Pelvic Floor Dysfunction

Abstract

Pelvic floor dysfunction (PFD) refers to a broad constellation of symptoms and anatomic changes related to abnormal function of the pelvic floor musculature. The disordered function corresponds to either increase activity (hypertonicity) or diminished activity (hypotonicity) or inappropriate coordination of the pelvic floor muscles. Alterations regarding the support of pelvic organs are included in the discussion of PFD and are known as Pelvic Organ Prolapse (POP). The clinical aspects of PFD can be urologic, gynecologic, or colorectal and are often interrelated. Another way to compartmentalize the concerns are anterior- urethra/bladder, middle- vagina/uterus and posterior- anus/rectum. Anatomy and Function The pelvic floor is a combination of multiple muscles with ligamentous attachments creating a dome-shaped diaphragm across the boney pelvic outlet. This complex of muscles spans from the pubis (anterior) to the sacrum/coccyx (posterior) and bilateral to the ischial tuberosities. The bulk of the pelvic musculature is the levator ani, composed of the puborectalis, pubococcygeus, and iliococcygeus. The puborectalis wraps as a sling around the anorectal junction accentuating the anorectal angle during contraction and is a primary contributor to fecal continence. Elevation and support of the pelvic organs are associated with the pubococcygeus and the iliococcygeus. The pubococcygeus is the most medial component which separates, fashioning the levator hiatus with openings for the urethra, vagina (females), and anus. The bulbospongiosus and ischiocavernosus muscles are the primary contributors to the superficial portion of the anterior pelvic floor. The more superficial musculature of the posterior pelvic floor constitutes the external anal sphincter. The transverse perineal muscles cross the mid-portion of the superficial aspect of the pelvic floor and coalesce with the bulbospongiosus muscles and external anal sphincter as the perineal body.The nerve supply to the pelvic floor structures is primarily from sacral nerves S3 and S4 as the pudendal nerve. The predominant blood supply is derived from parietal branches of the internal iliac artery.The muscles of the pelvic floor have three functions: Support of the pelvic organs- bladder, urethra, prostate (males), vagina and uterus (females), anus, and rectum, along with the general support of the intra-abdominal contents. Contribute to continence of urine and feces. Contribute to the sexual functions of arousal and orgasm Conditions A wide variety of conditions are attributed to PFD due to hypertonicity, hypotonicity, loss of pelvic support, or mixed concerns. Urologic Difficult urination: hesitancy, delay in the urinary stream. Cystocele: bulging or herniation of the bladder into the vagina (anterior). Urethrocele(urethral prolapse): bulging of the urethra into the vagina (anterior) Urinary incontinence: involuntary leakage of urine. Gynecologic Dyspareunia: pain with or following sexual intercourse. Uterine prolapse: herniation of the uterus via the vagina beyond the introitus. Vaginal prolapse: herniation of the vaginal apex beyond the introitus. Enterocele: bulging or herniation of the intestines into the vagina (apical/posterior). Rectocele: bulging or herniation of the rectum into the vagina (posterior). Colorectal Constipation: paradoxical contraction or inadequate relaxation of the pelvic floor muscles during attempted defecation (dyssynergic defecation). Fecal incontinence: involuntary leakage of stool (not related to sphincter disruption). Rectal prolapse: intussusception of the rectum beyond the anal verge (Procedentia) or proximal to the anus (Occult). General Pelvic pain: chronic pain lasting more than three to six months, unrelated to other defined conditions. Levator spasm: another term for chronic pelvic pain related to the levator ani musculature. Proctalgia fugax: fleeting spastic pain related to the levator ani musculature. Perineal descent- bulging of the perineum below the boney pelvic outlet.