Pelvic Floor Disorders

Overview

The "pelvic floor" is the group of muscles that form a sling or hammock across the floor of the pelvis. Together with surrounding tissues, these muscles hold the pelvic organs in place so they can function correctly. The pelvic organs include the bladder, urethra, intestines, and rectum. A woman's pelvic organs also include the uterus, cervix, and vagina.

A pelvic floor disorder occurs when the pelvic muscles and connective tissue weaken or are injured. The most common pelvic floor disorders are urinary incontinence, fecal incontinence, and pelvic organ prolapse. Pelvic floor disorders are more common among older women.

Many women are reluctant to tell their healthcare provider about symptoms because they may feel embarrassed. In addition, many women think that problems with bladder control are normal and live with their symptoms. However, bladder control problems are treatable, and these treatments can help women with pelvic floor problems.

Related Terms 

• Pelvic organ prolapse 
• Urinary incontinence 
• Fecal incontinence 
• Accidental bowel leakage 
• Bowel incontinence 
• Cystocele 
• Prolapsed bladder, 
• Anterior vaginal wall prolapse
• Fallen bladder

Signs and Symptoms

Because there are different types of pelvic floor disorders, symptoms can vary or overlap. Women with pelvic floor disorders may experience:

• Heaviness, fullness, pulling, or aching in the vagina that gets worse by the end of the day or is related to a bowel movement
• Seeing or feeling a "bulge" or "something coming out" of the vagina
• Difficulty starting to urinate or emptying the bladder completely
• Leaking urine when coughing, laughing, or exercising
• A strong, urgent, or frequent need to urinate
• Pain while urinating
• Constipation

Some women with pelvic floor problems do not have symptoms at first.

Urinary incontinence signs and symptoms can include:

• Leaking urine during everyday activities such as lifting, bending, coughing, or exercising
• Being unable to hold in urine after feeling a sudden, strong urge to urinate
• Leaking urine without any warning or urge
• Being unable to reach a toilet in time
• Wetting the bed during sleep
• Leaking during sexual activity

Fecal incontinence symptoms depend on the type:

• With urge fecal incontinence, a person knows when they need to pass stool but cannot control passing stool before reaching a toilet.
• With passive fecal incontinence, a person passes stool or mucus without knowing it.
• Leaking stool or difficulty controlling gas
• Some medical experts include streaks or stains of stool or mucus on underwear, called soiling, as a symptom of fecal incontinence.

Cystocele symptoms may include:

• A vaginal bulge or the feeling that something is falling out of the vagina
• Pressure in the vagina or pelvis
• Urine leakage
• Difficulty starting the flow of urine
• A slow urine stream
• Frequent or urgent urination

These symptoms may get worse when straining, lifting heavy items, coughing, or standing for a long time, and may get better when lying down.

Related Health Effects

Fecal incontinence can cause:

• Discomfort or irritation of the skin around the anus
• Emotional and social distress, such as fear, embarrassment, social isolation, loss of self-esteem, anger, or depression
• Quality-of-life issues, such as not being able to exercise, work, attend school, or go to social gatherings

People with fecal incontinence may also have other health problems, including:

• Diarrhea
• Poor overall health
• Chronic diseases and disorders such as irritable bowel, type 2 diabetes, inflammatory bowel disease, and diseases that affect the nerves of the anus, pelvic floor, or rectum
• Damage to or weakness of the muscles of the anus, pelvic floor, or rectum
• Urinary incontinence
• Proctitis, an inflammation of the lining of the rectum

Bladder control problems can also affect quality of life:

• Reduced physical activity: Some activities such as running, jumping, or brisk walking may cause some people with urinary incontinence to leak.
• Emotional distress: Untreated bladder problems can lead to depression or social anxiety.
• Intimacy problems: Some people may avoid intimacy because they worry they may leak urine during sex.

A cystocele may put pressure on or lead to a kink in the urethra and cause urinary retention, a condition in which a person cannot empty all the urine from the bladder. In rare cases, a cystocele may result in a kink in the ureters and cause urine to build up in the kidney, which can lead to kidney damage.

