What are the treatment options for pelvic floor dysfunction?

Treatment Options for Pelvic Floor Dysfunction

Pelvic floor physiotherapy with biofeedback should be offered as first-line treatment for all patients with pelvic floor dysfunction, as it is evidence-based, low-risk, and effective across multiple conditions including urinary incontinence, fecal incontinence, pelvic organ prolapse, and pelvic pain. 1

Initial Conservative Management

Pelvic Floor Muscle Training (PFMT)

• PFMT is the cornerstone of treatment and should be prescribed before considering medications or invasive interventions. 1, 2
• Proper technique requires instruction from trained healthcare personnel to maximize effectiveness and prevent incorrect muscle activation. 1
• Exercises should involve isolated pelvic floor muscle contractions held for 6-8 seconds with 6-second rest periods between contractions, performed twice daily for 15 minutes per session. 1
• Treatment must continue for a minimum of 3 months to achieve optimal results. 1
• Success rates with comprehensive PFMT approaches can reach 90-100% when properly implemented. 1
• For stress urinary incontinence specifically, PFMT achieves up to 70% improvement in symptoms and increases continence rates while improving quality of life. 1

Biofeedback Therapy

• For defecatory disorders, pelvic floor retraining by biofeedback therapy is recommended over laxatives (strong recommendation, high-quality evidence). 3
• Biofeedback can be implemented through programs that allow patients to view voiding curves in real-time or through programs that teach muscle isolation using perineal EMG surface electrode feedback. 1
• Biofeedback improves rectoanal coordination during defecation and reduces constipation symptoms despite reduced laxative use. 3
• Combination of PFMT with biofeedback shows improved results compared to PFMT alone. 4

Lifestyle and Behavioral Modifications

• Education about bladder/bowel dysfunction, timed voiding, adequate fluid intake, and aggressive management of constipation must be provided. 1, 2
• Proper toilet posture with buttock support, foot support, and comfortable hip abduction can significantly improve symptoms. 1, 2
• 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. 1, 2
• Pelvic floor (Kegel) exercises combined with cognitive behavioral therapy can decrease anxiety, discomfort, and lower urinary tract symptoms. 1
• Conservative measures alone may benefit approximately 25% of patients with fecal incontinence. 1, 2

Medication Options

For Urinary Symptoms

• Antimuscarinics or beta-3 adrenergic receptor agonists, or a combination of both, can improve bladder storage parameters in patients with neurogenic lower urinary tract dysfunction. 2
• Low-dose vaginal estrogen should be used for women with more severe symptoms or those who don't respond to conservative measures. 1, 2

For Pain Symptoms

• Lidocaine can be offered for persistent introital pain and dyspareunia. 1, 2

Advanced Interventions When Conservative Measures Fail

For Fecal Incontinence

• Biofeedback therapy is recommended for patients with fecal incontinence who don't respond to conservative measures. 1
• Perianal bulking agents (e.g., intraanal injection of dextranomer) may be considered when conservative measures and biofeedback therapy fail. 1, 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. 1, 2
• Barrier devices should be offered to patients who have failed conservative or surgical therapy. 1, 2

Electrical Stimulation

• Electrical stimulation can augment the benefit of biofeedback and PFMT, though PFMT may be more effective than some types of electrical stimulation alone. 1, 4

Surgical Options

Indications for Surgery

• Anal sphincter repair (sphincteroplasty) should be considered in postpartum women with fecal incontinence and in patients with recent sphincter injuries. 1, 2
• Pelvic floor retraining should be attempted before surgery for patients with impaired pelvic floor function during defecation. 3
• Referral to specialists (urologist, urogynecologist for urinary incontinence, or colorectal surgeon for fecal incontinence) may be necessary when conservative treatments fail. 1, 2

Surgical Considerations

• Pouch of Douglas protrusion is best addressed with sacrocolpopexy, usually performed in conjunction with other gynecologic procedures in patients with pelvic floor abnormalities such as cystoceles, rectoceles, enteroceles, and vaginal vault prolapse. 3
• Based on available evidence, botulinum toxin injection or stapled transanal resection cannot be recommended outside of clinical trials. 3

Treatment Algorithm

Step 1: Initial Assessment and Conservative Treatment

• Discontinue medications that can cause constipation and perform blood tests as guided by clinical features. 3
• Begin therapeutic trial with fiber supplementation and/or osmotic or stimulant laxatives before anorectal testing (strong recommendation, moderate-quality evidence). 3
• Initiate PFMT with proper instruction from trained healthcare personnel for minimum 3 months. 1

Step 2: Add Biofeedback if No Response

• Anorectal tests should be performed in patients who do not respond to initial measures (strong recommendation, high-quality evidence). 3
• Add biofeedback therapy to PFMT program. 1, 4

Step 3: Consider Advanced Interventions

• For persistent symptoms despite adequate trial of PFMT and biofeedback, consider perianal bulking agents or sacral nerve stimulation. 1, 2
• Evaluate for surgical candidacy if conservative and advanced interventions fail. 1, 2

Measuring Treatment Success

• Treatment success is 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. 1
• Long-term adherence to pelvic floor muscle training maintains benefits. 1

Critical Pitfalls to Avoid

Common Errors

• Pelvic floor abnormalities often involve multiple compartments, requiring comprehensive assessment rather than treating isolated symptoms. 1, 2
• Behavioral or psychiatric comorbidities should be addressed concurrently for optimal treatment outcomes. 1, 2
• Patients with refractory disease may require further evaluation with full urodynamic studies or magnetic resonance imaging. 1

Technique Errors

• Patients must maintain normal breathing throughout Kegel exercises—never holding breath or straining to avoid Valsalva maneuver. 1
• Instruction on proper technique by trained healthcare personnel is essential to obtain optimal benefits and prevent incorrect muscle activation. 1