Pelvic Floor Dysfunction
Dr. Moldwin is Assistant Professor of Urology at the Albert Einstein College of Medicine and is Director of the Interstitial Cystitis Center at Long Island Jewish Medical Center (LIJMC) in New Hyde Park, NY. Dr. Moldwin completed his clinical training at the University of Chicago and his urological training at LIJMC. He then received a Valentine’s Fellowship award and pursued research investigations in IC at Thomas Jefferson Medical College. He subsequently returned to New York to establish the Interstitial Cystitis Center at LIJMC. Dr. Moldwin is active in both basic and clinical IC research and has published extensively. He is a frequent contributor to the ICA Update and has recently written and published a patient-oriented book entitled, The Interstitial Cystitis Survival Guide (New Harbinger Publications).
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Dr. Moldwin will explain pelvic floor dysfunction (PFD), its relationship to IC, and current available treatments for correcting it. The pelvic floor muscles support the pelvic organs, bladder and rectum, and their function is critical to activities such as urinating, having bowel movements, and sexual intercourse. Spasm of these muscles is commonly seen in IC patients, resulting in complaints such as poor urine stream, constipation, lower back pain, pain with ejaculation or vaginal penetration, pelvic pain or pressure, or urinary frequency and urgency. Treatment of PFD, when present in the IC patient, is strongly recommended, along with bladder-directed therapy to achieve the optimal relief of symptoms. This workshop will review how PFD is diagnosed and several simple, but effective, methods of self-care.
Dr. Robert Moldwin: I would like to go over what PFD is, and how to recognize it and treat it. I will also talk about therapies that can be used and give some ideas in terms of self-care therapy as well.
It is necessary to understand what the pelvic floor muscles are in order to see how they can become dysfunctional. The pelvic floor muscles rest as a hammock in the pelvis. (slide) This is a picture looking directly down into the pelvis with all the organs removed. It is a very broad base of muscles and these muscles have to perform complex tasks. For example, these muscles need to contract when you walk around without urinating. They have to relax during sexual intercourse. They also need to relax during a bowel movement. Even more importantly, one part of the muscle may be contracting while the other is relaxing. For example, you would most likely rather not have a bowel movement while you are having sexual intercourse. It is extremely complex physiology. Unfortunately, this has not been adequately explored by any physiological study that I am aware of. We are looking at it more closely because we know that dysfunction of these muscles is causing a lot of problems.
(slide) This is a view from the other side. You can see how the muscles act as a sling for the rectum, vagina, and urethra. I also want to show you where they insert. They go from all the way in the front, to all the way around, and to the lower back. (slide) This is a sagittal view of the pelvis. This shows the muscles crossing, along the GU (genitourinary) diaphragm. Here are the levator muscles, all coming together. You can see how complex this area is. There is smooth muscle at the neck of the bladder that needs to relax when you urinate. All these muscles come into play during voiding. For patients who describe urethral discomfort or pain on voiding, the urethra can be inflamed. There is a lot going on in a small space.
I don’t want to leave out males with IC. We tend to speak about females when we talk about IC. Pelvic floor dysfunction is seen in both men and women. It is often called prostatodynia in men. This is one of the forms of prostatitis. (slide) You can see the muscles at the base of the corporal bodies. These muscles get erect during an erection and they expel the semen during orgasm. These are appendages to the pelvic floor muscles, but when the pelvic floor muscles become dysfunctional, these muscles sometimes follow suit and become spastic.
What is pelvic floor dysfunction (PFD)? This is non-neurogenic, uncoordinated behavior of the pelvic floor musculature. This is not like Parkinson’s or multiple sclerosis. This is a person who has no obvious neurological disease and the muscle function is uncoordinated. One example of being uncoordinated is shown here (slide): normally the bladder sits in a funnel of muscle. When one voids, the muscle of the bladder contracts, thereby forcing out urine. At the same time, the muscles of the pelvic floor, the levator muscles, and the muscles of the GU diaphragm have to relax. That is the normal process of voiding; it is a complex neurological mechanism. When this happens, there is a good stream of urine. In a patient with PFD, the bladder contracts and the muscles open up, but they are in spasm. They are not working properly. They open and urine does come out, but this can lead to disruptive symptoms.
