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Scand J Urol Nephrol ; Epidemiology of genital prolapse:observations from the Oxford Family Planning Association study. Br J Obstet Gynaecol ; Risk factors in childbirth causing damage to the pelvic floor innervation.

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Int J Colorectal Dis ; The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolpase and stress incontinence. A neurophysiological study. Joint hypermobility in women with genital prolapse. Lancet ; Rectal prolapse: Relationship with joint mobility. Aust N Z J Surg ; Collagen synthesis in women with genital prolapse or stress urinary incontinence. Neurourol Urodyn ; Changes in metabolism of collagen in genitourinary prolapse.

What predisposes young women to genital prolapse? Estrogen, progesterone and androgen receptor expression in levator ani muscle and fascia. Estrogen receptor a and b expression in the vaginal walls and uterosacral ligaments of premenopausal and postmenopausal women. Fertil Steril ; Estrogen levels and estrogen receptors in patients with stress urinary incontinence and pelvic organ prolapse.

Using native tissue for vaginal anatomy repair

Int J Gynaecol Obstet ; Increases in pudendal nerve terminal motor latency with defecation straining. Br J Surg ; Bowel dysfunction: A pathogenic factor in uterovaginal prolapse and urinary stress incontinence. Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses. Occup Med ; The incidence of genital prolapse after the Burch colposuspension. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse.

True incidence of vaginal vault prolapse: Thirteen years experience. J Reprod Med ; Uroflowmetry in women with urinary incontinence and pelvic organ prolapse. Br J Urol ; During weight lifting, pelvic floor muscle contracts together with diaphragm and abdominal wall.

Practice Bulletin No. Pelvic Organ Prolapse : Obstetrics & Gynecology

Without anal mucosa migration, hemorrhoidal bed is compressed in anal canal, straining would not allow engorgement of hemorrhoidal vein except in those with preexisting third to fourth degree of hemorrhoid or weight lifting in extreme squatting position. Women suffer from pelvic floor related disorders much higher than men.

The main reason is because of vaginal delivery. Even without delivery, women have a bigger hiatus with vaginal passage on their pelvic floor. Severe constipation and urinary incontinence are more common in elderly women, with rates of constipation two to three times higher than that of their male counterparts [ 12 — 15 ]. With muscle dystrophy due to aging and accumulative effect from chronic constipation, the pelvic floor support weaken and this may lead to increase in incidence of pelvic floor related disorders. A population-based study reported that the cumulative incidence of chronic constipation CC is higher in the elderly compared to a younger population [ 12 ].

The proportion of women with one or more pelvic floor disorder dramatically increased from 6. Pregnancy alone without birth trauma is an independent factor contributing to weaken pelvic floor [ 17 ]. Physiological weakened pelvic floor with permanent damage manifests practically the same symptoms as found in PFD, such as constipation, UI, haemorrhoid, anal fissure, and perineal pain.

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Pelvic floor is traumatized due to overstretching by newborn with or without episiotomy wound. Objective evaluations of pelvic floor muscle strength revealed a significant decrease after vaginal delivery compared to nulliparous patients [ 19 ]. Risk of urinary incontinence significantly increases among those experiencing vaginal delivery [ 18 ]. First delivery is the most significant and its prevalence increases with parity [ 20 ].

It is undeniable fact that birth trauma is an important factor for pelvic floor damage. But if it is compared to bigger trauma to other part of body e. Overweight and obesity were the most common disorders affecting urogynecological patients Waist circumference was associated with stress UI, suggesting that overweight and obesity results in higher risk of that pathology. Increased body weight is also a predictor of severity of future symptoms. Pelvic floor muscle relaxes and descends during defecation; with straining, it descents further.

Perineal descent was first described by Parks in [ 23 ]. Chronic repetitive straining for constipation would accumulatively lead to descending perineum syndrome and pelvic organs prolapse [ 23 ]. Further descent would result in stretching of pudendal nerve and lead to incontinence. CT defecography showed pelvic floor not only descends but also the levator hiatus opens during defecation [ 24 ]. Great majority of constipation is obstructive in nature secondary to weakness in pelvic floor support, especially the posterior aspect and patients with pelvic floor disorders usually present with constipation [ 3 , 9 , 25 ].

Collectively, these evidences clearly show straining during defecation or constipation and damage of pelvic floor support forming a vicious cycle and leading to various pelvic floor and constipation related disorders Figure 6. Cough causes impulsive, sudden increase in intra-abdominal pressure and challenges the continence function of pelvic floor muscle and results in stress urinary incontinence. Chronic cough accumulatively weakens pelvic floor support and leads to more PFD not limited to UI [ 26 , 27 ].

