Pelvic Floor Disorders (PFDs)

A PFD occurs when the muscles or connective tissues of the pelvic area weaken or are injured. The most common PFDs are urinary incontinence, fecal incontinence, and pelvic organ prolapse. PFDs are more common among older women.

NICHD supports and conducts research on PFDs. For example, NICHD-supported studies evaluate therapies and improve ways to measure treatment outcomes and patient satisfaction.

About Pelvic Floor Disorders (PFDs)

What is the pelvic floor?

The “pelvic floor” is the group of muscles that form a sling or hammock across the floor of the pelvis. Together with surrounding tissues, these muscles hold the pelvic organs in place so they can function correctly. The pelvic organs include the bladder, urethra, intestines, and rectum. A woman’s pelvic organs also include the uterus, cervix, and vagina.1

What is a PFD?

A PFD occurs when the pelvic muscles and connective tissue weaken or are injured. The most common types of PFDs are the following:

  • Pelvic organ prolapse. “Prolapse” happens in women when the pelvic muscles and tissue can no longer support one or more pelvic organs, causing them to drop or press into the vagina. For instance, in uterine prolapse, the cervix and uterus can descend into the vagina and may even come out of the vaginal opening. In vaginal prolapse, the top of the vagina loses support and can drop toward or through the vaginal opening. Prolapse also can cause a kink in the urethra, the tube that brings urine from the bladder to the outside of the body.
  • Bladder problems. Urinary symptoms can include urinating too often in the day or night, strong urgency to urinate, or urinary leakage. The leaking of urine, a problem called urinary incontinence, can occur in women or men. This leakage may occur as a result of an exertion (like a cough or sneeze) or other factors involving the bladder muscles. The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) offers information about different types of bladder control problems, including these common types:
    • Stress incontinence
    • Urge or urgency incontinence (also called overactive bladder)
    • Overflow incontinence

Bowel control problems. The leaking of liquid or solid stool from the rectum, called fecal incontinence, can occur in women and men. It can result from damage to or weakening of the anal sphincter, the ring of muscles that keeps the anus closed, or from other causes. NIDDK also offers information on fecal incontinence.

Citations

  1. American College of Obstetricians and Gynecologists. (2017). Pelvic support problems. Retrieved September 3, 2019, from https://www.acog.org/Patients/FAQs/Pelvic-Support-Problems?IsMobileSet=false external link

What are the symptoms of pelvic floor disorders (PFDs)?

Because there are different types of PFDs, symptoms of different PFDs can vary or overlap. For example, women with PFDs may1,2,3:

  • Feel heaviness, fullness, pulling, or aching in the vagina that gets worse by the end of the day or is related to a bowel movement
  • See or feel a “bulge” or “something coming out” of the vagina
  • Have difficulty starting to urinate or emptying the bladder completely
  • Leak urine when coughing, laughing, or exercising
  • Feel an urgent or frequent need to urinate
  • Feel pain while urinating
  • Leak stool or have difficulty controlling gas
  • Have constipation
  • Have difficulty making it to the bathroom in time

Some women with pelvic floor problems do not have symptoms at first.1 Many women are reluctant to tell their healthcare provider about symptoms because they may feel embarrassed.1 In addition, many women think that problems with bladder control are normal and live with their symptoms.3 However, bladder control problems are treatable, and these treatments can help women with pelvic floor problems.

Citations

  1. Pelvic Floor Disorders Network. (n.d.). What are pelvic floor disorders? Retrieved September 3, 2019, from https://pfdnetwork.azurewebsites.net/About/PelvicFloorDisorders.aspx external link
  2. American Urogynecologic Society. (2017). Pelvic organ prolapse: Symptoms & types. Retrieved September 3, 2019, from https://www.voicesforpfd.org/pelvic-organ-prolapse/symptoms-types external link
  3. American Urogynecologic Society. (2017). Bladder control. Retrieved September 3, 2019, from https://www.voicesforpfd.org/bladder-control external link

What causes pelvic floor disorders (PFDs)?