The symptoms of PFD are similar to IC. A patient with IC typically has pelvic pain, the pain often worsens with bladder filling. They usually have day and nighttime urination, and their symptoms are affected by foods, in many instances. The patients who have PFD have similar complaints with a subtle difference (keep in mind that PFD can coexist with IC): IC should not normally result in a poor urinary flow rate. One exception is that if you are urinating tiny volumes each time, you will never be able to generate a good force of the urine stream. If you still have a poor urinary flow rate, that is suggestive of something else going on. In a male, you have to consider the presence of the prostate gland, which can also be causing problems. The first focus of attention in a male is typically on the prostate as a cause of blockage.
Constipation can also exist in a patient with PFD. Constipation occurs for the same reasons a patient will have problems with urination; the patient tries to push out the bowel movement, but the muscles around the anus and the pelvic floor muscles are contracting at the same time. The stool sits in the rectal vault.
There are two different types of complaints regarding intercourse: either there is terrible pain during intercourse because the penis is coming directly into the rigid muscles, or there is discomfort the day later. This is commonly seen in both IC and PFD patients.
Many patients have the sense of incomplete bladder emptying. They feel like they have to void again as soon as they are finished. Some patients cannot empty their bladder. Usually patients who have just PFD and no significant IC do not have nighttime frequency. They just have frequency during the day. There is also a typical history of straining with urination. It is interesting to see the number of patients who tell me they don’t strain, yet during testing that we perform, they are straining quite a bit.
How is a patient evaluated for PFD? The patient should have a history typical of pelvic floor problems. A physical examination is done. When I do a physical exam, I feel the muscles of the pelvic floor. This involves pushing into the 5 and 7 o’clock positions, down into the muscles. Usually the patient finds this very uncomfortable. I can watch the patient’s face and see them grimace. When I do this to patients who have kidney stone disease, this doesn’t bother them at all. That sets these patients apart from patients who do not have PFD. I also do a uroflow test. (A test which determines the quality of the urine flow with regard to the rate of flow, the volume, the strength of the stream, etc). (slide) This patient pushed, stopped, pushed. They came back to baseline several times during voiding; this is dysfunctional voiding. The patient is voiding mainly by pushing and straining. I often do a bladder scan (a form of ultrasound) using a probe that goes over the pubic bone after the patient urinates. This tells us how much is left in the bladder. Most of the time the patients do empty their bladders, but it may not feel like it. Sometimes the PFD is so severe that patients retain urine in their bladders, sometimes significant volumes.
What starts pelvic floor dysfunction? Why does this occur with IC and with vulvodynia? Many patients with PFD start with a urinary tract infection. They are voiding so much because of the infection. After treatment with an antibiotic, the burning may go away, but the sensation of incomplete emptying and the constant frequency of urination continue. There may be another course of antibiotics, with no results. Now it is not a problem of the infection any longer. For some reason during the infection, the patient started to void in a dysfunctional way. The same thing occurs with IC. There is a primary bladder problem; the patient is voiding a lot and they try to push out the urine to empty their bladder. There is a sensation of incomplete bladder emptying, urgency and frequency, and the patient strains with urination. This can cause more tightening of the pelvic floor. This can cause more symptoms, which provokes you to push and strain over and over. You have to break out of this cycle.
There is a very intimate relationship between bladder function and pelvic floor function; when one contracts, the other should relax. There is one other step that occurs: if your bladder contracts and you simultaneously have a contraction of your pelvic floor muscles, your bladder contractions stop. How are you going to get the urine out? You are forced to push with urination. This adds insult to injury.
This is probably one of the major reasons people start to void dysfunctionally. (slide of a dirty public toilet). Most women will crouch and stoop over a public toilet.
