Pelvic Floor Dysfunction: A Treatment Update
by Matthew E. Karlovsky, MD and Robert M. Moldwin, MD
 The pelvic floor is comprised of muscles and fascia and has three
functions: support of the pelvic organs, contraction, and relaxation. Their function is
critical to proper micturition, defecation, and sexual intercourse. In the past, pelvic
floor dysfunction (PFD) has been variously termed spastic pelvic floor syndrome, levator
ani syndrome, proctalgia fugax, vaginismus, male chronic pelvic pain syndrome,
non-neurogenic neurogenic bladder, and coccydynia — all terms based upon the varied
presenting features of the same phenomenon. Pelvic floor dysfunction may be defined as
spasm or discoordination of the pelvic floor musculature. Spasm of these muscles commonly
manifests with urological symptoms including poor urine stream, pelvic pain or pressure,
urinary frequency and urgency, urge incontinence, and ejaculatory pain. These are the same
complaints seen in patients with chronic pelvic pain (CPP) syndromes including
interstitial cystitis (IC) and chronic prostatitis (CP). Other frequent co-existent
symptoms include chronic constipation, lower back pain, penile, vaginal, peri-rectal pain,
vulvodynia, dyspareunia, or generalized pain. Treatment of PFD, when present in IC or CP,
is strongly recommended, along with bladder or bowel-directed therapy to achieve the
optimal relief of symptoms. This article will review pelvic neuroanatomy, pathophysiology,
PFD diagnosis, and treatment.
Anatomy
The pelvic floor muscles (PFM) include the levator ani (pubococcygeus, ileococcygeous,
puborectalis), coccygeus, pyriformis, obturator and perineal muscles (see Figure 1). The
levators derive circulation from the parietal branches of the internal iliac artery and
innervation from sacral nerves S3 and S4, via the pudendal nerve. At rest, the PFM support
the bladder and urethra in the anterior vaginal compartment, the anus and rectum in the
posterior compartment, and the cervix and uterus in the middle compartment. Like all
skeletal muscles, resting tone is maintained by slow-twitch (type 1) efferent fibers,
which contribute to the integrity of the proper anatomic positions of the pelvic organs,
in addition to supportive fascia. These vary with hormone status, parity and body habitus.
Voluntary contraction of the pelvic floor arises from a conscious impulse, while reflex
contractions occur to close the urethra, anus and vagina, to prevent urine and stool loss,
and as a vaginal protective mechanism. Phasic recruitment of large motor units propagated
by fast twitch (type 2) fibers occurs in response to abdominal pressure increases such as
coughing. Feedback inhibition (“guarding reflex”) of the detrusor muscle will
result in diminution of detrusor pressure, preventing bladder contraction. For an
efficient contraction, the PFMs must have strength (via recruitment) and endurance (over
time). In addition, during sexual arousal and orgasm, pelvic floor muscle contraction
facilitates vasocongestion and contract involuntarily, respectively.
Please refer to the Apr/May 2005 issue for the complete text. In the event you need to order a back issue, please click here.
— Apr 2005
The full article is now available as a PDF and may be
purchased for $5 and downloaded immediately:
|