Pelvic floor dysfunction (PFD) is a term used to describe a variety of disorders involving moderate to severe impairment of the pelvic floor muscles. The pelvic floor is a sheet of muscles designed to support the abdominal viscera as well as maintain urethral, anal, and vaginal continence. Collectively referred to as the levator ani, it includes the pubococcygeus, puborectalis, and iliococcygeus (1). PFD can be divided into two broad categories: relaxing and nonrelaxing. The symptoms associated with relaxing PFD are more recognizable and include urinary incontinence and prolapse of pelvic structures. The less common of the two types is hypertonic, or nonrelaxing, dysfunction of the pelvic floor (2). In this disorder, muscles of the pelvic floor remain in a contracted state causing increased pressure and pain. The pain is persistent and typically worsens throughout the day and with daily activities, such as walking, physical activity, and passing stool (3).
There are limited data and research on nonrelaxing PFD, and the mechanism through which it develops is not clearly understood. Continuous voluntary holding of urine or stool is a possible mechanism through which involuntary muscle contractions of the pelvic floor may occur. The trunk of the body operates in a kinetic chain. Because of the interactions between the hips, pelvis, and spine, dysfunction in any part of this interconnected chain may account for overcompensation by the pelvic floor muscles and the development of hypertonicity (2). Ultimately, the collaboration of several different events and symptoms can contribute to the development of nonrelaxing PFD.
Beginning after the fall soccer season of her freshman year, an 18-year-old female collegiate soccer player presented with symptoms of loss of appetite and crampy pelvic discomfort. The symptoms were initially attributed to her menses. A few weeks later, she began to have diarrhea after every meal. Over the next months, she also developed numbness and tingling in her left leg, which progressed to complete loss of sensation. Other symptoms included sharp, stabbing pains in her vaginal area 10 to 15 times per day and pain in her lower back that was deep and aching. This progressed to a tingling sensation and became constant, spreading into her buttocks. She became satiated and nauseous when she ate even small amounts of food. This lead to a 15-lb weight loss.
Due to the severity of her symptoms, she left college for the second semester and returned home to pursue a diagnosis and treatment. She developed dysfunctional uterine bleeding, with bleeding for a few days, multiple times per month, and was seen by a gynecologist. Complete blood count, complete metabolic panel, thyroid stimulating hormone, and prolactin were normal. She had a normal pelvic ultrasound and magnetic resonance imaging (MRI). The physician performed a diagnostic laparoscopy with normal findings. She was then started on oral contraceptive pills with normalization of her period. She was evaluated by neurosurgery. Neurologic physical examination showed decreased sensation of her lateral left foot and weakness in her left lower extremity. MRI of her brain and lumbar spine were both normal. She also had a normal EMG and nerve conduction study. After evaluation by an infectious disease specialist, extensive laboratory work-up revealed normal complement, iron studies, lactate dehydgrogenase, hepatitis panel, viral panel, including West Nile virus, cytomegalovirus, and Epstein-Barr virus, autoimmune studies, celiac panel, anti-streptolysin-O, and heavy metals levels. Tests also were negative for syphilis, lyme, toxocara, and strongyloides. She was started on gabapentin.
Throughout this time, she also developed urinary symptoms, including frequency, urgency, and incontinence and was evaluated by urology. Her examination showed no prolapse, but she did have tenderness over the levator ani muscle on palpation. She was diagnosed with levator spasm and referred for pelvic floor physical therapy.
She was treated by a pelvic rehabilitation specialist with therapy focused on pelvic floor tissue mobility, core, hip, and lower-extremity strength and balance, and reconditioning. Medical treatment included baclofen by mouth and per rectum as needed to help relieve the muscle spasm. Her weakness and numbness improved, and her bowel and bladder functions began to normalize. She was able to return to school for the fall semester 5 months later. Her rehabilitation program focused on continued core and hip strength and improving cardiovascular endurance. She was eventually able to return to her collegiate soccer team 2 years after her symptoms began.
Symptoms Associated with Nonrelaxing PFD
Patients with hypertonic pelvic floor disorders can present with a range of symptoms. This can often lead to a delayed or missed diagnosis. Symptoms include the inability to evacuate urine or stool, sexual dysfunction, and pain (2). Pain symptoms can be categorized as visceral pain, myofascial pain, or a combination of the two. Often times, women present with pelvic pain which cannot be attributed to the findings on a physical examination, imaging, or other testing (4). These symptoms also are present in pelvic organ prolapse. However, pelvic organ prolapse can be properly diagnosed, and therefore differentiated, by physical examination (5). Symptoms of pain are often described as a pressure and typically difficult to localize. Pain worsens as physical activity level increases from light walking to more vigorous exercise. Symptoms usually develop slowly, sometimes starting as early as adolescence.
