The influence of defaecating proctograms on clinical decision-making in pelvic floor disorders.

Risk of pelvic floor disorders increases after menopause and may be linked to estrogen deficiency. We aimed to systematically and critically assess the literature on vaginal estrogen in the management of pelvic floor disorders in postmenopausal women and provide evidence-based clinical practice guidelines. MEDLINE and Cochrane databases were searched from inception to July 2014 for randomized controlled trials of commercially available vaginal estrogen products compared with placebo, no treatment, or any medication for overactive bladder or urinary incontinence. We double-screened 1,805 abstracts and identified 12 eligible papers. Studies were extracted for participant information, intervention, comparator, efficacy outcomes, and adverse events, and they were individually and collectively assessed for methodological quality and strength of evidence. Evidence was generally of poor to moderate quality. Vaginal estrogen application before pelvic organ prolapse surgery improved the vaginal maturation index and increased vaginal epithelial thickness. Postoperative vaginal estrogen use after a midurethral sling resulted in decreased urinary frequency and urgency. Vaginal estrogen and immediate-release oxybutynin were similar in improvement of urinary urgency, frequency, and urgency urinary incontinence in women with overactive bladder, but oxybutynin had higher rates of side effects and discontinuation. Conversely, the addition of vaginal estrogen to immediate or extended-release tolterodine did not improve urinary symptoms more than tolterodine alone. One study reported an improvement in stress urinary incontinence with use of vaginal estrogen. Vaginal estrogen application may play a useful role as an adjunct in the management of common pelvic floor disorders in postmenopausal women.

Consensus Definitions and Interpretation Templates for Fluoroscopic Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

This systematic review synthesizes current evidence on the prevalence, risk factors, pathophysiology, clinical manifestations, and management of pelvic floor disorders (PFD) following gynecologic cancer surgery and adjuvant therapy, with an emphasis on rehabilitation, multidisciplinary care, and quality of life. Following PRISMA 2020 guidelines, PubMed, Embase, Scopus, and Web of Science were searched for English-language studies published between January 2000 and May 2025. Eligible studies included adult women with gynecologic malignancies reporting outcomes related to urinary or fecal incontinence, pelvic organ prolapse, chronic pelvic pain, or sexual dysfunction. Data were extracted using a standardized form, qualitatively synthesized, and the risk of bias was assessed using the Newcastle-Ottawa Scale. Thirty studies met the inclusion criteria. PFD were highly prevalent, particularly after radical surgery and adjuvant therapies. Stress urinary incontinence and prolapse were more frequent after radical surgery, while urgency incontinence, vaginal stenosis, and chronic pelvic pain were linked to radiotherapy. Chemotherapy was associated with neurogenic bladder and bowel dysfunction. Independent risk factors included advanced age, obesity, and postmenopausal status. PFD significantly impaired physical, psychological, sexual, and social quality of life. Nerve-sparing and minimally invasive techniques showed promise in reducing dysfunction. Conservative measures-pelvic floor muscle training, biofeedback, vaginal dilators, and lifestyle modification-were effective for many patients, while surgical procedures such as slings and sacrocolpopexy were reserved for severe cases. Emerging options include local estrogen or DHEA after radiotherapy and onabotulinumtoxinA for refractory urge incontinence. PFD are underrecognized yet common and disabling complications inwomen treated for gynecologic cancers. Multidisciplinary management integrating pelvic floor rehabilitation and individualized survivorship care is essential to improve outcomes and quality of life. Further research should establish standardized screening, preventive strategies, and evidence-based rehabilitation protocols for this high-risk population.

PurposeTo explore the experiences of women with breast cancer and pelvic floor (PF) dysfunction and the perceived enablers and barriers to uptake of treatment for PF dysfunction during their recovery.MethodPurposive sampling was used to recruit 30 women with a past diagnosis of breast cancer and PF dysfunction. Semi-structured interviews were conducted, and data were analysed inductively to identify new concepts in the experiences of PF dysfunction in women with breast cancer and deductively according to the capability, opportunity, motivation and behaviour (COM-B) framework to identify the enablers and barriers to the uptake of treatment for PF dysfunction in women with breast cancer.ResultsParticipants were aged between 31 and 88 years, diagnosed with stages I–IV breast cancer and experienced either urinary incontinence (n = 24/30, 80%), faecal incontinence (n = 6/30, 20%) or sexual dysfunction (n = 20/30, 67%). They were either resigned to or bothered by their PF dysfunction; bother was exacerbated by embarrassment from experiencing PF symptoms in public. Barriers to accessing treatment for PF dysfunction included a lack of awareness about PF dysfunction following breast cancer treatments and health care professionals not focussing on the management of PF symptoms during cancer treatment. An enabler was their motivation to resume their normal pre-cancer lives.ConclusionParticipants in this study reported that there needs to be more awareness about PF dysfunction in women undergoing treatment for breast cancer. They would like to receive information about PF dysfunction prior to starting cancer treatment, be screened for PF dysfunction during cancer treatment and be offered therapies for their PF dysfunction after primary cancer treatment. Therefore, a greater focus on managing PF symptoms by clinicians may be warranted in women with breast cancer.

