What are the treatment options for pelvic floor dysfunction?

Treatment Options for Pelvic Floor Dysfunction

Pelvic floor muscle training (PFMT) should be recommended as first-line treatment for patients with pelvic floor dysfunction to improve urinary symptoms and quality of life. 1, 2

First-Line Conservative Approaches

• Pelvic floor physiotherapy reliably enhances strength and endurance of pelvic floor muscles across diverse patient groups, with improvements associated with reduction of lower urinary tract symptoms (LUTS) and better quality of life 1
• Education about bladder/bowel dysfunction, timed voiding, adequate fluid intake, and aggressive management of constipation should be provided as part of initial management 2
• Lifestyle modifications, including proper toilet posture with buttock support, foot support, and comfortable hip abduction, can significantly improve symptoms 2
• Conservative measures alone may benefit approximately 25% of patients with fecal incontinence 2
• Comprehensive treatment approaches incorporating multiple conservative strategies can achieve success rates of 90-100% 2

Biofeedback and Advanced Physiotherapy

• Biofeedback therapy can be implemented through programs that improve flow rate by having patients view voiding curves in real-time 2
• Biofeedback combined with PFMT shows improved results compared to PFMT alone for treating urinary incontinence, pelvic pain, and other pelvic floor disorders 3
• Biofeedback therapy is recommended for patients with fecal incontinence who don't respond to initial conservative measures 2
• Electrical stimulation can augment the benefits of biofeedback and PFMT in treating various pelvic floor dysfunctions 3

Medication Options

• Antimuscarinics or beta-3 adrenergic receptor agonists, or a combination of both, may be recommended to improve bladder storage parameters in patients with neurogenic lower urinary tract dysfunction 1
• Solifenacin succinate (5mg and 10mg) has demonstrated significant reductions in urinary frequency, incontinence episodes, and increased voided volume compared to placebo in clinical trials 4
• Low-dose vaginal estrogen can be used for women with more severe symptoms or those who don't respond to conservative measures 2
• Lidocaine can be offered for persistent introital pain and dyspareunia 2

Catheterization Options (When Applicable)

• Intermittent catheterization should be recommended rather than indwelling catheters to facilitate bladder emptying in patients with neurogenic lower urinary tract dysfunction 1
• For patients who require a chronic indwelling catheter, suprapubic catheterization is preferred over an indwelling urethral catheter 1
• Self-catheterization is associated with better quality of life compared to catheterization performed by a caregiver 1

Advanced Interventions

• Perianal bulking agents (e.g., intraanal injection of dextranomer) may be considered when conservative measures and biofeedback therapy fail 2
• Sacral nerve stimulation should be considered for patients with moderate or severe fecal incontinence who haven't responded to conservative measures and biofeedback therapy 2
• Barrier devices should be offered to patients who have failed conservative or surgical therapy 2

Surgical Options

• Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with fecal incontinence and in patients with recent sphincter injuries 2
• Referral to specialists, such as a urologist or urogynecologist for urinary incontinence, or a colorectal surgeon for fecal incontinence, may be necessary when conservative treatments fail 2

Treatment Effectiveness and Monitoring

• Treatment success should be measured by improvement in voiding and bowel diary, flow rate, post-void residual urine measurement, frequency and severity of incontinence episodes, and urinary tract infection recurrence 2
• PFMT increases the chance of improvement in prolapse stage by 17% compared to no PFMT 5
• PFMT has been shown to be effective for stress urinary incontinence with a documented success rate of 56.1% vs. 6% without such treatment 6

Common Pitfalls and Special Considerations

• Constipation management is crucial and often discontinued too early; treatment may need to be maintained for many months before the patient regains bowel motility and rectal perception 2
• Pelvic floor abnormalities often involve multiple compartments, requiring comprehensive assessment 1
• Behavioral or psychiatric comorbidities should be addressed concurrently for optimal treatment outcomes 2
• Despite evidence-based research indicating the efficacy and cost-effectiveness for treatment of urinary incontinence, PFMT is underutilized as a first-line treatment in clinical practice in the USA 7
• Psychosomatic factors must be taken into account as they can have a major effect on treatment outcomes 6