You know now what I think causes PFD in many instances, but in most cases we don’t know the cause; it may go back to the person’s childhood. There are some points in therapy. The first and most important point is to stop pushing and straining. Many people don’t realize they are doing this. People will sit down and involuntarily contract the muscles up and down. Have you ever noticed people who have an unconscious habit of chewing on their jaw? It has become part of their behavior and they don’t realize they are doing it. You have to realize where those muscles are and stop pushing and straining inadvertently.
It is very important not to be constipated. When the rectum is full of feces, that distention causes problems with bladder function. The pelvic floor dysfunction associated with constipation will stop the bladder contractions. I am extremely aggressive in management of constipation in patients with PFD. I use laxatives such as Milk of Magnesia ®, Senokot ®, and even an enema. If you continue to be chronically constipated, you will have a more difficult time getting control of the pelvic floor problems.
I suggest warm baths twice a day. Some patients prefer to take showers and I tell them that they are not going to get much better unless they take baths. You must sit in the tub. If you had a sore shoulder, you would put a hot compress on that. Warm baths are important in the overall management of PFD. You may feel great in the tub until you get out, but over time, you will start to see a difference. It may take 6 weeks to see improvements.
I used to hold off on giving muscle relaxants early in the course of the therapy. I do this now as first line management. I typically give Valium® in a very low dose, 2 mg, three times a day. This is unlikely to cause any problems with “addiction.” Why do I use this as opposed to other muscle relaxants? Valium in this low dosage usually does not make people sleepy. The lowest dose that the medication is made is 2 mg and this can be cut in half. What happens with therapy for patients who have PFD as well as IC? When you treat patients who have PFD as a single entity, the response rate is excellent. About 70% of our IC patients appear to have PFD. There is a decline in pain, urgency, frequency, and nocturia. This means that even before we get involved in therapy for IC, they do much better. If they don’t do as well as we would like, we then do therapy for the bladder. If I identify a patient who has questionable IC, but I definitely know they have PFD, I immediately go to aggressive therapy on the pelvic floor dysfunction, and see what their response is.
There are other therapies that can be used for PFD. Relaxation techniques are important. I work with a social worker and we make relaxation tapes for patients. Self-hypnosis can be helpful also. Stress seems to be one of the major initiating factors for worsening of pelvic floor dysfunction symptoms. The muscles tighten, much like a tension headache. Yoga and Tai Chi are helpful strategies. I have never had a patient who has taken a Yoga class who said it made them worse. You should always tell the instructor about your particular problem. Stretching is great, but you don’t want to put too much tension on those muscles at any given time.
Biofeedback is another form of self-care, but it may be difficult to get this covered by insurance. This can be coded as therapy for muscle spasms. The concept of biofeedback is to give the patient some information about a bodily function. For example, you may not know what your heart rate is, but if I did an EKG, you would be able to see it, and perhaps control your heart rate just by watching the numbers. Biofeedback has been useful in the management of urinary incontinence. We teach patients where the muscles are and how to increase their tone (tighten). It is also useful for PFD and pelvic pain. Biofeedback doesn’t make you better by itself. The patient learns where the muscles are and how to relax them. Biofeedback has been used in many areas of medicine.
(slide) This is a probe that sits in the vaginal vault. It will pick up the electrical activity of the muscles. In males, we use an anal probe. The patient watches a monitor as the muscles contract. (slide) This is a typical patient who has spasms of the pelvic floor. They cannot generate any force and cannot relax the muscles. They do not have good control over the muscles. The lower graph represents electrical activity generated by the abdominal muscles. We commonly see patients contracting what they think is their pelvic floor muscles, but they are really contracting the abdominal muscles. The patient needs to keep the activity of the abdominal muscles down, and to learn how to control the pelvic floor muscles. The advantage of biofeedback is that it may benefit patients who may have difficulties with side effects of medications. There are many patients who do well on the basic therapies, but they need biofeedback as adjunctive therapy, not just as the sole therapy. This is the best role for biofeedback. It is labor intensive, however. Pelvic floor treatment with biofeedback and learning to control the muscles can take many weeks. The patient may have to go to a physical therapist for 1-2 sessions a week initially. Once you are learn how to do the therapy, you can get a unit to take home.