The complete picture about what contributes to the development of pelvic floor problems is not clear and is quite complex, but the following conditions are being studied as risk factors for the development of PFDs:

  • Childbirth. Pregnancy, childbirth, and their link to pelvic floor problems have been an active area of research, but the connection is not clear. A recent NICHD-funded study showed that, among first-time mothers, mode of delivery (such as vaginal versus surgical) was linked to risk for PFDs. In some studies, the risk increases with the number of children a woman has delivered.1 The risk may be greater if forceps or a vacuum device is used during delivery.2 However, because pelvic problems also affect women who have never been pregnant, and because delivering via cesarean section only reduces but does not eliminate the risk of pelvic floor problems, the relationship among pregnancy, childbirth, and PFDs remains unclear.2
  • Factors that put pressure on the pelvic floor. These factors include overweight or obesity, chronic constipation or chronic straining to have a bowel movement, heavy lifting, and chronic coughing from smoking or health problems.1,3,4
  • Getting older. The pelvic floor muscles can weaken as women age and during menopause.4
  • Having weaker tissues. Genes influence the strength of a woman’s bones, muscles, and connective tissues. Some women are born with conditions that affect the strength of connective tissues, and they are more likely to have pelvic organ prolapse.2
  • Surgery. Previous hysterectomy and prior surgery to correct prolapse are associated with higher risks of PFDs.1

Race. Certain groups of women, such as white or Latina women, appear to be at higher risks for some forms of PFDs.2

Citations

  1. Wu, J. M., Vaughan, C. P., Goode, P. S., Redden, D. T., Burgio, K. L., Richter, H. E., & Markland, A. D. (2014). Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstetrics and Gynecology, 123(1), 141–148. Retrieved November 13, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970401/
  2. Hallock, J. L., & Handa, V. L. (2016). The epidemiology of pelvic floor disorders and childbirth: An update. Obstetrics and Gynecology Clinics of North America, 43(1), 1–13. Retrieved November 13, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4757815/
  3. Irwin, G. M. (2019). Urinary incontinence. Primary Care: Clinics in Office Practice, 46(2), 233–242. Retrieved September 3, 2019, from https://doi.org/10.1016/j.pop.2019.02.004 external link
  4. American Urogynecologic Society. (2017). Pelvic organ prolapse. Retrieved September 4, 2019, from https://www.voicesforpfd.org/about/what-are-pfds/ external link

How are pelvic floor disorders (PFDs) diagnosed?

A healthcare provider may be able to diagnose a PFD with a physical exam. In some cases, a woman’s healthcare provider will see or feel a bulge during a routine pelvic exam that suggests a prolapse. In other cases, a woman may see her doctor about symptoms she is experiencing, such as problems with bladder or bowel control. In addition to a physical exam, a doctor also will ask about medical history, including whether a woman has been pregnant, has had surgery, and takes any medicines.1

Depending on the findings from the exam or the severity of the symptoms, a healthcare provider may do tests. Some tests used to help with the diagnosis or with treatment planning include:

Bladder control problems

  • Cystoscopy. This test examines the insides of the bladder to look for problems, such as bladder stones, tumors, or inflammation.1
  • Urinalysis. This urine test can detect if you have a bladder infection, kidney problems, or diabetes.2
  • Urodynamics. This test is used to evaluate how the bladder and urethra are working.2 It can help determine the plan for surgery to treat certain forms of bladder control problems.1

Bowel control problems3,4

  • Anal manometry. This test evaluates the strength of the anal sphincter muscles.
  • Colonoscopy or sigmoidoscopy. This procedure examines the inside of the colon or the sigmoid (the part of the bowel near the rectum) to look for signs of disease or inflammation that may be causing symptoms.
  • Dynamic defecography. This test is used to evaluate the pelvic floor and rectum while the patient is having a bowel movement.

Citations

  1. American Urogynecologic Society. (2017). Bladder control: Diagnosis. Retrieved September 4, 2019, from https://www.voicesforpfd.org/bladder-control/diagnosis/ external link
  2. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2018). Diagnosis of bladder control problems (urinary incontinence). Retrieved September 4, 2019, from https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems/diagnosis
  3. NIDDK. (2017). Diagnosis of fecal incontinence. Retrieved September 4, 2019, from https://www.niddk.nih.gov/health-information/digestive-diseases/bowel-control-problems-fecal-incontinence/diagnosis
  4. American Urogynecologic Society. (2017). Bowel control: Diagnosis. Retrieved September 4, 2019, from https://www.voicesforpfd.org/bowel-control/diagnosis/ external link

How are pelvic floor disorders (PFDs) treated?

