Pelvic floor dysfunction (PFD) is a common but complex condition. However, successful management can produce life-changing improvements for women. Here we talk to two Jean Hailes experts and get their clinical tips and best-practice insights for two common presentations of PFD – urinary incontinence and prolapse.
PFD can cause urinary and/or fecal incontinence, chronic pelvic pain, pelvic organ prolapse and sexual dysfunction such as dyspareunia. For many women, these symptoms are taboo topics with some choosing to suffer in silence rather than openly discuss it with a health professional.
“Patients tend not to volunteer [this type of] information so as clinicians, you need to ask them about it,” urges Jean Hailes urogynaecologist Dr Payam Nikpoor.
Building a good rapport with the patient is crucial when asking sensitive questions, for example about incontinence symptoms or leaking urine during intercourse. Dr Nikpoor says that sometimes patients might need one or more consultations before they feel comfortable discussing this sort of information.
Medicine is an art and not a recipe to administer. And doctors’ bedside manner drives the rapport they build with their patients.”Dr Payam Nikpoor, Jean Hailes urogynaecologist
An estimated 37% of women in Australia are living with some degree of urinary incontinence (UI) according to the RACGP.
Establishing the type of UI – stress, urge, nocturnal enuresis, continuous, coital – is the all-important first step because treatment and management depends on the clinician’s initial assessment and investigation.
Risk factors for UI include pregnancy and childbirth, obesity, menopause, certain types of surgery and some neurological and musculoskeletal conditions. Vaginal delivery, especially with instrumental delivery, is a significant risk factor for incontinence.
Successful management of UI relies on thorough history taking. Dr Nikpoor says it’s important to establish its presence and its severity. Questions a clinician might consider include:
To establish severity, it’s important to ask the extent to which the condition affects lifestyle. “Use the patient’s own words,” advises Dr Nikpoor. “How many pads are they using? What absorbent products do they use?”
“Also, suggest they keep a bladder diary in which they would record episodes of urgency and sensation, the activities performed during or immediately before the involuntary loss of urine. Record the number of times she uses pads.”
He believes that recording episodes for at least two days – not necessarily consecutive days – will yield useful data for both the clinician and the patient.
There are a number of indicators that suggest something else is going on beyond simple presentations of urinary incontinence and it is at this point the patient might be referred to a specialist. These indicators can include:
Sometimes referred to as 'dropped uterus or bladder' by the patients, pelvic organ prolapse (POP) presents with symptoms of heaviness and pressure in the vagina and pelvis.
Patients sometimes describe it as a feeling of ‘bulge’, something coming down from or out of the vagina. Sometimes women say it feels as if they’re sitting on a ball or an orange.
Typically, these symptoms become more pronounced as the day goes on and towards the end of the day when patients report being more aware of the bulge or being more bothered by it.
There should be a general assessment of mobility, cognitive status, and BMI.
There’s a direct relationship between obesity and stress and urge incontinence. And there is evidence to suggest that weight loss can result in an up to 70% improvement in overactive bladder (OAB) symptoms as well as stress incontinence symptoms.”Dr Payam Nikpoor, Jean Hailes urogynaecologist
He recommends that the clinician also undertake a vaginal and pelvic examination, looking for atrophy, dermatitis, erosion, lesions/ulcers, foreign bodies etc. A digital examination can assess for prolapse, tender/trigger points and adnexal masses.
A pelvic floor muscle assessment should also be considered. The clinician would be looking for integrity of the muscles/defects, tone at rest and squeeze, coordination, endurance, force, hypertonic and hypotonic muscles.
Dr Nikpoor suggests a mid-stream urine (MSU) test to check for infection. A pelvic ultrasound can be useful in assessing any pelvic masses or large fibroids with pressure effects on the bladder. In conditions such as obesity, physical examination may be inadequate or inconclusive.
Urodynamic testing would be considered if the type of urinary incontinence was unclear, or if first line treatment failed to address the symptoms adequately. A cystoscopy might also be considered.
