Pelvic floor dysfunction: recognise and refer

Incontinence and pain shouldn’t be taken as normal, and Kegel exercises can make things worse – but a specialist physiotherapist can help.

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I had absolutely no desire to learn about incontinence and pelvic health during my undergrad physiotherapy degree. To me it was dirty and boring, and I couldn’t understand the importance of it.  

My first real-world interaction with pelvic health began when I worked alongside contact sport athletes and was faced with keeping incontinence pads in my medical bag for those players with a vulva. I eventually began working with many pre- and postnatal mothers and it became rapidly apparent that the majority were experiencing some form of pelvic pain or incontinence. But let’s not forget the penis owners! I had just as many seeking treatment for similar symptoms.  

Seeing people held back from achieving their full potential because they were embarrassed to wet themselves, or unable to have pleasurable sex because of pelvic pain or wearing adult diapers was heart breaking. What I found most distressing was the acceptance by many vulva-owning patients that incontinence and pelvic pain was normal, especially after pregnancy. Interestingly, this view was not shared by my penis-owning patients. They sought and were referred for medical intervention significantly earlier and were in a position to prioritise their treatment (we can save the discussion around healthcare inequality for another time).  

What is incontinence?  

Incontinence can involve partial or full loss of bladder and/or bowel control. Incontinence doesn’t discriminate and affects people across the lifespan from all walks of life.  

Urinary incontinence affects approximately 40% of Australian women and 10% of Australian men. More than 50% of community-dwelling women affected are under 50 years of age and up to 70% of adults with urinary leakage do not seek medical advice for their symptoms¹.   

The acceptance and normalcy around incontinence being a “fact of life” for postnatal women and older populations demonstrate the disparity in our healthcare system and community. The latest round of advertisements selling incontinence pads is a great example of this; they depict smiling women in the gym calling it their “secret weapon”. I can assure you that no person I have treated for incontinence has been excited about wearing a pad.  

It is crucial that current and future healthcare workers learn to recognise the risk factors associated with incontinence and pelvic floor dysfunction. In doing this, it will start a conversation around the taboo topic and help to dispel an unnecessary stigma around a very common and treatable condition.  

Who is at risk of developing incontinence or pelvic floor dysfunction? 

Pelvic floor muscles are a sling-like structure from the coccyx to the pubic bone that surround and support the bladder, bowel and genitals.  

It is not only postnatal women that are at risk of developing incontinence or pelvic floor dysfunction. Other at-risk groups for vulva and penis owners include²³⁴⁵⁶:  

• Chronic constipation or straining  

• Being overweight or obese  
• Chronic respiratory conditions (repetitive coughing can weaken the pelvic floor)  
• Connective tissue disorders  
• Contact or high-impact athletes (e.g., gymnasts, trampoliners, weightlifters) 
• Pregnancy and vaginal or caesarean delivery (there is an increased risk if vaginal delivery involves a larger baby, forceps, prolonged second stage of active labour, >Gr2 perineal tear)  

• Cancer patients  
• Menopause  
• Chronic emotional stress  
• Poor toilet habits; for example, healthcare professionals holding on or rushing to pee/poo between appointments  
• Older age  

• Post prostate surgery or prostatitis  

Role of a pelvic health physiotherapist  

You don’t have to be an expert in incontinence or pelvic pain. That’s where a referral to a pelvic health physiotherapist (PHP) can help. A PHP has specialised skills in rehabilitating weakened, stretched or overactive pelvic floor muscles. You may think prescribing some Kegel pelvic floor contractions will be a quick fix. However, some vulva and penis owners may have a pelvic floor that is too tight and doing this can worsen their condition.   

If any patient presents to you with risk factors for pelvic floor dysfunction, consider referring to a PHP for a pelvic assessment. Other potential presentations include^{7 8 9 10 11:}  

• Premature ejaculation, erectile dysfunction or difficulty achieving orgasm  
• Prenatal women (prevention is better than cure! Pelvic floor muscle training in the prenatal period significantly reduces postnatal perineal tear incidence and urinary incontinence, as well as many other benefits)  
• Small leakage or difficulty emptying, for example, benign prostatic hypertrophy (this is associated with urinary retention greater than incontinence, but a pelvic floor physiotherapist can still help) 
• Period pain (period pain is not normal and should be investigated beyond the prescription of an NSAID) 
• Pain on penetration  
• Sensation of heaviness in the vagina (potential prolapse) 
• Recurrent UTI or thrush 

Everyone deserves to have a functional, pain-free and pleasurable pelvic floor. It is the most rewarding experience seeing someone’s confidence and joy come back from no longer being tied to a toilet or wearing incontinence pads. All current and future healthcare workers can promote having a healthy pelvic floor by recognising pelvic dysfunction risk factors, openly discussing incontinence and knowing where your local PHP is located.  

References 

1. Key statistics on incontinence, The continence foundation of Australia, 2021 
2. Understanding Incontinence, Continence Foundation of Australia, 2021 
3. Urinary Incontinence in Older Adults, NIH National institute of ageing; 2017 
4. Hage-Fransen M, Wiezer M, Otto A, Wieffer-Platvoet M, Slotman M, Nijhuis-van der Sanden G, Pool-Goudzwaard A, Pregnancy and obstetric-related risk factors for urinary incontinence, fecal incontinence or pelvic organ prolapse later in life: A systematic review and meta-analysis, Acta Obstet Gynecol Scand, 2021 
5. Milios JE, Ackland TR, Green DJ, Pelvic floor muscle training in radical prostatectomy: a RCT of the impacts on pelvic floor muscle function and urinary incontinence. BMC Urol, 2019  
6. Van der Velde J & Everaerd W, The relationship between involuntary pelvic floor muscle activity and experience threat in women with and without vaginismus, Behaviour Research & Therapy, 2001 
7. Brennan R, Frawley H, Martin J, Haines T, Group based pelvic floor muscle training for all women during pregnancy is more cost-effective than postnatal training for women with urinary incontinence, J.Physiotherapy, 2021 
8. Romeikiene K, Bartkeviciene D, Pelvic floor dysfunction prevention in prepartum and postpartum periods, Medicina, 2021  
9. BirthTrauma.org, 2020 
10. Pelvic Pain Foundation of Australia, 2021  
11. The Royal Women’s Hospital, 2021  

Shea-Cara Hammond is a medical student at the University of Wollongong (MD) and holds a Bachelor of Physiotherapy (First Class Honours)