Nonrelaxing Pelvic Floor Dysfunction – Symptoms, Treatment

Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by non relaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect the quality of life. Focus on the global symptom complex, rather than the individual symptoms, may help the clinician identify the condition. The primary care provider is in a position to intervene early, efficiently, and effectively by

  • (1) recognizing the range of symptoms that might suggest nonrelaxing pelvic floor dysfunction,
  • (2) educating patients,
  • (3) performing selective tests when needed to confirm the diagnosis, and
  • (4) providing early referral for physical therapy.

Several terms such as pelvic floor tension myalgia, piriformis syndrome, and levator ani syndrome have been used to describe this entity, but the term non-relaxing pelvic floor dysfunction may be preferable because it will help the clinician identify a recognizable pattern of symptoms. Because it is difficult to precisely characterize which muscles are responsible for dysfunction, this general term is preferred over more specific descriptors that attribute the disorder, sometimes erroneously, to a specific muscle (eg, levator ani syndrome, coccygodynia, piriformis syndrome, puborectalis dyssynergia).

The pelvic floor consists of bone, muscles, and connective tissue; together, these elements provide support to the pelvic organs, spine, and pelvic girdle and assist with urinary, defecatory, and sexual function. In particular, these functions require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. Hence, their impaired relaxation or paradoxical contraction can result in various symptoms such as impaired voiding or defecation, pelvic pain,, and sexual dysfunction.

Women with these disorders tend to have the dysfunctions diagnosed and managed by specialists who usually focus on symptoms pertaining to their expertise (eg, urologists for bladder problems, gastroenterologists for defecatory problems, physiatrists for low back or pelvic pain). This concise review is geared toward primary care providers because they are in a position to intervene early, efficiently, and effectively by

  • (1) recognizing the range of symptoms that might suggest a nonrelaxing pelvic floor disorder,
  • (2) educating patients,
  • (3) performing selective tests when needed to confirm the diagnosis, and
  • (4) referring the patient early for pelvic floor physical therapy.

Causes of Nonrelaxing Pelvic Floor Dysfunction

The most commonly implicated mechanism for these symptoms is dysfunctional voiding or defecation, which either was never learned correctly or was acquired in adulthood through the voluntary holding of urine or stool. This voluntary holding might be attributable to habit, lifestyle, occupation, or constant recruitment of muscles used to avoid bowel or bladder incontinence.Conditions that result in dyspareunia (eg, atrophic vaginitis, vulvodynia) may trigger involuntary muscle contraction of the pelvic floor. This pattern is reinforced over time, particularly if intercourse is continued despite the pain, and can potentially lead to persistent contraction of the pelvic floor and symptoms of nonrelaxing pelvic floor dysfunction.

Injury to the pelvic floor from surgery or trauma can result in painful, hypertonic muscles. Pelvic surgical procedures such as mesh placement or permanent sutures in the muscles, as well as obstetric injury, have been reported to result in muscular pain and hypertonicity of the pelvic floor.

Visceral pain syndromes associated with chronic pelvic pain include irritable bowel syndrome, endometriosis, and interstitial cystitis or painful bladder syndrome. These may be associated with non relaxing pelvic floor muscles through central and peripheral sensitization and lowering of nociceptive thresholds, resulting in neuropathic up-regulation, hypersensitivity, and allodynia. Pain may be referred from visceral organs to muscles and vice versa.

Several recent studies have demonstrated neural “cross-talk” between pelvic organs, which, while necessary for normal physiologic regulation of bowel, bladder, and sexual function, may explain why shared painful symptoms of the rectum, bladder, and pelvic and adnexal structures might develop. The underlying mechanism for this phenomenon is poorly understood, but it may be mediated by the peripheral and central nervous systems.

Postural or gait abnormalities, skeletal asymmetry, and prolonged sitting may trigger symptoms in some individuals. Because the lower extremity, hip, abdomen, pelvis, and spine are a connected kinetic chain, any dysfunction along this chain may cause overcompensation and dysfunction of other associated muscles. A recent, small, blinded, prospective study of women with chronic pelvic pain showed a higher frequency of abnormal pelvic musculoskeletal findings (eg, asymmetric iliac crests) in those with pelvic pain compared with controls.

Consistent with clinical experience, a meta-analysis showed a significant association between sexual abuse and a lifetime diagnosis of functional gastrointestinal disorders, nonspecific chronic pain, and chronic pelvic pain. The prevalence of abuse is higher in patients treated at tertiary care centers and in those with severe or multiple symptoms compared with those with milder and more limited symptoms. Moreover, a history of abuse is linked to poorer health status, increased physician visits, and disability. Because a history of abuse is common in the general population, and even more so in women with multiple concerns related to the pelvic floor, it is important to inquire about a history of abuse in women with nonrelaxing pelvic floor dysfunction.

Often, the specific cause or inciting event that leads to non relaxing pelvic floor dysfunction is never identified. A series of events or a combination of factors may contribute to the development of the problem. Perpetuating factors include those that commonly complicate chronic pain such as sleep disturbance, depression, and anxiety.