I would like to tell you about some therapy that is adjunctive to biofeedback – electrical stimulation. Through the same probe, electrical energy can be disseminated to the muscles. This is a very low amount of electrical stimulation. There are some patients, however, who are overly sensitive in this area, and a patient may get worse before they get better. This is common.
(slide) This is a picture of the Neotonus® chair. A magnetic field is generated which stimulates nerve activity in the pelvic floor. My first introduction to this machine was at a urologic conference. The equipment was in a box sitting on a counter. I was told to put my arm over the box and let my hand hang down. They turned on the machine, and I could not control the movements of my hand. There are no electrodes or needles, just the generation of the magnetic field. For patients who have problems getting devices into the vaginal vault or rectal area, this might be an effective form of care. However, we have no evidence that it will or will not help an IC patient. My feeling is that it will be incorporated into the armamentarium of the IC patient at some point in time. The disadvantage is that the chair is extremely expensive, costing over $25,000.
There are nerves that go to the muscles of the pelvic floor. Perhaps by altering the way those nerves function, we can benefit the way that the pelvic floor muscles work. There is good evidence that this is helpful. There is a device called Interstim® which is FDA-approved for urinary urgency incontinence. These patients are leaking urine all the time because of abnormal bladder contractions. It is also approved for “urgency/frequency syndrome.” This is broad terminology that means it is open for patients with IC and/or PFD. There is a procedure, called a “test stim,” that involves placing a small needle directed to the very lower part of the spine. This is done under local anesthesia. The needle (which is subsequently removed) delivers a wire that is left in place temporarily. The wire is hooked to a portable stimulation pack that sends electrical energy to the nerve. The patients get a “buzzing” sensation in the pelvis. This can improve symptoms significantly in many patients. The patients go home with wire taped in place, but it is not sutured and can come out very easily. If a patient has some symptom improvement, a permanent device, much like a pacemaker, can be placed. This is a battery-operated unit that is placed near the upper part of the buttocks. The batteries can last at least 2-5 years. This does not work for everybody and the reoperation rate is about 30 percent. In many instances, reprogramming of the device is necessary. At some point in time, even under the best circumstances, the battery eventually has to be changed. Dr. Toby Chai at the University of Maryland had 6 patients with IC who had the Interstim. They had excellent improvement in urgency, frequency, and also pain. This is “cutting edge,” but is not used for patients who have not tried multiple other therapies.
In summary, I hope I have given you a good idea of what pelvic floor dysfunction is, the basic methods of treatment, and self-care techniques. Many patients who are able to stop pushing and straining with urination can have their symptoms subside to a great degree.
Question: Does vulvar vestibulitis affect PFD? Dr. Moldwin: PFD is commonly seen in vulvar vestibulitis, or any form of vulvodynia. We don’t know why that occurs. We also see it in patients who have fibromyalgia, vulvodynia, and IC. PFD is a very common problem, even by itself.
Question: Can a total abdominal hysterectomy and removal of the ovaries injure the pelvic floor muscles? Dr. Moldwin: It is not described in the literature. I think all of us who have taken care of IC patients and patients who have PFD have seen these things occur after surgery. What about the surgery specifically affected the muscles? Even catheterization during the surgery or a urinary tract infection seems to play a role in these patients’ symptoms. Could there have been some kind of nerve or muscle damage during the surgery that could lead to these symptoms? I suppose that could happen but it is almost impossible to identify. I think that there is something about the perioperative period (pertaining to the time close to [before and after] an operation) that made people start to void in a dysfunctional fashion.
