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The pelvic floor muscles play a critical role in urination, defecation, childbirth and sexual function. They surround and support the urethra, vagina and anus superficially while providing a supportive “shelf” for the internal pelvic organs. Their natural resting state is “toned” so that they keep the urethra and anus closed (relaxing during urination, defecation and during childbirth), yet they have the ability to contract quickly at a time of an acute stress, such as a cough or sneeze, in order to maintain continence. When these muscles lose their inherent tone, they lose their ability to properly support the internal pelvic organs and to maintain urine and feces within the bladder and rectum respectively. In short, lax pelvic floor muscles result in urinary and fecal incontinence, pelvic organ prolapse and sexual dysfunction.
Although loss of muscle tone is not uncommon with age, it is not inevitable. Muscle laxity is not only preventable, it is reversible (if it has not progressed too far). The muscles of the pelvic floor are no different from any of the other muscles in our bodies. They too need to be exercised and properly maintained if they are to remain toned and able to optimally function.
Sometime during our cultural evolution the pelvic floor and its functions became taboo. Despite the fact that everyone urinates, defecates, has (or will have, when mature) sex and women continue to give birth, discussion or even reference to the pelvis and its contents has been deemed improper, gauche or downright lewd. While boys and men banter about their “members” with all too much bravado, it’s been distinctly “unladylike” for women to even mention their own body parts by proper names. Many women are so unaccustomed to looking at, touching, and heaven forbid, enjoying the pleasures of their own bodies that they have trouble acknowledging and then articulating when something is wrong. Adding to the problem is that, until recently, doctors were men who were equally uncomfortable discussing the functions of the female pelvis beyond childbearing and eliminating. So with no clear knowledge of their own bodies and no one to turn to for help, women have suffered in silence as they’ve “leaked” when they laughed, as their internal pelvic organs protrude to the outside, when they can no longer feel their husbands during intercourse or when the mere thought of intercourse causes searing pain to emanate from their pelvises. Ladies, suffer no more. There is help for pelvic floor disorders.
Ruth* had stress incontinence. After her husband had a second stroke, he had right side paralysis and Ruth assumed full care of him, including sitting him up in bed, transporting him in and out of his wheelchair and lifting his wheelchair in and out of their van.
“I knew that I had to do something. I hated wearing the protective garments and yet, I was leaking more and more. This year, I realized that my husband is getting better and we have many years left together. I didn’t want to spend them leaking this way. I asked my doctor for help and he referred me to Dr. Houser.”
Elizabeth Houser, MD is an urologist with The Urology Team. “Women must understand that there are effective treatments available for incontinence,” says Houser. “Leaking urine is not a normal part of aging.”
Ruth had started on physical therapy to strengthen her pelvic floor muscles, but found the treatments uncomfortable. “I was really uncomfortable and somewhat embarrassed by the treatments. Additionally, I had to have therapy several times a week. Adding that to my husband’s therapies just got to be too much. I opted to have surgery to fix the problem once and for all.”
“Surgery is a very appropriate option for the treatment of stress incontinence when other treatment modalities fail or are unacceptable to the patient,” explains Melody Denson, MD, urologist with The Urology Team. “Whenever possible, we try to utilize other treatments so that patients are not exposed to the potential risks of surgery. But sometimes it’s just the best option.”
Denson was instrumental in compiling patient educational booklets describing the causes and treatments of overactive bladder, urge and stress incontinence, as well as pelvic floor prolapse for patients of The Urology Team. “When approaching urologic problems, you have to not only look at physical signs and symptoms, but also at what patients themselves may be doing in their lives that may be exacerbating their problems. Many times we can make lifestyle changes and do physical therapy and make significant changes in a person’s condition.”
“Solving urologic problems, especially in women, is very much like detective work,” says Angela Treadway, DPT, a physical therapist with North Austin Urology and the Mi Center for Female Sexual Dysfunction. “Every patient that comes in has a set of symptoms and it’s my job to compare those symptoms to the big picture to figure out what is causing the patient distress. In almost all cases, there is more than one contributing factor.”
Treadway focuses on making her patients active participants in their treatment. “It’s not about me giving them answers and telling them what to do. The patient is really best equipped to bring all their systems back into balance. It’s my job to give patients the tools and power to do that.”
Treadway, like the urologists, uses a comprehensive approach, incorporating diet, exercise, physical therapy and lifestyle behavioral changes to help patients cope with their urologic problems. “There are lots of new treatments available. Patients need to know that there is help and that we are here.”
Knowing where to turn for help is very important. Claudia* developed vulvodynia – chronic pelvic pain – after she had surgery to remove endometriosis. “I struggled with endometriosis for years and finally had surgery to remove some lesions in 2001. Although the surgery was a complete success and resolved my endometriosis symptoms, I had severe pelvic pain afterwards. I should have told my doctor that I was in pain, but instead I stayed quiet, hoping the pain would go away. Looking back, I realize that I went back to work too soon which was a major factor contributing to my pain.”