Symptoms specific to the bladder include urethral pain, paruresis, and a constant urgency to void the bladder. Paruresis is the inability to urinate when a person perceives judgment from others around (6). Symptoms of the lower colorectal area include painful or obstructed bowel movements and constipation. Vaginal symptoms consist of pain after intercourse, vulvodynia, and vaginismus (5).
Differential Diagnosis and Work-up
For any patient with possible PFD, the differential diagnoses to consider and the appropriate work-up varies based on the presenting symptoms. For urinary symptoms, other diagnoses that should be considered include cystitis or urethritis. Endometriosis should be considered for gynecologic symptoms. Proctitis, anal fissures, or hemorrhoids should be investigated for complaints of anorectal symptoms. Neuromuscular symptoms could be a sign of pudendal neuropathy or sacral spinal cord pathologies. These conditions should be ruled out as appropriate based on symptoms. Additional studies to consider in this work-up include cystoscopy, endoscopy, hysteroscopy, abdominal or pelvic ultrasound, or laparoscopy (7,8).
A thorough physical examination is appropriate to diagnose many patients with pelvic floor disorders. Observation of the muscles during contraction and relaxation may identify deficits in either. A lubricated cotton swab can be used to test for vulvodynia and specify locations producing pain. Palpation of the pelvic floor muscles, including the levator ani, should then be done assessing for tenderness and muscle tone. Sometimes trigger points can be found in the muscles as small tender nodules (2,5). Further studies also can be useful to aid in the diagnosis. EMG can be used to better characterize muscle action. Patients with vestibulitis have been characterized by five criteria on EMG study. These criteria included muscle instability, poor muscle recovery between contractions, elevated resting tone, reduced frequency of contraction, and reduced strength of contractions. White et al. (9) found that 88% of patients diagnosed with vestibulitis had at least three of these criteria. Fowler and Kirby (10) also demonstrated abnormal EMG findings in the urethral sphincter of patients with difficulty voiding. Endoanal MRI has shown good result in characterizing defecatory disorders (8).
Comprehensive treatment of pelvic pain should include a multidisciplinary approach. Especially important is early intervention including both medical and therapeutic management. General medical treatment for chronic pelvic pain includes analgesic medication. Nerve block injection, transcutaneous electrical nerve stimulation, and sacral neuromodulation also have been successful (6). Physical therapy has been an important treatment for women’s health issues for almost 50 years and has proven effective in treating pelvic pain and its sequelae (11). Physical therapists are trained in soft tissue mobilization of myofascial trigger points, which can address pelvic pain symptoms, as well as bladder and bowel dysfunction (12,13). They also can address movement reeducation. Physical therapists can instruct patients with pelvic pain on exercises for lumbopelvic stabilization and core strengthening to address any deficits in the kinetic chain (2). Alongside manual and movement interventions, patient education about anatomy and function is a critical element of treatment for pelvic pain.
There are some data on specific therapy techniques in PFD patients. Physical therapists can teach the patient how to mindfully relax pelvic floor muscles. The patient focuses their mental attention to the pelvic floor muscles and then voluntarily tries to relax them. This action is referred to as reverse kegels. Reverse kegels provide biofeedback to reprogram the muscles to relax properly (14). Myofascial pain is typically treated using manual manipulation, or Thiele massage. Montenegro et al. (15) found that the mean tenderness score for women with chronic pelvic pain was improved after 1 month of repeated Thiele massages. This suggests that Thiele massage is indeed beneficial to patients with hypertonic pelvic muscles.
Muscle memory often causes muscles to return to their original nonrelaxed state after physical therapy. For this reason, medical therapy may be useful to maintain the relaxed state. In a retrospective chart review of 26 women who had received diazepam suppositories, in addition to physical therapy, pelvic floor pain was assessed. Pain was rated subjectively by the Female Sexual Function Index and the Visual Analog Scale for Pain. Twenty-five of 26 patients subjectively reported a reduction in pain (16). Botulinum toxin (Botox) injections also have been studied as a treatment option for nonrelaxing PFD. In a retrospective case series of 160 women with myofascial pelvic pain, it was found that Botox in combination with myofascial release therapy, significantly reduced myofascial pelvic pain (17). Patients included in this study were older than 18 years and had previously received treatment for myofascial pelvic pain. The results of this study are based on pretreatment and posttreatment pain scores. More than 50% of patients reported an improvement in pelvic pain (17).
