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Pelvic Floor Insufficiency – Causes and Treatment

Pelvic floor insufficiency refers to a weakening of the pelvic floor muscles and connective tissue. It can lead to urinary incontinence and pelvic organ prolapse.

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Things worth knowing about "Pelvic Floor Insufficiency"

Pelvic floor insufficiency refers to a weakening of the pelvic floor muscles and connective tissue. It can lead to urinary incontinence and pelvic organ prolapse.

What is Pelvic Floor Insufficiency?

Pelvic floor insufficiency describes a weakness or functional impairment of the muscles and connective tissue forming the pelvic floor. The pelvic floor is a group of muscles and ligaments that close the base of the pelvis and support the pelvic organs, including the bladder, bowel, and uterus. When this muscular layer is weakened, various complaints can arise that significantly reduce quality of life.

Causes

Pelvic floor insufficiency can result from multiple contributing factors:

Pregnancy and childbirth: Vaginal deliveries, especially prolonged pushing stages or delivery of large babies, place significant strain on the pelvic floor.
Hormonal changes: During menopause, declining oestrogen levels weaken the connective tissue and musculature.
Chronic cough: Persistent elevated intra-abdominal pressure, such as in COPD or smoking-related cough, can overload the pelvic floor.
Overweight and obesity: Excess body weight continuously increases pressure on pelvic structures.
Heavy physical labour: Repeated lifting of heavy loads stresses the pelvic floor.
Ageing: General decline in muscle strength with advancing age also affects the pelvic floor.
Pelvic surgery: Procedures such as hysterectomy can weaken supporting structures of the pelvic floor.

Symptoms

The symptoms of pelvic floor insufficiency depend on the severity of the weakness and may vary greatly between individuals:

Urinary incontinence: Involuntary urine leakage, particularly during physical activity such as coughing, sneezing, or exercise – known as stress incontinence.
Faecal incontinence: Involuntary loss of stool or flatulence.
Urgency incontinence: Sudden, strong urge to urinate followed by involuntary leakage.
Pelvic organ prolapse: Descent of the uterus, bladder (cystocele), or rectum (rectocele) into or beyond the vaginal canal.
Pelvic pressure or heaviness: A sensation of fullness or a foreign body in the lower abdomen.
Painful intercourse: Dyspareunia due to altered pelvic anatomy.
Incomplete emptying: Difficulty fully emptying the bladder or bowel.

Diagnosis

Diagnosis of pelvic floor insufficiency involves a combination of medical history, physical examination, and further investigations:

Gynaecological or urological examination: Assessment of pelvic floor muscle tone and potential organ prolapse.
Urodynamic studies: Measurement of bladder function and urinary flow to differentiate types of incontinence.
Pelvic ultrasound: Imaging of pelvic floor muscles and organs to detect structural changes.
Pelvic MRI: Detailed imaging of connective tissue and pelvic organs.
Bladder diary: A record of urine volumes and frequency to evaluate bladder function.

Treatment

Conservative Treatment

Conservative measures are typically the first line of treatment:

Pelvic floor exercises: Targeted muscle-strengthening exercises, ideally guided by a physiotherapist specialising in pelvic floor rehabilitation.
Biofeedback: A technique that makes muscle activity visible or audible to support training accuracy.
Electrical stimulation: Electrical impulses are used to activate and strengthen pelvic floor muscles.
Weight reduction: Losing excess weight reduces chronic pressure on the pelvic floor.
Pessary therapy: A supportive pessary device is inserted into the vagina to mechanically support prolapsed organs.
Hormone therapy: Topical oestrogen application can strengthen connective tissue in postmenopausal women.

Surgical Treatment

If conservative measures are insufficient or the condition is severe, surgical options may be considered:

Colporrhaphy: Surgical repair and tightening of the vaginal walls.
Sacrocolpopexy: Fixation of the uterus or vaginal vault to the sacrum, typically performed laparoscopically.
Sling procedures (TVT/TOT): Placement of a suburethral tape to treat stress urinary incontinence.

Prevention

Preventive measures can significantly reduce the risk of developing pelvic floor insufficiency:

Regular pelvic floor exercises, especially during and after pregnancy
Maintaining a healthy body weight
Lifting heavy objects using correct technique to protect the pelvic floor
Treating chronic cough promptly
Avoiding constipation and maintaining regular, soft bowel movements

References

Abrams P et al. – Incontinence: 6th International Consultation on Incontinence. ICI-ICS, 2017.
Bø K et al. – Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Elsevier, 2015.
Haylen BT et al. – An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction. Neurourology and Urodynamics, 2010; 29(1): 4-20.

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