Causes and Risk Factors

The complete picture of what contributes to the development of pelvic floor problems is not clear and is quite complex. The following conditions are being studied as risk factors:

• Childbirth: Pregnancy, childbirth, and their link to pelvic floor problems have been an active area of research, but the connection is not clear. 
• Factors that put pressure on the pelvic floor: These include overweight or obesity, chronic constipation or chronic straining to have a bowel movement, heavy lifting, and chronic coughing from smoking or health problems.
• Getting older: The pelvic floor muscles can weaken with aging and during menopause.
• Having weaker tissues: Genes influence the strength of a woman's bones, muscles, and connective tissues. Some women are born with conditions that affect the strength of connective tissues, and they are more likely to have pelvic organ prolapse.
• Surgery: Previous hysterectomy and prior surgery to correct prolapse are associated with higher risks of pelvic floor disorders.
• Race: Certain groups of women, such as White or Latina women, appear to be at higher risks for some forms of pelvic floor disorders.

Many factors, including pregnancy and childbirth, surgery, and getting older can weaken pelvic floor muscles. If these muscles are weak, a person may start to leak small amounts of urine, stool, or gas.

Fecal incontinence has many causes, including digestive tract disorders and chronic diseases. Specific causes include:

• Diarrhea, or loose, watery stools can fill the rectum quickly and are harder to hold in than solid stools. Diarrhea is the most common risk factor for fecal incontinence for people not staying in hospitals, nursing homes, or other similar institutions.
• Constipation, or hard stools, can stretch and weaken the muscles in the rectum over time, allowing watery stools to leak out.
• Muscle injury or weakness that can occur after surgery or trauma.
• Nerve damage that can occur from long-term straining to pass stool, brain injury, or spinal cord injury.
• Neurologic diseases such as dementia, multiple sclerosis, Parkinson's disease, stroke, and type 2 diabetes can cause incontinence.
• Hemorrhoids can keep the muscles around the anus from closing completely.
• Childbirth by vaginal delivery can cause injuries to the anal sphincters.

Risk factors for fecal incontinence include being older than age 65, being physically inactive, having certain chronic diseases, having had the gallbladder removed, and being a current smoker.

Prevention Guidance

Because researchers are not sure what causes pelvic floor disorders in some women but not in others, there is no sure way to prevent them from occurring. However, there are some ways to reduce the risk of pelvic floor disorder:

• Controlling weight and making other lifestyle changes 
• Doing Kegel exercises correctly and routinely 
• Not smoking and quitting smoking, since smoking can lead to a chronic cough that stresses the pelvic floor

For a cystocele, steps to help prevent worsening include:

• Doing pelvic floor muscle exercises: Strong pelvic floor muscles help hold the pelvic organs in place. Pelvic floor focused exercises can make the muscles stronger.
• Maintaining a healthy weight: Being overweight puts pressure on the pelvis.
• Avoiding heavy lifting and lift correctly: When lifting heavy objects, use your legs instead of your waist or back.
• Preventing and treating constipation: Get enough fiber in your diet, drink plenty of water and other liquids, and get regular physical activity.
• Controlling chronic cough: Get treatment for a chronic cough and avoid smoking.

Depending on the cause, changing what you eat and drink can help prevent or relieve fecal incontinence. If fecal incontinence is caused by diarrhea, avoiding foods and drinks that worsen symptoms, such as alcoholic beverages, caffeine, dairy products, fatty and greasy foods, and spicy foods, may help.

Diagnosis

A healthcare provider may be able to diagnose a pelvic floor disorder with a physical exam. In some cases, a woman's healthcare provider will see or feel a bulge during a routine pelvic exam that suggests a prolapse. In addition to a physical exam, a doctor will ask about medical history, including whether a woman has been pregnant, has had surgery, and takes any medicines.

Depending on the findings from the exam or the severity of the symptoms, a healthcare provider may order tests.

For bladder control problems:

• Cystoscopy examines the insides of the bladder to look for problems such as bladder stones, tumors, or inflammation.
• Postvoid residual urine measurement can determine how much urine is left in the bladder after urination.
• Urinalysis can detect a bladder infection, kidney problems, or diabetes.
• Urodynamics evaluates how the bladder and urethra are working. It can help determine the plan for surgery to treat certain forms of bladder control problems.

For bowel control problems:

• Anal manometry evaluates the strength of the anal sphincter muscles.
• Colonoscopy or sigmoidoscopy examines the inside of the colon or the sigmoid (the part of the bowel near the rectum) to look for signs of disease or inflammation that may be causing symptoms.
• Dynamic defecography evaluates the pelvic floor and rectum while the patient is having a bowel movement.

