anus and rectum.
- Video-defecogram: It is a radiological exploration used to investigate possible disorders during evacuation (prolapse, rectocele, enterocele), as well as the state of the pelvic musculature.
- Dynamic pelvic MRI: It evaluates the same as the video-defecography, with the added advantage of not irradiating and analyzing, at the same time, the behavior of the pelvic organs.
- Percutaneous nerve evaluation (PNE): This is performed under local anesthesia and allows to know whether stimulation of the sacral nerve roots improves urinary or stool incontinence, certain types of constipation, or chronic pelvic pain.
- Intestinal transit time: After taking capsules containing small rings visible by X-ray, X-rays are taken to see their distribution in the intestine and their evacuation in cases of severe chronic constipation.
In addition, other examinations are sometimes necessary, in addition to an evaluation by different specialists, given the diversity of clinical presentations of pelvic floor problems.
Treatment of pelvic floor pathology
Multidisciplinary management by different specialists is essential, if the case requires it. Regarding the processes affecting the rectum and anus, the therapies are, basically:
- Medical and hygienic-dietary treatment. The correction of abnormal defecatory habits, the intake of fiber, liquids, and control of certain medications, whether beneficial or harmful, is important as a first measure.
- Kegel type pelvic floor muscle exercises to strengthen the anal and urethral sphincters, as well as the rest of the perineal muscles. These exercises basically consist of contracting and lifting the muscles of the pelvic area for a few seconds, followed by relaxation of the same, while in a seated position.
- Biofeedback (sphincter and pelvic floor reeducation), to treat both anal incontinence and constipation due to difficulty in expulsion. It consists of teaching the patient to improve the contraction or relaxation of the sphincters and to coordinate it at the moment when stool or gas reaches the rectum, by observing their muscular activity. This allows to have a reference to overcome, making the appropriate maneuvers to correctly contract or relax the sphincter muscles and not others.
- Sacral root neuromodulation: This consists of implanting an electrode close to a sacral nerve root, connecting it to a battery if the percutaneous nerve evaluation test (PNE) was satisfactory.
- Surgery: Pelvic floor disorders often require surgery to treat rectal prolapse, rectocele, enterocele, cystocele, uterine prolapse, vaginal vault eversion, or certain cases of anal or urinary incontinence. Some of them can be performed laparoscopically. Due to the existence of a wide variety of problems and specific surgical techniques, each case will be specifically analyzed.
Can pelvic floor problems be prevented?
Prolonged deliveries, those requiring significant instrumentation or significant multiparity are in themselves risk factors. The same applies to habitual evacuatory efforts over the years. Pregnancy itself, chronic cough, removal of the uterus, prostate cancer surgery, a history of low back pain or obesity are also relevant in the appearance of these pelvic floor problems.
Thus, careful attention to childbirth and the reduction of evacuatory efforts and correction of constipation throughout life will contribute to reducing the incidence of these problems, which appear more frequently in women after the onset of menopause, as hormonal activity and muscle tone decrease.
Those who are at risk for pelvic floor problems should avoid physical exercises of high intensity or that put pressure on the pelvis, such as jumping rope, lifting weights, or sports that involve fast running, among others. However, certain sports are healthy, such as swimming, cycling or walking. In addition, the pelvic floor can be protected when doing gymnastics, for example, by lifting not too heavy weights in a seated position, keeping the legs together when doing gymnastics, adopting a relaxed position or trying to be gentle with squatting exercises. Regardless of this, there are specific pelvic floor exercises, such as the Kegel exercises already discussed.