Treatment can often help when symptoms are bothersome or restrict a woman’s activities.1,2 Some types of treatments include the following. You can also download or link to our Pelvic Floor Disorders and Common Treatments infographic.

Talk to your healthcare provider about ways to reduce or ease symptoms. Your healthcare provider may recommend actions, such as the following3:

  • Limit foods and drinks that stimulate the bladder. Some foods and drinks, such as caffeinated beverages, carbonated beverages, citrus fruits and drinks, artificial sweeteners, and alcoholic beverages, can stimulate the bladder and make you need to use the bathroom.
  • For certain bowel problems, eat a high-fiber diet. Fiber helps your body to digest food. It helps make stool the right consistency, which can also prevent constipation and the chronic straining associated with having a bowel movement when constipated. Fiber is found in fruits, vegetables, legumes (such as beans and lentils), and whole grains. Fiber supplements are also available.
  • Lose weight. For women who are overweight or obese, losing weight may reduce bladder control and pelvic organ prolapse symptoms by relieving pressure on pelvic organs.

Nonsurgical treatments commonly used for PFDs include2,4:

  • Bladder training. This involves using the bathroom on a set schedule to regain bladder control and applying techniques to overcome inappropriate urges to urinate. A woman starts by using the bathroom at a specific interval and slowly, over many months, increases that time, with a goal of using the bathroom only every 2.5 to 3 hours.3
  • Pelvic floor muscle training (PFMT). Often referred to as Kegel exercises, PFMT involves squeezing and relaxing the pelvic floor muscles. If performed correctly and routinely, PFMT may improve the symptoms of urinary incontinence and prolapse.3 However, PFMT cannot correct prolapse. Women can do the exercises on their own or with the help of a pelvic floor physical therapist.3 Biofeedback during pelvic floor physical therapy is sometimes used to help teach women which muscle group to squeeze.
  • Medicine. Medicine is sometimes prescribed to treat certain bladder control problems or to prevent loose stools or frequent bowel movements.5
  • Vaginal pessary. This plastic device is used to treat prolapse. It can sometimes be used to improve bladder control. A woman or her healthcare provider inserts the pessary into the vagina to help support the pelvic organs. A woman’s doctor will fit her for a pessary that is a comfortable shape and size and instruct her on how to use and care for it.6

In some cases, surgery is the best treatment option, especially when other treatments are not helpful.1,7 Some surgical treatments can be performed as outpatient procedures, which means the patient can usually go home the same day as the procedure.

  • For prolapse. Surgery involves repairing the prolapse and attempting to restore a well-supported anatomy. There are many ways to do this, depending on the type of prolapse and other factors. Women with uterine prolapse may also have the uterus removed (hysterectomy). Women who have surgery to repair prolapse may need surgery at the same time to correct or prevent bladder control problems. Some women choose to have a surgery called colpocleisis. This surgery treats prolapse by narrowing and shortening the vagina. It works well and carries a low risk, but it is not a good choice for women who want to be able to have vaginal intercourse.7
  • For bladder control problems. Surgery works well to treat problems with urinary leakage that occur as a result of an activity such as sneezing, coughing, laughing, or exercising (stress incontinence). Stress incontinence occurs when the exertion squeezes the bladder and urine leaks out because the support around the urethra has weakened.6 The type of surgery used most often is a mid-urethral sling. The surgeon places material under the urethra to support it and prevent urine leakage during activity.6 In another procedure, “bulking agents” can be injected near the bladder neck and urethra to make the tissues thicker and close the bladder opening. Repeat injections may be needed over time.8
  • For bowel control problems. Surgery may be needed to repair a damaged anal sphincter muscle, inject medications into the sphincter, or implant a stimulator for the nerves that control the bowel function.9

