What You Need To Know About Pelvic Floor Dysfunction

The morning after I gave birth to my first daughter, in 2017, I eased myself out of bed and felt a sudden gush of fluid. I panicked. I’m an ob-gyn, and my first thought was that I was having a postpartum hemorrhage. It could be fatal. I could bleed to death. 

I rushed to the bathroom expecting to see a pool of blood in my diaper, only to find it filled with colourless fluid. I stared, mystified by the lack of red. And then I realized what had happened: My bladder had completely emptied without warning, and I had no ability to stop it. I had officially joined the one in three women who experience incontinence after childbirth.

My pregnancy and delivery had been relatively uncomplicated: I had a vaginal birth and my daughter weighed less than seven pounds. Incontinence was not even on my radar. Yet, in the weeks following my delivery, I continued to leak urine. 

I told myself that this was normal. I made sure that my bladder never got too full, taking frequent trips to the bathroom, and I attempted pelvic floor exercises I found online. My new life was consumed with the chaos of early motherhood and I found it difficult to make the time to prioritize myself. I kept telling myself things would get better. But, even as an ob/gyn, I really wasn’t sure what to expect next. 

Three months postpartum, I noticed a significant improvement in my symptoms, and by six months I was able to do most exercises without leaking (although I doubt I will ever attempt jumping jacks again). Like many women, things aren’t the same as they were before childbirth and I worry about what will happen as I get older.

Pelvic floor dysfunction is incredibly common: One in two women will suffer from it in their lifetime, according to the International Federation of Gynecology and Obstetrics. While one in three women will experience urinary leakage, one in 10 will suffer from leakage of stool. One in three women who have had a child will be affected by pelvic organ prolapse, a condition in which one or more of the pelvic organs drop down from their normal position and bulge into or out of the vagina.

Despite the frequency of these conditions, pelvic dysfunction is rarely discussed. In fact, the pudendal nerve, one of the main nerves of the pelvic floor, derives from the Latin word pudendum, which means “parts to be ashamed of.” 

Here is what you need to know about pelvic floor dysfunction.

What is pelvic floor dysfunction?

The pelvic floor is a dynamic network of ligaments, connective tissue, muscles and nerves at the bottom of the pelvis that holds up the pelvic organs—the uterus, bowel and bladder. Stretching or injury to any of these parts can cause dysfunction of the organs. This can result in symptoms such as incontinence (the involuntary loss of urine or stool), inability to empty the bowel or bladder fully or a bulge that falls into or out of the vagina, called prolapse. Many women will also experience symptoms of sexual dysfunction (pain with intercourse, reduced sexual desire and arousal and difficulty achieving orgasm) and pelvic pain.

Dr. Roxana Geoffrion, a Vancouver-based urogynecologist (a specialist in problems of the pelvic floor) and president of the Canadian Society for Pelvic Medicine, refers to the constellation of symptoms as pelvic floor disorders. “Rarely do symptoms come in isolation,” she says. “Research shows that 80 percent of women who experience symptoms will have symptoms of more than one pelvic floor disorder at a time.”

What is pelvic organ prolapse? 

Pelvic organ prolapse is classified based on which organ—bladder, rectum or uterus—bulges into or out of the vagina. Many women will have more than one type of prolapse at a time.

“Patients often notice symptoms for the first time in the shower,” says Dr. May Sanaee, a urogynecologist in Edmonton. “[Some may feel] like they are sitting on a ball or an egg, others have a constant sensation of something irritating in the vagina, like a dry tampon.” While most women do not describe the sensation as painful, some find sex uncomfortable and others visit their doctors because they are worried that they have a tumour, she says.

In extreme cases, the entire vagina turns inside out and the uterus, vagina, rectum or bowel can be seen bulging outside the vaginal opening, says Sanaee. These severe cases can result in rubbing and bleeding and an inability to urinate. She says it is important to know that even in these cases, prolapse will not become cancer, nor will the vagina or uterus fall out of the body.

For most women, prolapse occurs slowly. The initial stretching of ligaments often occurs during pregnancy or childbirth, and over time conditions such as obesity, chronic coughing or constipation as well as repetitive heavy lifting or straining can further weaken these ligaments.

Up to 40 percent of women have mild prolapse with minimal or no symptoms and the prolapse is only noted on examination. Pelvic floor exercises and physiotherapy can often help to both prevent and improve symptoms, and in some cases prevent progression of the disorder. A pessary (a small, silicone device that comes in different shapes and sizes and sits inside the vagina to support the uterus, bladder or rectum and/or prevent incontinence) or surgery may be suggested in order to improve your quality of life and prevent complications like rubbing, which could lead to bleeding or infection.

Less commonly, symptoms of prolapse occur suddenly. This can happen when you’re squatting down to pick up something heavy, causing an abrupt pull on already stretched tissues. You’ll either see or feel tissue prolapsing that you had not noticed in the past.

Women with connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome, are also at an increased risk of prolapse.

Who is at risk of pelvic floor dysfunction?

Pregnancy and vaginal childbirth remain the most common risk factors for pelvic floor dysfunction, but it can also occur in women who have not given birth. Aging, family history, smoking and obesity are also risk factors.

