Jay Iyer and Ajay Rane The pelvic floor consists of the muscles, ligaments, and connective tissue that constitute the pelvic organ supports. The pelvic organs include the bladder, uterus and cervix, vagina, rectum and bowel. The supporting pelvic floor not only prevents the descent of these organs, but also maintains their anatomical position and helps in their normal function. Pelvic floor dysfunction (PFD) is a group of disorders that affects these various structures and can therefore lead to bladder and/or bowel dysfunction.The condition cannot only affect daily activities, sexual function, and exercise, but it can also impact negatively on one’s emotional and psychological state. The presence of pelvic floor dysfunction can have a detrimental impact on body image and sexuality. Diagnosis is often delayed because most women are embarrassed to discuss their condition. The International Continence Society (ICS) defines prolapse as the descent of one or more of the anterior vaginal wall, the posterior vaginal wall, and the apex or the vault of the vagina. Symptoms generally include difficulty in emptying the bladder or rectum, urinary or faecal incontinence, pelvic pressure, vaginal bulge and/or sexual dysfunction. ICS defines urinary incontinence (UI) as the involuntary loss of urine. The most common recognised subtypes of UI are stress urinary incontinence (SUI), urge urinary incontinence (UUI), and mixed urinary incontinence (MUI). Overactive bladder (OAB) syndrome presents most commonly as urinary urgency, and can be accompanied by frequency and nocturia, with or without urge incontinence, in the absence of urinary tract infection (UTI) or other obvious pathology. Includes the involuntary passage of gas, mucus, liquid, or solid stool. The most common type of incontinence is watery/liquid stool (>20%), followed by hard and normal stool (approximately 9% for both). The prevalence as suggested by international population‐based studies of faecal incontinence is between 0.4 and 18%. The puborectalis muscle, part of the levator ani muscle, wraps like a sling around the lower rectum, acts to control the anorectal angle and consequently facilitates evacuation of bowel content. During a bowel movement, the puborectalis muscle relaxes to allow the bowel contents to pass. If the muscle does not relax and/or contracts paradoxically, it can lead to straining and functional constipation, which is challenging to treat. Levator syndrome refers to abnormal muscle spasms of the pelvic floor. Spasms may occur after a bowel movement or may be idiopathic. Patients often have long periods of vague, dull, or achy pressure high in the rectum. These symptoms may worsen when sitting or lying down. Levator spasm is more common in women than men. Coccygodynia is pain of the coccyx, usually worsened with movement and after defecation. It is usually caused by trauma to the coccyx, although in a third of patients no cause may be found. This functional disorder is caused by spasms of the rectum and/or the muscles of the pelvic floor, leading to sudden abnormal anal pain that often awakens patients from sleep. This pain may last from a few seconds to several minutes and goes away between episodes. The pudendal nerves are mixed nerves, with predominant sensory supply to the pelvic floor, external genitalia and perineum. Pudendal neuralgia is chronic pelvic floor pain involving the pudendal nerves. This pain may first occur after childbirth, but often waxes and wanes without reason. The prevalence of PFD increases steadily with age. With improved life expectancy, the prevalence and burden of the disorder is bound to increase. The burden of the disease is perceived not just at an individual level but healthcare providers also are affected and the impact on healthcare is likely to increase. About 316 million women suffer from genital prolapse worldwide. Based solely on patient symptoms, the prevalence of pelvic organ prolapse (POP) is 3–6%; however, it rises up to 50% if based on clinical examination because most of the mild cases are asymptomatic. According to the Women’s Health Initiative (WHI) in the United States, 40% of women have some degree of POP with 14% having uterine prolapse. The incidence of POP surgery varies from 1.5–1.8 per 1000‐woman years with peak age at 60–69. The probability of having a surgical correction for POP by age 80 is estimated to be one in five. Based on the WHI data, incidence of stage 1–3 prolapse is estimated to be 9.3 per 100 woman‐years for cystocele, 5.7 per 100 woman‐years for rectocele, and 1.5 per100 woman‐years for uterine prolapse. Prolapse progression ranged from 1.9% for uterine prolapse, to 9.5% for cystocele, and 14% for rectocele. Older, parous women are more likely to develop new or progressive prolapse. In the United States, POP is thought to be the leading cause of more than 300 000 surgical procedures per year with 25% undergoing reoperations at a total cost of more than one billion dollars annually. The estimated direct annual cost of ambulatory care utilisation for pelvic floor disorders during a nine‐year period (1996–2005) increased by 40% and, if extrapolated to POP surgery, the total annual cost would be over 1.4 billion. UI is more common in women than men and studies from numerous countries have reported the prevalence of UI in women to range from approximately 5–70%, with most studies reporting a prevalence of any UI in the range of 25–45%. In nonpregnant women aged 20 years and above, the prevalence has been reported at 10–17%. These figures increase with increasing age, and in women 65 years and older, more than 50% of the population is affected. The estimated cost of UUI with OAB in the United States during 2007 was $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020. With the addition of SUI, this figure may be higher. The prevalence and epidemiology of anal incontinence is poorly documented and under‐reported by patients primarily due to embarrassment and concerns regarding treatment options. The prevalence of faecal incontinence in American women is estimated to impact 2.2–24% depending on the definition used. Severe faecal incontinence, defined as incontinence greater than or equal to one episode monthly, is reported to be present in 6.3% of women. Furthermore, obstetric anal sphincter injuries in vaginal births are serious complications that share a well‐known association with anal incontinence. Injury to the anal sphincter during childbirth approximately doubles the risk of developing anal incontinence within six months after a first delivery.
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Introduction and Epidemiology of Pelvic Floor Dysfunction
Introduction
Types of Pelvic Floor Dysfunction
Pelvic Organ Prolapse (POP)
Urinary Incontinence
Anal Incontinence
Paradoxical Puborectalis Contraction
Levator Syndrome
Coccygodynia
Proctalgia Fugax
Pudendal Neuralgia
Epidemiology
Pelvic Organ Prolapse
Urinary Incontinence
Anal Incontinence
Predisposing Factors
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