Question: I have heard that Kegel exercises are bad for IC patients. (Exercises aiming to strengthen the muscles supporting the floor of the pelvis). Dr. Moldwin: This is a controversial issue. Gynecologists sometimes tell their patients who have PFD to do Kegel’s exercises. From a urologic point of view, they have spastic muscles to begin with and if they do Kegel’s exercises, you are making them tighter rather than relaxing them. Many patients tell me that makes them much worse. In our department (and there are different philosophies), we emphasize learning with biofeedback how to use the muscles correctly. I don’t have patients use the Kegels to build up the muscle, because I find that my patients have worsening of their symptoms.
The other philosophy used by some physical therapists is that you should do Kegel’s because if you have a weak muscle that is in spasm, if you build it up over time, perhaps the muscle tone and the proper way that the muscle works comes back. There are no studies regarding this. I haven’t found this to be true, however.
If you work with a physical therapist with reference to PFD, make certain that they have experience in the management of pelvic pain. The knee-jerk reaction from many physical therapists is to treat a PFD patient like a patient who has stress incontinence, from coughing or sneezing. That is not the same type of strategy in the management of pelvic pain due to dysfunctional muscles. Make sure they are comfortable with the care of pelvic pain syndromes.
Many physical therapists can use myofascial release as adjunctive therapy. This involves using their fingers to find muscle bands and trigger points to stretch out these muscles. The physical therapists who are comfortable with pelvic floor issues are able to deal with these problems.
Question: I am a male with IC who is having terrible spasms that start in my rectum and travel to the penis. The pain is not constant.
Dr. Moldwin: Male patients with PFD are difficult to treat. When their muscles go into spasms, they contract with significant force. The muscles that line the tubes that give erections have to contract when one has an orgasm. There are many men who are afraid to have an orgasm because of this. This is a terrible problem. The therapy has to be that much more aggressive for men, compared to women.
Question: Is there a topical cream for PFD? Dr. Moldwin: There is no topical preparation, it is internal. The muscles are deep in the body and no cream would be able to reach them. As far as associated problems, particularly in postmenopausal females, vaginal atrophy (thinning of the vaginal lining because of estrogen loss) can also play a role in PFD. Sometimes giving estrogen replacements as creams may be helpful.
Another important issue is if your IC goes into remission, would your PFD go into remission? Yes, that can happen and sometimes if your PFD goes into remission, your IC can get better.
Question: It feels like I have IC in my rectum. I have extreme urgency to have a bowel movement. After I evacuate it feels like I still have to go. Is this PFD? Dr. Moldwin: Yes, there is no question about that. Just like people feel like they cannot empty their bladders, many feel like they haven’t finished having a bowel movement. If you are having problems with constipation, it is time to see a gastroenterologist to better evaluate that. Question: Is there a satisfactory urinalysis to detect bladder cancer in the IC patient? Dr. Moldwin: If there is blood in the urine associated with IC, it is not necessarily due to the IC. We may see blood in the urine a little more commonly in an IC patient as compared to the patient population without IC. It is incumbent upon any practitioner to evaluate the patient for kidney stones and cancer when blood is present. For cancer, there may be some X-rays, looking into the bladder and a urine cytology, much like a Pap smear of the urine.
Question: Is the Neotonus chair of value for males? Dr. Moldwin: Good question – I don’t know. All of these things are just beginning to be evaluated. Right now, the Neotonus chair has been designed to build up the muscles of the pelvic floor in the management of stress incontinence. Like many of the other modalities that have been helpful in the treatment of PFD, I think this is one of those in that category. In the future we may see this, but reimbursement is one of the issues that needs to be sorted out.
Question: Is the concept of pelvic floor therapy conflicting with bladder retraining protocols? Dr. Moldwin: I don’t think there is a conflict. You need be careful during the bladder retraining protocol when you try to hold higher volumes of urine. You may be tightening your muscles and that is not what you want to do. You have to keep the muscles relaxed.
Question: Is the vaginal probe used for electrical stimulation useful in PFD? Dr. Moldwin: Yes, although there seems to a conflict in the way physical therapists and physicians use therapy, they still result in improvement of symptoms.