Women who give birth later in their reproductive life are also at an increased risk, as are women who give birth to large babies, multiple babies and those who give birth by vacuum or forceps delivery. Certain maneuvers can be used during the birthing process, however, to protect the perineum and prevent birth injury, which can in turn helps prevent pelvic floor dysfunction.

When should I seek help for pelvic floor dysfunction?

If you’ve recently had children, consult the Postpartum Pelvic Floor Health Index, a screening tool for women and physicians created by Geoffrion. The tool, published in the journal Canadian Family Physician and available on Geoffrion’s website, Be Pelvic Health Aware, lists 10 symptoms that women commonly experience postpartum. Geoffrion suggests women seek help if they answer “yes” to any of the questions at six months postpartum and beyond.

“The key is recognizing the difference between dysfunction and distress,” says Geoffrion. If you’re experiencing symptoms but are not necessarily bothered by them, you might not require treatment. But if symptoms become distressing, impact your quality of life or cause problems like an inability to empty the bladder or recurrent urinary tract infections, then it is time to get help, she says.

Prevention, as with most health concerns, is key. Recognizing risk factors and symptoms at an early stage means that there’s still time to focus on lifestyle modifications like weight loss and quitting smoking, as well as interventions such as pelvic physiotherapy, which has been shown to decrease the likelihood of needing surgery. Family physicians, nurse practitioners and pelvic physiotherapists are all great resources to assess symptoms and determine if further referrals are necessary.

What are possible solutions for pelvic floor dysfunction?

Kegel exercises are often the first thing that comes to mind when thinking of prolapse and incontinence. But while kegels can benefit some women, they can make things worse for others, especially those who have overdeveloped, tender pelvic floor muscles, says Sanaee. She recommends seeing a pelvic physiotherapist to properly identify and treat the issue.

Therapists use a variety of techniques both inside the vagina and externally. They’ll also teach you how to do specific exercises at home. Even one session can be of benefit, says Sanaee, who notes that cost can be a limiting factor. 

While some private healthcare plans will cover pelvic physiotherapy, Sanaee and Geoffrion would like to see provincial health care plans cover a portion of pelvic physiotherapy sessions, especially postpartum and after surgery. In many provinces, the government covers a certain number of physiotherapy appointments after orthopaedic procedures such as knee replacements. “We would hope to have the same after surgery for prolapse,” says Sanaee.

A pessary can also help. For prolapse, pessaries are fit in doctors’ or physiotherapists’ offices, while others for incontinence can be ordered online without seeing a doctor. (It's still a good idea to see a doctor first to make sure a pessary can help your specific issue.)

Some women experiencing prolapse may require surgery. This can involve removing the uterus or suspending the organs to hold the prolapse up. In some cases, the prolapse may return and may require a second procedure. In cases of recurrence your surgeon may discuss using a mesh. The mesh is placed inside the abdomen to prevent the prolapse from falling back down. For women suffering from incontinence, a different type of mesh is sometimes placed under the urethra to prevent leakage of urine. (For some patients, mesh can cause other issues, so it’s important to speak to your doctor about the benefits and risks.)

If you have severe prolapse, and are no longer sexually active or are a poor candidate for abdominal surgery, your surgeon may suggest a procedure which closes the vagina by stitching the sides together. This is called a colpocleisis. Surgery may be performed by a gynecologist, urologist or a urogynecologist, but recurrent cases, or cases involving mesh, are more likely to require a urogynecologist. 

Sanaee recognizes that it can be confusing to find the right care for prolapse or other forms of pelvic dysfunction. Traditionally, women’s health has not been a priority in medicine, and there are dubious products on the market that are attempting to exploit that void. 

One of those products is the vaginal laser, a device marketed for its potential for “vaginal rejuvenation,” with some companies claiming it also treats urinary incontinence. In Canada, controlled studies are not required for regulatory approval of many new medical devices and women’s health advocates say recent randomized-controlled studies have not shown that vaginal lasers are effective for preventing and treating incontinence long-term. 

Other devices like the kegel chair use energy to stimulate the pelvic floor muscles to treat pelvic floor dysfunction. A popular claim for this device is that it’s like doing “thousands of kegels” in a single session. A full treatment of six sessions can cost around $2,000, with maintenance sessions from $200 to $300. Similar to the vaginal laser, randomized trials on long-term benefits are still lacking—and for some women, especially those with overactive pelvic floors, this device has the potential to make symptoms worse. 

The symptoms of pelvic floor dysfunction are distressing and it’s natural to feel desperate for a solution. That said, Sanaee encourages women to seek out a trusted health care provider for a proper assessment before trying products with a high price-tag, and to use resources such as Voices for PFD and Your Pelvic Floor to find reliable information on pelvic floor dysfunction. 

“We are here for you,” says Sanaee. Specialists across the country are working together to standardize care, to make sure that this aspect of women’s health is a part of all medical education and that care is accessible to all Canadian women. 

As I think back on my own journey with pelvic floor dysfunction, I am encouraged by the many passionate physicians, nurses and physiotherapists working in this field who want to make a difference and understand that the pelvic floor is so much more than “a part to be ashamed of.”