“Many women with pelvic pain actually have pelvic girdle dysfunction or overly tense pelvis musculature,” explains Colleen Basler, LPT, RMT and owner of The Physical Therapy Specialty Clinic. “Constant misalignment and muscle tension can cause nerve compression leading to chronic pain. Realignment relieves tension and exercises strengthen the muscles.” Basler adds “Many women contribute to their pelvic disorders by creating bladder and bowel dysfunction. Chronic constipation or chronic bladder holding can cause pressure on the nerves of the pelvic floor damaging them. Then, add pregnancy, labor and delivery, and nerves can become stretched beyond their functional length and cease to function properly. It’s imperative that pelvic pain be addressed before it becomes chronic so that nerves aren’t damaged beyond repair.”
After many visits to her surgeon and several failed treatment attempts (including antidepressants), Claudia was referred to Basler. Together they developed a comprehensive treatment plan that included Cognitive Behavioral Therapy, yoga, massage therapy, physical therapy and reduction in Claudia’s work schedule. Claudia began to notice improvement in her pain three-to-four months into the regimen and after nine months, she says that the pain is mostly gone. “I’m just sorry that I waited and took so long to talk about my problem. I tried to find answers myself but nothing made sense. It’s hard to push past the privacy issue, but you must speak up. Don’t suffer because there is help.”
Troy Robbin Hailparn, MD is an outspoken advocate for treatment of pelvic floor disorders and an OB/GYN specializing in vulvovaginal surgery. For the past six years, Hailparn has been treating sexual disorders, primarily functional problems, in women that are the result of pregnancy, labor and delivery.
“After the birth of a baby, especially a large baby, a woman’s vagina is larger yet her partner is not. Many women experience marked decrease in sensation during intercourse following pregnancy. Insurance not only doesn’t cover treatments to correct these issues, they don’t even acknowledge them – there are no insurance codes for post partum functional pelvic disorders. In the eyes of the insurance companies, these disorders don’t exist. There is no counseling around these issues. Women are told to Kegel but unless they perform the Kegels properly and in such a way to train the pelvic floor muscles, they are not helping anything.”
Hailparn performs surgeries that tighten the muscles of the vaginal wall as well as reshape the labia. She also gives her patients specific instructions on how to do Kegels and a regimen to follow that will strengthen the pelvic floor muscles.
“We have to get away from the idea that these are cosmetic issues,” says Hailparn. “These are functional problems. If a woman can’t hold a tampon in her vagina after giving birth, that’s a functional issue. If she must press on the posterior vaginal wall to pass stool, that’s a functional problem. When a woman can no longer feel her husband during intercourse (and it’s straining her marriage), that’s a functional problem. These are common problems following childbirth but they are not normal and women should not have to suffer with them. There is hope and there is help but women have to speak up and speak out. These conditions must be recognized as medical problems, not cosmetic issues.”
It’s time to break the silence.
Common Pelvic Floor Disorders
Vulva:
The external part of the female genitalia that includes the mons, the labia, the clitoris, the vestibule (the area between the urethra opening and the vaginal opening), the urethra and the vaginal opening.
Perineum:
The area between the vulva and the anus.
Stress Incontinence:
Involuntary escape of urine with increased internal pressure as occurs with laughing, coughing, sneezing or heavy lifting. Pelvic muscles are lax and unable to quickly contract to seal off the urethral sphincter preventing urine leakage.
Urge Incontinence:
The persistent feeling of having to empty
one’s bladder even after having recently voided.
Overflow Incontinence:
Involuntary escape of urine when bladder is over-full.
Usually due to prolonged holding of urine and
disregarding cues to void.
Interstitial Cystitis/Painful Bladder Syndrome:
Recurrent/persistent pain and discomfort of
the bladder and surrounding pelvic structures.
Fecal Incontinence:
Involuntary escape of stool from the rectum.
Vulvodynia:
Chronic vulvar pain without a readily identifiable source.
Dyspareunia:
Painful sexual intercourse.
Contributors
Elizabeth Houser, MD, and Melody Denson, MD
The Urology Team – www.urologyteam.com
Angela Treadway, DPT
The Mi Center for Female Sexual Dysfunction – miaustin.com
North Austin Urology – northaustinurology.com
Colleen Basler, LPT, RMT
The Physical Therapy Specialty Clinic – 512.219.5377
Troy Robbin Hailparn, MD
Laser Vaginal Rejuvenation Institute of San Antonio – cosmeticgyn.net
Teresa Irwin, MD
Central Texas Wellness Rejuvenation Center – lvriofcentraltexas.com