Symptoms of Nonrelaxing Pelvic Floor Dysfunction

Symptoms of non relaxing pelvic floor dysfunction are associated with voiding dysfunction, anorectal dysfunction, sexual dysfunction, and pain. Symptoms tend to develop slowly and insidiously; for some patients, they may begin in childhood (eg, defecatory disorders). Difficulty evacuating stool or straining with bowel movements, a sense of incomplete evacuation, bloating, and constipation are bowel symptoms characteristic of non relaxing pelvic floor dysfunction. Urinary symptoms include frequency, hesitancy, urgency, dysuria, bladder pain, and sometimes urge incontinence. Insertional or deep dyspareunia, a pelvic ache after intercourse, low back pain radiating to the thighs or groin, and pelvic pain unrelated to intercourse are also common. It is important to inquire about the range of symptoms that may suggest nonrelaxing or hypertonic pelvic floor dysfunction in women who present with bowel, bladder, or sexual concerns.

Treatment

A careful clinical examination is very useful and sometimes sufficient for identifying non-relaxing pelvic floor dysfunction. Appropriate testing should be performed as indicated to exclude other conditions that cause chronic pelvic pain (eg, colorectal, gynecologic, neurologic, or urologic conditions). When symptoms or examination findings are complex, further objective assessment is needed, and referral to a subspecialist should be considered. The diagnostic evaluation might include anorectal manometry with balloon expulsion, anal endosonography, defecography, urodynamic testing, cystoscopy, electromyography, ultrasonography, and static or dynamic magnetic resonance imaging. Anorectal manometry and rectal balloon expulsion studies can help confirm the diagnosis of defecatory disorders by documenting inadequate intra-abdominal pressure during straining, incomplete evacuation of the rectum, and inadequate relaxation of anal canal pressures.


Education

Providing education about the anatomy and function of the pelvic floor is important and should be a routine part of women’s health care, particularly around the times of childbirth and menopause, when changes in the pelvic floor are common. Women are frequently unfamiliar with pelvic floor muscles and their function. A recent study showed that 45% of adult women in Austria were unable to perform a voluntary contraction of the pelvic floor muscles during a routine gynecologic examination. Pelvic floor strengthening exercises (Kegel exercises) originally were developed to treat urinary incontinence and are commonly taught today, but it is important to remember that the pelvic floor has many other functions beyond maintaining urinary continence. Thus, instruction on relaxation and integrated function of the pelvic floor muscles is equally important. Having a model or diagram of the pelvic floor in the office and a hand mirror for education about anatomy may be particularly useful.

Therapy

Pelvic floor rehabilitation with neuromuscular education is the cornerstone of therapy for women with nonrelaxing pelvic floor dysfunction. Therapy is ideally provided by a physical therapist with training in pelvic floor dysfunction. The specific therapy used is guided by symptoms and usually includes strategies to optimize lumbopelvic and spinal function and to improve bowel, bladder, and sexual function. Manual techniques may include trigger point massage, myofascial release, strain-counter strain, and joint mobilization, among others. In addition, exercises to strengthen and stabilize the core muscles usually are included with pelvic floor physical therapy.

Physical therapy techniques for alleviating dyspareunia associated with hypertonicity of the pelvic floor have been described. In a systematic review of existing manual physical therapy techniques for musculoskeletal pelvic pain, 59% to 80% of patients were reported to have marked or complete relief. However, most studies included in the review were case series; controlled clinical trials still are necessary.

Biofeedback is a neuromuscular training approach in which patients learn how to appropriately contract or relax muscles; efforts are aided by visual or auditory feedback of muscle activity. Controlled clinical trials demonstrate that biofeedback therapy to improve anal and pelvic floor relaxation improves symptoms in defecatory disorders. Surface electromyography–assisted biofeedback to enhance anal contraction is superior to Kegel exercises alone in patients with fecal incontinence that is unresponsive to other conservative measures. Retraining to increase (or decrease) rectal sensation is possible in patients with sensory disorders.

Women with deep dyspareunia associated with nonrelaxing pelvic floor dysfunction generally should be counseled to avoid penetrative sexual activity until pelvic floor muscles are rehabilitated. Referral to a sex therapist is also important, particularly if the dyspareunia is long-standing, associated with personal or relational distress, or unresponsive to initial physical therapy of the pelvic floor. If a woman has experienced physical, sexual, or emotional abuse, her treatment plan needs to take into consideration the nature of the abuse and the status of her recovery. Members of her treatment team need to be aware of the abuse history and may need to modify their treatment approaches accordingly.

Neuropathic pain modulators, including amitriptyline, nortriptyline, gabapentin, and pregabalin, are frequently used for managing other conditions of chronic pain, but tricyclic antidepressants may aggravate bowel and bladder symptoms and should not be the first-line therapy for non relaxing pelvic floor dysfunction. Other methods to treat refractory non relaxing pelvic floor dysfunction may include trigger point injections using a local anesthetic and corticosteroid; botulinum toxin type A trigger point injections; acupuncture; and neuromodulation with sacral, pudendal, and posterior tibial nerve stimulation. These treatments are associated with varying degrees of success.

References

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