By pushing and straining to urinate, you are squeezing the rectal and abdominal muscles. This makes you increase the intraabdominal pressure. That pressure is directed onto the bladder. The bladder is being squeezed from the outside. Your bladder is a muscle. When you get the urge to urinate, the bladder will contract as a muscle and the urine will come out. Pushing and straining with PFD is detrimental. It is better that you urinate, and even if you don’t feel like you have emptied, void again 10-15 minutes later. (Double voiding)
Question: I have painful intercourse. What should I do? Dr. Moldwin: I think anything that you believe will help relax you is fine. Stress reduction techniques are great. I didn’t get a chance to talk about sex, IC and PFD. Why does intercourse make PFD worse in many instances? The female patient is going to have a penis put into her vagina. If you perceive that you are going to have pain, your natural response is to tighten up. You strain, and then when the penis comes in, it is pushing into hard, tender muscles. We emphasize to go very slowly. You shouldn’t have full penetration at the outset. There should be multiple sessions of going deeper. You can use vaginal dilators (dildos) placed into the vaginal vault and learn to relax around the probe.
Question: Why is there pain the day after intercourse? Dr. Moldwin: That is like getting punched in the eye. You don’t see the swelling the day it happens. When you work out in the gym, you don’t feel the pain until the next day. Pelvic floor dysfunction and vulvodynia go hand in hand. Most practitioners who deal with vulvodynia find that most of their patients have pelvic floor dysfunction. That is treated immediately as well as neuropathic problems. They use creams as well as medications for nerve problems. The patient’s significant other can do myofascial release by putting their finger into the vaginal vault, finding the trigger points, and pushing on them.
Question: I have a lot of pain after I exercise. Dr. Moldwin: You have to know your limitations. The body gives you pain for certain reasons. Your body is telling you not to do that. I am a big believer in keeping fit. Yoga is probably the best thing for you. Even people who are doing bench pressing, which requires bearing down, are tightening their pelvic muscles in order to keep from urinating. That is a natural reaction in that set of circumstances. You should not be doing that. You have to notice that while you are exercising. If you are having problems with certain exercises, hold off on them for a while or at least tone down your exercise regimen. Be careful of sitting on a bicycle seat. There are seats with no cushioning between the scrotum or vagina and the anus. When people sit on the gap in the seat, they tighten their muscles, because there is no support there.
Question: I have more pain if I am in a certain position. Dr. Moldwin: You are certainly not alone. For whatever reason, there are a lot of patients who have positional issues. If they lie on their back at night, they feel better or worse than if they lie on their stomach. The same thing applies in terms of exercises. It may have something to do with pressure of the filled bladder on some aspect of the muscles or nerves in that area. This is something you may have to experiment with. I see this very commonly.
Question: If you have a patient with urgency and frequency who has a small amount of residual urine, you tell them to double void (urinate, then wait 10-15 minutes and urinate again). Do you tell them to do the Crede method? Dr. Moldwin: Crede means to push above your pubic bone to squeeze out the urine with your fingers. You don’t bear down. I don’t advise people to do use Crede. Generally speaking, I think the best thing to do is to employ simple therapy and see how things go. If the patient is retaining a large amount of urine, that is different. That patient needs more sophisticated evaluation. This is a different area than what I am talking about.
Question: How long are the benefits from bladder distention supposed to last? Dr. Moldwin: There are many patients who have PFD and just have a cystoscopy or hydrodistention, or a urethral dilation (which are not appropriate for IC or PFD patients) and they get better initially. The muscles have been overstretched. In many instances it improves the symptoms temporarily. I think that the improvement is short-lived. Once in a while a patient will respond for a long time. If you repeat the hydrodistention, the improvement doesn’t seem to last as long. Many times if it is repeated a third time, there is no improvement. I don’t think this is a physiologic way to approach this problem. The most appropriate thing to do is to learn to relax the muscles.
Following the hydrodistention procedure, the symptoms are usually worse for about 3 weeks. Those who respond get on the average three months of improvement. That is not impressive. The bladders that have the lowest capacity on hydrodistention will generally have the best symptom improvement.
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