Doctors may also use the following to diagnose fecal incontinence:

• Blood tests show signs of anemia, inflammation, and infection.
• Stool tests show the presence of blood and signs of infection and inflammation.
• Electromyography checks how well the muscles and nerves of the anus and pelvic floor are working.
• Imaging tests, such as magnetic resonance imaging (MRI) or ultrasound, to look for problems in the anus, pelvic floor, or rectum.

Treatment and Management

Treatment can often help when symptoms are bothersome or restrict a woman's activities. Some women do not need treatment for their pelvic floor disorders. 

Lifestyle Changes

Your healthcare provider may recommend:

• Limiting food and drinks that stimulate the bladder: Caffeinated and carbonated beverages, citrus fruits and drinks, artificial sweeteners, and alcoholic beverages can stimulate the bladder.
• Eating a high-fiber diet for certain bowel problems: Fiber helps make stool the right consistency and can prevent constipation. Fiber is found in fruits, vegetables, legumes (such as beans and lentils), and whole grains. Fiber supplements are also available.
• Losing weight: For women who have overweight or obesity, losing weight may reduce bladder control and pelvic organ prolapse symptoms by relieving pressure on pelvic organs.

Nonsurgical Treatments

Nonsurgical treatments commonly used for pelvic floor disorders include:

• Pelvic floor muscle training (PFMT): Often called Kegel exercises, PFMT involves squeezing and relaxing the pelvic floor muscles. If performed correctly and routinely, PFMT may improve the symptoms of urinary incontinence and prolapse. However, PFMT cannot correct prolapse. Women can do the exercises on their own or with the help of a pelvic floor physical therapist. Biofeedback during pelvic floor physical therapy is sometimes used to help teach women which muscle group to squeeze.
• Medicine: Medicine is sometimes prescribed to treat certain bladder control problems or to prevent loose stools or frequent bowel movements.
• Vaginal pessary: This plastic device treats prolapse and can sometimes improve bladder control. A woman or her healthcare provider inserts the pessary into the vagina to help support the pelvic organs. A woman's doctor will fit her for a pessary that is a comfortable shape and size and instruct her on how to use and care for it.

Additional nonsurgical treatments for urinary incontinence include:

• Medicines such as anticholinergics, beta-3 agonists, and tricyclic antidepressants to relax the bladder
• Botulinum toxin A (Botox), injected into the bladder to relax it and make more room for urine
• Electrical nerve stimulation to change the bladder's reflexes using mild pulses of electricity

Additional nonsurgical treatments for fecal incontinence include:

• Biofeedback therapy to help learn exercises to strengthen pelvic floor muscles and sense when stool is filling the rectum
• Sacral nerve stimulation- a type of electrical stimulation that helps the sacral nerves (which control the anal sphincters, colon, and rectum) work properly
• Nonabsorbable bulking agents injected into the wall of the anus to bulk up the tissue and help the sphincters close better
• Vaginal balloons - a device that inflates a balloon inside the vagina to put pressure on the wall of the rectum and keep stool from passing

Surgical Treatments

In some cases, surgery is the best treatment option, especially when other treatments are not helpful. Some surgical treatments can be performed as outpatient procedures.

For prolapse:

• Surgery involves repairing the prolapse and attempting to restore a well-supported anatomy.
• Women with uterine prolapse may also have the uterus removed (hysterectomy).
• Some women choose colpocleisis, a surgery that treats prolapse by narrowing and shortening the vagina. It works well and carries a low risk, but it is not a good choice for women who want to be able to have vaginal intercourse.

For bladder control problems:

• The most common surgery is a mid-urethral sling, in which the surgeon places material under the urethra to support it and prevent urine leakage during activity.
• Bulking agents can be injected near the bladder neck and urethra to thicken the tissue and close the bladder opening. Repeat injections may be needed over time.
• An artificial urinary sphincter can be implanted in men to help keep the urethra closed and prevent leaks.

For bowel control problems:

• Sphincteroplasty is the most common fecal incontinence surgery. It reconnects the separated ends of an anal sphincter torn by childbirth or another injury.
• Artificial anal sphincter surgery places a cuff around the anus and implants a small pump under the skin to control the passage of stool. This surgery is not common because it may cause side effects.
• Colostomy is a surgery in which the colon is brought through an opening in the abdominal wall, and stools are collected in a bag outside the abdomen. Doctors may recommend this as a last resort.

Not all women are good candidates for surgery. In general, women who want to have children should not have these types of surgery. Also, prolapse can recur even after surgery is performed to correct it.