More common in older women than younger women, rectoceles may be secondary to pelvic floor weakness and/or pelvic floor dysfunction with impaired rectal evacuation. Rectoceles may be small (<2 cm), medium (2-4 cm), or large (>4 cm). Arguably, large rectoceles are more likely to be associated with symptoms (e.g., difficult defecation). It can be challenging to ascertain the extent to which a rectocele is secondary to pelvic floor dysfunction and/or whether a rectocele, rather than associated pelvic floor dysfunction, is responsible for symptoms. Surgical repair should be considered when initial treatment measures (e.g., bowel modifying agents and pelvic floor biofeedback therapy) are unsuccessful. We summarize the clinical features, diagnosis, and management of rectoceles, with an emphasis on outcomes after surgical repair. This review accompanies a retrospective analysis of outcomes after multidisciplinary, transvaginal rectocele repair procedures undertaken by three colorectal surgeons in 215 patients at a large teaching hospital in the UK. A majority of patients had a large rectocele. Some patients also underwent an anterior levatorplasty and/or an enterocele repair. All patients were jointly assessed, and some patients underwent surgery by colorectal and urogynecologic surgeons. In this cohort, the perioperative data, efficacy, and harms outcomes are comparable with historical data predominantly derived from retrospective series in which patients had a good outcome (67%-78%), symptoms of difficult defecation improved (30%-50%), and patients had a recurrent rectocele 2 years after surgery (17%). Building on these data, prospective studies that rigorously evaluate outcomes after surgical repair are necessary.

Urogenital consequences in ageing women

Rectal prolapse is a common pelvic floor disorder. Its pathogenesis primarily involves the degeneration and impairment of the supporting tissues of the rectum, leading to their laxity and consequent displacement of the rectum. As the pelvic cavity is a complex system consisting of gynecology, urology, and coloproctology, rectal prolapse often coexists with other pelvic relaxation disorders, such as perineal descent, pelvic floor hernias, and uterovaginal prolapse. Traditionally, pelvic-related disciplines have operated independently, creating disciplinary boundaries that restricted perspectives to single specialties. This compartmentalization focuses narrowly on repairing specific anatomical structures while neglecting the integrity of the pelvic floor system, thereby hampering the diagnosis and comprehensive management of pelvic floor disorders. This is a key reason for the high recurrence rates and poor long-term outcomes associated with traditional surgical approaches. The Integral Theory Paradigm (ITP) views the pelvic floor as an indivisible functional unit, emphasizing pelvic floor dysfunction caused by laxity of muscles, fasciae, and ligaments. By providing an interdisciplinary theoretical foundation, it has significantly advanced systematic innovations in the research, diagnosis, and treatment of pelvic floor disorders. Since the 21st century, with the development of the Integral Theory and membrane anatomy, the adoption of autologous fascial ligament reconstruction techniques has brought new prospects for the surgical management of rectal prolapse.

Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery

To define the unique effects of age on the pelvic floor muscle and to outline current treatments of pelvic floor dysfunction in the older population. Aging has muscular, hormonal, and neurological effects on the pelvic floor that may lead to pelvic floor dysfunction. Muscular changes lead to decreased force output and weakness on clinical examination. Hormonal effects exacerbate pelvic tissue changes, most notably in the postmenopausal woman. Neurological changes are less well-defined, but gradual denervation of the pelvic floor, especially noted in parous women, has been implicated as a possible cause of pelvic floor weakness and dysfunction. Medical treatments include pessaries, medications, implanted electrical stimulation, and surgery. Pelvic floor physical therapy, including strength training and coordination training, as well as pain-relieving modalities at the level of the pelvic floor muscle, is an effective conservative management option for older adults with pelvic floor dysfunction. The literature available regarding treatment of pelvic floor dysfunction is more robust for older females compared to males. There are numerous unique considerations in the treatment of the older adult with pelvic floor dysfunction, due to muscular, hormonal, and neurological changes with age. Conservative management, including physical therapy, should be considered prior to surgical intervention. Further research is especially needed regarding the effects of age and the treatment of age-related pelvic dysfunction in the older male.

