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2 Introduction and Epidemiology of Pelvic Floor Dysfunction
Jay Iyer and Ajay Rane
Introduction
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.
Types of Pelvic Floor Dysfunction
Pelvic Organ Prolapse (POP)
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.
Urinary Incontinence
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.
Anal Incontinence
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%.
Paradoxical Puborectalis Contraction
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
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
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.
Proctalgia Fugax
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