What is the treatment for an overstretched pelvic floor muscle such as the puborectalis, pubococcygeus, or levator ani?

Treatment of Overstretched Pelvic Floor Muscles

Pelvic floor muscle training (PFME) is the first-line treatment for overstretched pelvic floor muscles such as the puborectalis, pubococcygeus, or levator ani, with the goal of restoring muscle strength, power, endurance, and coordination to provide urethral support and prevent incontinence. 1

Understanding the Clinical Context

Overstretched pelvic floor muscles typically result from:

• Obstetric trauma during vaginal delivery, particularly multiparity, which can cause direct muscle avulsion or denervation injury 2, 3
• Chronic straining and increased intra-abdominal pressure from constipation or heavy lifting 2
• Advanced age and hormonal changes in postmenopausal women 2
• Obesity and chronic disease burden 2

The most common presentation is muscle avulsion (complete detachment from the pubic bone insertion), which occurs in approximately 26% of women who delivered vaginally and is associated with anal sphincter defects in 19% 2. Unilateral puborectalis avulsion causes asymmetric hiatal enlargement of approximately 7% 4.

First-Line Conservative Treatment: Pelvic Floor Muscle Exercise (PFME)

PFME strengthens the pelvic floor muscles to provide urethral support, prevent urine leakage, and suppress urgency, and has been recommended as first-line treatment for urinary incontinence since first described by Kegel. 1

Key Components of PFME:

• Muscle identification: Patients must learn to isolate and contract the puborectalis, pubococcygeus, and iliococcygeus muscles without recruiting abdominal, gluteal, or thigh muscles 1
• Exercise parameters: Focus on improving strength, power, endurance, relaxation, or a combination of these parameters 1
• Proper instruction: Clinicians and physical therapists must understand pelvic floor muscle anatomy, evaluation, regimen, and instruct patients how to train the muscles properly 1

When PFME is Most Effective:

• Stress urinary incontinence as first-line behavioral therapy 1
• Post-surgical rehabilitation following decompression procedures (e.g., cauda equina syndrome), where pelvic floor muscle training should begin immediately post-operatively once cleared by neurosurgery 5
• Continence recovery when combined with bladder training protocols 5

Surgical Intervention for Severe Muscle Avulsion

When conservative treatment fails or when there is complete muscle rupture/avulsion diagnosed by clinical examination and ultrasound, surgical repair is indicated 3.

Transvaginal Levator Ani Repair:

Levator ani muscle repair using a transvaginal approach has demonstrated full restoration of normal puborectalis muscle function (Wexner score 0/20) in 78.8% of patients after surgery, with all patients showing improvement in continence and sexual function. 3

Surgical Technique Details:

• Approach: Transvaginal repair of puborectalis and/or pubococcygei rupture at the level of insertion in the pubis 3
• Associated procedures: Often combined with posterior repair and levatorplasty (50% of cases) and sphincteroplasty (63.4% of cases) 3
• Complications: Low rate of minor complications (<7.7%), including postoperative pain (5.77%), urinary retention (3.85%), hematoma (1.92%), and perineal abscess (1.92%) 3

Outcomes:

• Dyschezia resolution: Among 28 patients with preoperative obstructive defecation, 64.3% had complete resolution and 35.71% improved by ≥50% 3
• Sexual function: Improvement in dyspareunia and sensation during intercourse in all patients 3
• Continence: Significant improvement in Wexner incontinence scores at 6 months post-surgery 3

Bilateral Plication of Puborectalis Muscles (PRP):

For vulvovaginal widening due to levator ani laxity, bilateral plication of the puborectalis bundles is an alternative surgical approach 6.

• Anatomical outcomes: Genital hiatus reduced from 65±5mm preoperatively to 31-35mm at 6 weeks through 12 months post-surgery (P<0.00001) 6
• Sexual function: More than 88% of patients observed improvement in quality of sexual intercourse (P<0.00001) 6
• Morbidity: Minor complication rate under 3% 6
• Stability: Anatomical outcomes remain stable at 12 months 6

Levator Sling Procedure:

For anal incontinence caused by destroyed or absent sphincter mechanism, a levator sling serving as a substitute puborectalis sling can be constructed by freeing the insertion of the pubococcygeus and iliococcygeus muscles from the coccyx 7. This technique has shown good to excellent results in patients with incontinence of varied causes 7.

Diagnostic Work-Up Before Treatment

Clinical Examination:

• Digital rectal examination to assess pelvic floor motion during simulated evacuation, resting tone of internal sphincter, puborectalis muscle contraction during squeeze, and check for acute localized tenderness 8
• Deviation of the anus on the side opposite the lesion is observed in 96.2% of patients with unilateral avulsion 3

Imaging:

• Endoanal and perineal ultrasound to confirm levator ani and puborectalis muscle rupture 3
• Ultrasound findings: Unilateral avulsion is associated with significant increase in hiatal area (P≤0.002), with avulsion accounting for approximately 7% increase in hiatal area on Valsalva maneuver 4

Common Pitfalls to Avoid

• Do not assume all pelvic floor dysfunction is due to weakness: Some patients have hypertonic pelvic floor (chronically elevated resting tone) rather than overstretched muscles, which requires relaxation training rather than strengthening 8
• Do not delay surgical evaluation in patients with complete muscle avulsion, as conservative treatment alone will not restore anatomical integrity 3
• Do not overlook associated conditions: Diarrhea is the most important independent risk factor for fecal incontinence (OR 53), often more significant than the structural pelvic floor defect itself 2
• Do not ignore neurological red flags: Pelvic floor numbness and urinary incontinence following lumbar spine surgery may indicate cauda equina syndrome requiring emergency MRI and decompression within 24-48 hours 5

Treatment Algorithm

1. Initial assessment: Clinical examination with digital rectal exam and ultrasound to determine extent of muscle damage 3
2. Conservative management: PFME as first-line treatment for partial tears or muscle laxity without complete avulsion 1
3. Surgical referral: For complete muscle avulsion confirmed on ultrasound, refer for transvaginal levator ani repair 3
4. Post-surgical rehabilitation: Immediate initiation of PFME once cleared by surgeon 5
5. Address contributing factors: Treat underlying diarrhea, optimize bowel function, and manage chronic straining 2