There is an ongoing discussion regarding abdominal muscle (AbM) and pelvic floor muscle (PFM) synergism. Therefore, this study aimed to investigate the cocontraction between AbMs and PFMs in women with or without pelvic floor dysfunction (PFD). The following databases were searched up to December 21, 2018: MEDLINE, EMBASE, LILACS, PEDro and CENTRAL. We included any study that assessed the cocontraction between PFMs and AbMs in women with and without PFD. Two reviewers independently screened eligible articles and extracted data. The outcomes were extracted and analyzed as continuous variables with random effect models. Twenty studies were included. A meta-analysis did not show differences in women with and without PFD. However, a sensitivity analysis suggested cocontraction of the transversus abdominis (TrA) during PFM contraction in healthy women (standardized mean difference (SMD) –1.02 [95% confidence interval (CI) −1.90 to −0.14], P=0.02; I2= not applicable; very low quality of evidence). Women with PFD during contraction of PFMs showed cocontraction of the obliquus internus (OI) (SMD 1.10 [95% CI 0.27 to 1.94], P=0.01; I2= not applicable; very low quality of evidence), and obliquus externus (OE) (SMD 2.08 [95% CI 1.10 to 3.06], P<0.0001; I2 = not applicable; very low quality of evidence). Increased cocontraction of the TrA may be associated with maximal contraction of PFMs in women without PFD. On the other hand, there is likely an increased cocontraction with the OI and OE in women with PFD.

Sexual dysfunction is prevalent among women with pelvic floor disorders presenting to urogynecologists. This review summarizes a workshop held at the 2024 annual International Urogynecology Association meeting and covers the treatment of common sexual dysfunction treatments in a urogynecology practice, how pelvic floor surgery can affect sexual health, and when to refer to a pelvic floor physical therapist or sexual health therapist. For patients suffering from female sexual interest/arousal disorder and orgasmic disorder, medical management, pelvic floor physical therapy, sex therapy, and mechanical devices can be utilized. For women requiring surgery, sexual function either improves or remains unchanged after prolapse surgery and midurethral sling surgery. Dyspareunia rates are lower after all prolapse surgery types compared with preoperative dyspareunia. De novo dyspareunia ranged from 0 to 9% after prolapse repairs. Management of pelvic floor disorders can have a positive impact on sexual function. Many treatments aremultidisciplinary and may require referral to a pelvic floor physical therapist or sex therapist.

Pelvic floor disorders are mostly a continuum of a disease process resulting from the loss of pelvic floor support. Although these diseases are commonly believed to afflict primarily women, the ease in examination of the pelvic floor in women makes the identification of pelvic floor disorders easier in women than in men. Anatomical differences in the size of the genital hiatus between the sexes also make women more prone to pelvic floor prolapse. Epidemiologic studies on pelvic floor prolapse suggest that it is a disease that will become more prevalent as the population ages. Olsen et al.1 reported the findings of pelvic organ prolapse on 149,554 women aged 20 years or older at Kaiser Permanente; their study showed that 11.1% of these women will have a lifetime risk of undergoing an operation related to pelvic prolapse or incontinence by the age of 80. Surgical repair related to the rectum or posterior compartment constituted 45% of the operations. Reoperation for prolapse was 29.9%, and the time interval between repeat procedures decreased with each successive repair.1 According to the government census, the population in the USA is projected to reach 440 million by 2050, and the population of 75 years old or older is projected to increase from 6% to 11%.2 These findings and trends help highlight the importance of pelvic floor disorders and the role of the colorectal specialist in the management of pelvic floor disorders.

Multidisciplinary management of pelvic floor disorders

Pelvic floor disorders are common and bothersome problems that include a variety of conditions. These conditions greatly affect the performance of daily activities and social function such as work, traveling, physical exercise, sleep and sexual function. Aging is a well-known factor affecting the pelvic floor and lower urinary tract anatomy and function. It is clear that the pelvic organs and their surrounding muscular and connective tissue support are estrogen-responsive. Treatment of pelvic floor disorders requires significant health-care resources and their impact is likely to increase in the near future. This literature review aims to provide an overview of both research and clinical aspects of the pathophysiology of urogenital estrogen deficiency and the role of local estrogen therapy as part of the management strategy of different pelvic floor disorders. The safety and risk concerns regarding the use of local estrogen therapy are addressed as well.

Levator ani muscle (LAM) avulsion is a common complication of vaginal childbirth and is linked to several pelvic floor disorders. Diagnosing and treating these conditions require imaging of the pelvic floor and examination of the obtained images, which is a time-consuming process subjected to operator variability. In our study, we proposed using deep learning (DL) to automate the segmentation of the LAM from 3D endovaginal ultrasound images (EVUS) to improve diagnostic accuracy and efficiency. Over one thousand images extracted from the 3D EVUS data of healthy subjects and patients with pelvic floor disorders were utilized for the automated LAM segmentation. A U-Net model was implemented, with Intersection over Union (IoU) and Dice metrics being used for model performance evaluation. The model achieved a mean Dice score of 0.86, demonstrating a better performance than existing works. The mean IoU was 0.76, indicative of a high degree of overlap between the automated and manual segmentation of the LAM. Three other models including Attention UNet, FD-UNet and Dense-UNet were also applied on the same images which showed comparable results. Our study demonstrated the feasibility and accuracy of using DL segmentation with U-Net architecture to automate LAM segmentation to reduce the time and resources required for manual segmentation of 3D EVUS images. The proposed method could become an important component in AI-based diagnostic tools, particularly in low socioeconomic regions where access to healthcare resources is limited. By improving the management of pelvic floor disorders, our approach may contribute to better patient outcomes in these underserved areas.