Patient education also is an important component of treatment. Pain neuroscience education (PNE) is a formalized treatment method that focuses on educating patients with chronic pain on the biological and physiological contributors to the experience of pain rather than focusing on a specific anatomical structure. The goal is to manage pain with the understanding that it may not be possible to completely eliminate the pain experienced by the patient. A systematic analysis of PNE used in the treatment of chronic musculoskeletal pain showed reduced pain, improved function, and decreased disability and health care utilization in patients (18).
Athletes and PFD
Symptoms of PFD are common among all women. A study of almost 2,000 women in the United States revealed that around one in four had at least one symptom or physical finding including urinary incontinence, fecal incontinence, or organ prolapse. The symptoms increased with age with around 10% of those ages 20 to 39 years old and almost 50% of those 80 years or older reporting at least one symptom. Increased parity and being overweight or obese also increased the prevalence (19). Because urinary incontinence is associated with weakness in pelvic floor muscles, exercise would be thought to decrease the risk by increasing muscle strength. Indeed, in a prospective study of women ages 37 to 54 years, the risk of urinary incontinence decreased with increasing moderate physical activity (20). However, urinary incontinence has been found frequently in female athletes. In various athletic populations, the prevalence ranges from 15% to 73% (21). Looking specifically at collegiate athletes, Nygaard et al. (21) found the prevalence to be 28%. In a study by Fernandes et al. (22), the prevalence in a cohort of soccer players was found to be three times higher than the prevalence in the control group of nonathletes. There is evidence that the prevalence is higher in high-impact sports. Nygaard et al. found the rate in gymnasts to be 67%, and the prevalence in trampolinists has been found to be as high as 80% (21,23). However, Poświata et al. (24) found 45.5% of endurance athletes including cross-country skiers and runners reported symptoms of urinary incontinence. Similarly, Araújo et al. (25) found 62.2% of long-distance runners reported urinary incontinence. These high rates in athletes are thought to result from an imbalance of contraction strength of the pelvic floor with increased intra-abdominal pressure during exercise. On MRI, nulliparous female athletes involved in high impact training were found to have increased cross-sectional area of the levator ani muscle and width of the puborectalis muscle. This is thought to result from hypertrophy in response to stress due to increased intra-abdominal pressure (1). However, on dynamic imaging, a similar group of athletes showed increased bladder neck descent on Valsalva maneuver compared with controls, suggesting that the increased mass does not result in improved function (26). Similarly, incontinent athletes had thicker pubovisceral muscles on MRI imaging, but this resulted in no difference in strength of contraction or displacement of the pelvic floor muscles during voluntary contraction measured by dynamic imaging (27). This difference may be exacerbated as the pelvic floor muscles become fatigued. It has been shown that strenuous exercise can decrease the maximum contraction pressure of the pelvic floor muscles (28). Similarly, after exercise, maximal vaginal descent increased and vaginal resting pressure decreased in groups of women doing strenuous exercise and those walking. The maximal and mean pelvic floor muscle strength did not change (29). Consistent with this theory, many authors have found a dose dependent relationship between activity and symptoms. Da Roza et al. (27) found that women who exercised the most demonstrated the highest prevalence of symptoms. Another study showed that volleyball and basketball players ages 18 to 30 years had significantly lower perineal pressures than nonathletes. There was a significant correlation between the number of games played per year, strength training, and on-court workouts and decreased pressures (30). Most of these studies use the Valsalva maneuver to simulate increased intra-abdominal pressure and pelvic floor response during exercise. However, recently, Dias et al. (31) used a model based on high-resolution MRI to show that the changes seen in the pelvic floor during jumping and landing were quite different than that seen during Valsalva, suggesting that this may not be an adequate comparison.
The majority of research and knowledge about the relationship between PFD and sports and exercise has been focused on urinary incontinence. Far less is known about the prevalence of nonrelaxing pelvic floor symptoms in athletes. Similarly, just as with incontinence, we know little about the effects of exercise in either protection or risk of developing these symptoms. As evidenced by this case, these symptoms can progress to be quite severe and drastically affect the life of an athlete. Increasing awareness of nonrelaxing PFD can lead to faster diagnosis and treatment. Further research may be able to help identify risk factors that may be modified to prevent this disorder.
The authors declare no conflict of interest and do not have any financial disclosures.
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