Refer Section 2. PFD—anterior, middle, and posterior. Constipation and constipation related anorectal disorders e. Academically, they are considered different from one another, but actually they are just different descriptions of the partially or fully the same problem from various different prospective.

Theoretically, pelvic floor is also divided into three compartments: Anterior compartment bladder and urethra. Since pelvic floor support is essentially for normal functioning of all the three compartments, weakness of the pelvic floor would lead to malfunction and manifest with symptoms from urinary system, reproductive, and also anorectal system [ 28 ]. Descending perineum syndrome also known as levator plate sagging refers to a condition where the perineum "balloons" several centimeters below the bony outlet of pelvis during strain, although this descent may happen without straining.

Study shows descend of pelvic floor by merely 1. Urinary incontinence UI is undoubtedly the most popular presentation of PFD but constipation is actually the earliest and the commonest manifestation of PFD. Constipation is the manifestation of posterior compartment in pelvic floor disorders. Even though posterior pelvic floor is complete compared to anterior part with levator hiatus, posterior pelvic floor does not have secondary support like urogenital diaphragm which provides additional support to pelvic floor muscle.

During defecation, feces guided by sacrococcyx bone beyond which it pushed down pelvic floor and bend terminal passage of defecation contribute to obstructive defecation. This explains why constipation is commonest manifestation of PFD [ 3 ]. Anal fissure may be the associated problem.


Anal mucosa tears occur when the anal mucosa is overstretched by hard stool or even forceful diarrhea [ 30 ]. A strong pelvic floor is associated with higher rates of sexual activity as well as higher sexual function scores [ 31 ]. In sexually active women, poorer sexual functioning was associated with more symptom distress and with pelvic floor surgery [ 32 ]. Urinary incontinence UI is involuntary leakage of urine. It is the manifestation of anterior compartment in PFD. Worldwide over million people have an incontinence problem, which is encountered often in healthy persons, especially in women.

Practically, they may not be clearly differentiated. Stress UI constitutes most of the UI. Stress urinary incontinence refers to situation of leakage when there is extra pressure on bladder on coughing or sneezing. It occurs due to weakness of pelvic floor support at the bladder neck area. Urge UI or overactive bladder, as the name indicates, is due to overactivity of the urinary bladder. Practically, it can be quite difficult to put blame on the weak sphincteric action as in stress UI or overactive bladder or in urge UI. One thing that is clear is with healthier strong pelvic floor muscle it helps to reduce the incidence of mixed UI [ 36 ].

With weakened pelvic floor support, residual urine occurs. Constipation is also another problem associated with PFD. Constipation increases chances of Escherichia coli contamination of the urinary system and logically contributes to increase incidence of UTI in those with PFD [ 37 ]. It is referred to as a feeling of pain and pressure in the bladder area or pelvic area. Along with this pain are lower urinary tract symptoms which have lasted for more than 6 weeks, without having an infection or other clear causes [ 38 ].

The exact cause is still considered unclear in medical world but obviously pudendal nerve would be stretched as PFD or perineum descend leading to pain and incontinence depending on the severity [ 23 ]. In PFD, the pelvic floor not only descends, the sphincteric grip of puborectalis thicken muscle which forms the brim of levator hiatus also relaxes and results in descend from their original position and prolapse of the pelvic organs through the common levator hiatus and to exterior usually to vagina orifice.

Symptoms may include: a sensation of a bulge or something coming down or out of the vagina, which sometimes needs to be pushed back,. Fecal incontinence could happen due to traumatized anal sphincter as in third degree perineal tear or due to damage of its nerve supply as in descending perineal syndrome. With weakened pelvic floor, descended anococcygeal part of pelvic floor constitutes to constipation in PFD.

The constipation may in turn contribute to fecal overflow incontinence, which is a very common type of fecal incontinence.

Assessment of Urinary Incontinence (UI) in Adult Patients

When pelvic floor descends further, it may cause stretching and damage nervous supply of the anal sphincter and lead to anal incontinence [ 23 ]. Pelvic floor strength can be measured subjectively and objectively using different approaches. It is a subjective measurement [ 41 ]. Laycock developed the Modified Oxford Grading System to evaluate the strength of the pelvic floor muscles by using vaginal palpation [ 42 ]. This measurement scale is widely used by physiotherapists since it can be used with vaginal palpation in the clinical evaluation.