Not all women are good candidates for surgery. In general, women who want to have children should not have these types of surgery.1 Also, prolapse can recur even after surgery is performed to correct it.1 Researchers are working to develop low-risk procedures and devices that work well to treat pelvic floor problems. Researchers are also comparing treatment methods to see what works best. For example, the Study of Uterine Prolapse Procedures - Randomized Trial (SUPeR) found comparable effectiveness in two types of surgery to treat vaginal prolapse. The Extended Operations and Pelvic Muscle Training in the Management of Apical Support Loss (E-OPTIMAL) study found that two other surgical treatments had comparable effectiveness. The Effects of Surgical Treatment Enhanced with Exercise for Mixed Urinary Incontinence (ESTEEM) study found that surgery may benefit women who have both stress and urge incontinence.

“Combination” can mean a woman is getting treated for more than one type of PFD, such as a treatment for both uterine prolapse and urinary incontinence. It can also mean using different treatments together to address PFDs, such as using PFMT and surgery to treat symptoms.

Researchers are studying combination treatments to find out how to get the best outcomes for women with PFDs. For instance, the Outcomes Following Vaginal Prolapse Repair and Mid-Urethral Sling (OPUS) study evaluated whether adding a procedure to treat stress incontinence at the time of surgery for pelvic organ prolapse in women who don’t have symptoms of stress incontinence can help to prevent stress incontinence from happening after surgery and without increasing risk. The Controlling Anal Incontinence by Performing Anal Exercises with Biofeedback or Loperamide (CAPABLe) study compared different combinations of treatments for anal incontinence.

Citations

  1. American College of Obstetricians and Gynecologists. (2017). Pelvic support problems. Retrieved September 4, 2019, from https://www.acog.org/Patients/FAQs/Pelvic-Support-Problems external link
  2. Balk, E., Adam, G. P., Kimmel, H., Rofeberg, V., Saeed, I., Jeppson, P., & Trikalinos, T. (2018). Nonsurgical treatments for urinary incontinence in women: A systematic review update. Comparative Effectiveness Review No. 212. AHRQ Publication No. 18-EHC016-EF. PCORI Publication No. 2018-SR-03. Rockville, MD: Agency for Healthcare Research and Quality. https://doi.org/10.23970/AHRQEPCCER212 external link.
  3. American Urogynecologic Society. (2017). Treatments: Lifestyle & behavioral changes. Retrieved September 4, 2019, from https://www.voicesforpfd.org/about/lifestyle-behavorial-changes/ external link
  4. American Urogynecologic Society. (2017). Bladder control: Treatments. Retrieved November 11, 2019, from https://www.voicesforpfd.org/bladder-control/treatments/ external link
  5. American Urogynecologic Society. (2017). Accidental bowel leakage medicines. Retrieved September 10, 2019, from https://www.voicesforpfd.org/bowel-control/medicines/ external link
  6. American Urogynecologic Society. (2017). Bladder control: Surgery. Retrieved September 4, 2019, from https://www.voicesforpfd.org/bladder-control/surgery/ external link
  7. American Urogynecologic Society. (2017). Pelvic organ prolapse: Surgery. Retrieved September 4, 2019, from https://www.voicesforpfd.org/pelvic-organ-prolapse/surgery/ external link
  8. National Institute of Diabetes and Digestive and Kidney Diseases. (2018). Treatments for bladder control problems (urinary incontinence). Retrieved September 10, 2019, from https://www.niddk.nih.gov/health-information/urologic-diseases/bladder-control-problems/treatment
  9. American Urogynecologic Society. (2017). Bowel control: Surgery. Retrieved September 4, 2019, from https://www.voicesforpfd.org/bowel-control/surgery/ external link
Pelvic Floor Disorders (PFDs) | NICHD - Eunice Kennedy Shriver National Institute of Child Health and Human Development
NICHD Information Resource Center
Phone: 1-800-370-2943
Email: NICHDInformationResourceCenter@mail.nih.gov
Fax: 1-866-760-5947
Mail: P.O. Box 3006, Rockville, MD 20847
For the Federal Relay Service, dial 7-1-1
top of pageBACK TO TOP