Important note about surgical mesh: The U.S. Food and Drug Administration (FDA) no longer allows surgical mesh kits on the market for the transvaginal repair of pelvic organ prolapse. Women who have had this form of surgery do NOT need the mesh removed if they do not have problems. For more information, visit the FDA's page on Pelvic Organ Prolapse.

Living With Pelvic Floor Disorders

Do not wait until your symptoms feel "really bad" to get help. Without treatment, symptoms can get worse and may affect your self-esteem, your ability to do your job, your relationships, and many other aspects of daily living.

For fecal incontinence, the following can help you cope:

• Using the toilet before leaving home
• Carrying a bag with cleanup supplies and a change of clothes when leaving the house
• Finding public restrooms before one is needed
• Wearing absorbent pads inside your underwear
• Wearing disposable underwear
• Using fecal deodorant over-the-counter medicines that reduce the smell of stool and gas
• Taking over-the-counter medicines to help prevent diarrhea before eating in restaurants or at social gatherings

Fecal incontinence is not something to be ashamed of. It is simply a medical problem. It can often be treated, is not always a normal part of aging, and will not usually go away on its own. Most people need treatment.

Fecal incontinence can cause anal discomfort such as irritation, pain, or itching. You can help relieve anal discomfort by:

• Washing the anal area after a bowel movement
• Changing soiled underwear as soon as possible
• Keeping the anal area dry
• Using a moisture-barrier cream in the area around the anus
• Wearing clothes and underwear that let air pass through easily

For urinary incontinence, certain products can help you cope with urine leaks:

• Absorbent, washable incontinence underwear
• Waterproof underwear
• Adult incontinence briefs
• Disposable pads worn in underwear
• Special skin cleaners and creams to keep the skin around the urethra from getting irritated

Bladder control problems are common, yet many people feel too embarrassed to talk about them. Talk with your healthcare professional about your bladder problems. Your healthcare professional can help you connect with a support group for people with similar problems.

Find Clinical Trials

Clinical trials uncover better ways to prevent, diagnose, treat, and understand diseases and conditions. To ensure results apply to everyone, volunteers of all ages, sexes, and backgrounds, including both healthy individuals and those with specific medical conditions, are needed. Find clinical trials on pelvic floor disorders. 

Find Treatment

See a healthcare professional if you have symptoms of a bladder problem, such as trouble urinating, a loss of bladder control, waking to use the bathroom, pelvic pain, or leaking urine. Here are some additional resources for how to find treatment:

• Voices for pelvic floor disorders offers a Find a Provider tool that links women to urogynecologists in their areas.
• The National Association for Continence provides a Find a Specialist service for finding healthcare providers who treat incontinence.

Community Support

• Voices for PFD is a consumer information website and online patient community sponsored by the American Urogynecologic Society Foundation.
• The National Association for Continence provides fact sheets and resources for talking to healthcare professionals.
• Information for New Moms provides a series of videos and educational information about changes to pelvic floor health that new moms may experience, available in English and Spanish.
• The American Urogynecologic Society is dedicated to research and education in urogynecology and the detection, prevention, and treatment of female lower urinary tract disorders and pelvic floor disorders.

Note: This resource list is for informational purposes only. It is not comprehensive, and an organization’s inclusion does not constitute an endorsement by NIH. 

Research Information

The National Institutes of Health (NIH) is the largest public funder of biomedical research in the world. NIH invests most of its budget in medical research seeking to enhance life and to reduce illness and disability. NIH-funded research has led to breakthroughs and new treatments helping people live longer, healthier lives, and building the research foundation that drives discovery. 

NIH established the Pelvic Floor Disorders Network (PFDN) in 2001 to encourage collaborative research on pelvic floor disorders and to improve patient care. The PFDN includes a data coordinating center and eight clinical centers located at universities and medical centers across the United States.

NIH research also includes studies of:

• The basic mechanisms of pelvic floor support and of pregnancy- and childbirth-related pelvic floor injury
• Genetic determinants affecting predisposition to pelvic organ prolapse
• How physical activity affects pelvic floor disorders
• Animal models of stem-cell homing for treatment of pelvic floor disorders
• Minimally invasive techniques for surgical repair of vaginal prolapse
• Patient-reported outcome measures
• Combination treatments to find out how to get the best outcomes for women with pelvic floor disorders

The NIH Pain Consortium promotes collaboration across NIH institutes and centers with programs addressing pain, including pelvic pain.

Find NIH-funded research projects using NIH RePORTER, a searchable database of current and past research projects supported by NIH and other federal agencies.