Dr Nikpoor believes conservative approaches should be the first choice of treatment. The aim should be to encourage the patient to modify risk factors and lifestyle including weight loss, the promotion of good bladder and bowel habits (available from the Continence Foundation of Australia website), proper fluid management (decreasing caffeine and alcohol intake), quitting smoking and avoiding excessive fluid intake.
Pessaries can also be used as part of this conservative approach for these two conditions. They are inserted in clinic during a physical examination. The clinician must choose the right size and shape of the pessary and it can be inserted either by the doctor, a pelvic floor physiotherapist, or a continence nurse.
“Anyone who has the adequate skills to assess the vaginal capacity, severity of prolapse, and technique of fitting a pessary may offer this practice,” says Dr Nikpoor. Regular follow-up – every four to six months – is recommended. He also suggests the use of vaginal oestrogen for postmenopausal women.
For prolapse and UI, Dr Nikpoor says that pelvic floor physiotherapy is critical.
A professional with a special interest in pelvic floor muscle rehabilitation, this physiotherapist works across all areas of PFD and in consultation with the GP or the specialist.
Jean Hailes physiotherapist Amy Steventon says that in an initial subjective assessment, the physio will enquire about bladder and bowel function. This will involve asking questions about urgency, frequency, incontinence, voiding and defecation dysfunction, and pain. Prolapse symptoms and sexual functioning will also be discussed.
The physio will also establish the woman’s exercise routines, lifestyle factors such as sleep and stress levels, as well as relevant history and medication.
“With the woman’s consent, this is then followed by an objective assessment of the pelvic floor muscles,” explains Ms Steventon. This assessment involves a vaginal and/or rectal examination, either digitally or by using a transabdominal ultrasound.
“Based on the assessment findings, the pelvic floor physio will then develop a program of exercises, involving both specific pelvic floor muscle training and appropriate general exercise that is tailored to a patient’s particular needs,” she says.
“An intensive four to six months regularly supervised, individualised pelvic floor muscle training programme has been shown to produce the best results.”
On completion of this programme, the physio will design a maintenance pelvic floor muscle exercise programme that can be incorporated functionally into everyday life.
One in three women perform their pelvic floor exercises incorrectly, underlining the need for the physio to ensure each woman understands correct technique. “Pelvic floor muscle training does not always involve strengthening, although this may be an important consideration,” she says. “Relaxation [particularly when treating painful sex or chronic pelvic pain] is an important component of pelvic floor muscle function. Co-ordination and functional use during daily activities also need to be considered,” she says.
There is, she points out, Level 1 Grade A evidence to support PFMT as a first line treatment for urinary incontinence.
“Cure or significant improvement in symptoms of stress urinary incontinence can occur in up to 80% of cases following pelvic floor physio treatment regimes. The research also showed that pelvic floor physiotherapy reduced the number of episodes and severity of urinary incontinence as well as improvements in the woman’s quality of life.
“Women with OAB (with or without leakage) also showed improvements after pelvic floor physiotherapy,” she says.
Where to find a pelvic floor physiotherapist
You can find this professional by visiting the Find a physio webpage on the Australian Physiotherapy Association website, then under ‘Refine your search’ select ‘Special interest area: Women’s, Men’s and Pelvic health’.
Dr Nikpoor says surgery would be considered based on a number of clinical factors and the woman’s own wishes. In the case of UI, this would include persistence of symptoms despite a regimen of supervised pelvic floor muscle exercises.
It is important to ascertain goals and objectives prior to the commencement of treatment so goal attainment can be measured after completion of the treatment programmes."Dr Payam Nikpoor, Jean Hailes urogynaecologist
“One way to look at this is to use a simple seven item questionnaire, Patient Global Impression of Improvement (PGI-I). A result of ‘very much better’ or ‘much better’ is used as a measure of success.”
Dr Nikpoor says women who have advanced prolapse might not be suitable for a conservative management and would benefit more with surgery.
“Indeed, women’s wishes as to their preferred treatment should be taken into consideration,” he says.