Pelvic health encompasses the function of the pelvic floor muscles, support of pelvic organs, urinary and bowel continence, and absence of pelvic pain. Pelvic floor disorders affect up to 25% of women.

Pelvic exam illustration — Pelvic health encompasses pelvic floor function, urinary and bowel continence, pelvic organ support, and absence of pelvic pain. Source: Unsplash.

Pelvic Floor Anatomy

The pelvic floor is a hammock of muscles (levator ani — pubococcygeus, iliococcygeus, puborectalis; and the coccygeus muscles) and connective tissue (endopelvic fascia, ligaments) that support the pelvic organs (bladder, uterus, rectum). The pelvic floor has three layers: the endopelvic fascia (level I — apical support: uterosacral and cardinal ligaments), the levator ani muscles (level II — lateral support), and the perineal membrane and body (level III — distal support). The pelvic floor functions: structural support of pelvic organs, continence (closure of urethra, vagina, and anus), sexual function, and coordination with intra-abdominal pressure (the pelvic floor contracts in response to increased pressure to prevent descent of organs).

Pelvic Organ Prolapse

Pelvic organ prolapse (POP) is the descent of one or more pelvic organs into the vagina. The lifetime risk of surgery for POP is 5-10%. Risk factors include vaginal childbirth (especially multiple deliveries, large babies, prolonged second stage), aging and menopause, obesity, chronic constipation or straining, heavy lifting, and connective tissue disorders. Stages: Stage 0 (no prolapse), Stage I (descent to above the hymen), Stage II (descent to the hymen), Stage III (descent beyond the hymen), Stage IV (complete eversion of the vagina). Cystocele — prolapse of the anterior vaginal wall with bladder descent. Symptoms: vaginal bulge, pressure, incomplete bladder emptying, urinary incontinence, difficulty voiding, and recurrent UTIs. Rectocele — prolapse of the posterior vaginal wall with rectum bulging forward. Symptoms: vaginal bulge, pressure, splinting (need to manually support the posterior wall or put fingers in the vagina to complete bowel movements), constipation, and fecal incontinence. Uterine prolapse — descent of the uterus and cervix into the vagina. Symptoms: vaginal bulge, pressure, low back pain, and “something falling out” sensation. Vaginal vault prolapse — apical descent after hysterectomy. Management of POP includes observation (if asymptomatic), pelvic floor muscle training (PFMT — Kegel exercises), vaginal pessary (ring, cube, or Gellhorn pessary fitted by a provider), and surgical repair (native tissue repair or mesh-augmented repair — transvaginal mesh is controversial with FDA safety warnings; sacral colpopexy using mesh via an abdominal or robotic approach is the gold standard for apical prolapse).

Prenatal checkup — Pelvic organ prolapse involves descent of pelvic organs into the vagina and is managed with conservative or surgical treatment. Source: Unsplash.

Urinary Incontinence

Urinary incontinence (UI) affects 15-50% of women, increasing with age. The economic burden exceeds $20 billion annually in the United States.

Stress urinary incontinence (SUI) — leakage with increased intra-abdominal pressure (coughing, sneezing, laughing, exercise). Mechanism: urethral hypermobility or intrinsic sphincter deficiency. Treatment: pelvic floor muscle training (first-line — 50-70% improvement), weight loss, lifestyle modifications (reduce caffeine, treat constipation), vaginal pessaries, and surgical options (mid-urethral sling — retropubic or transobturator — 80-90% success rate; urethral bulking agents for ISD).

Urge urinary incontinence (UUI) — leakage preceded by a sudden, strong urge to void. Mechanism: detrusor overactivity (involuntary bladder contractions). Treatment: bladder training (scheduled voiding every 2-4 hours, urge suppression techniques), behavioral modifications (avoid bladder irritants — caffeine, alcohol, acidic foods), anticholinergics (oxybutynin, tolterodine, solifenacin, darifenacin, trospium), beta-3 agonists (mirabegron, vibegron), and third-line treatments (sacral neuromodulation — InterStim, percutaneous tibial nerve stimulation — PTNS, intravesical botulinum toxin — Botox).

Mixed urinary incontinence — combination of SUI and UUI. Treat the dominant component first.

Chronic Pelvic Pain

Chronic pelvic pain (CPP) is non-cyclic pelvic pain lasting over 6 months, affecting 10-15% of women. Etiology is often multifactorial.

Endometriosis is the presence of endometrial-like tissue outside the uterine cavity, affecting 6-10% of women. Common sites: ovaries (endometriomas — “chocolate cysts”), fallopian tubes, uterosacral ligaments, pouch of Douglas, and peritoneal surfaces. Symptoms: dysmenorrhea (severe, progressive), chronic pelvic pain, dyspareunia (deep pain), dyschezia (pain with bowel movements), and infertility (30-50% of affected women). Diagnosis is suggested by history, physical exam (tenderness, nodularity), and ultrasound; definitive diagnosis is by laparoscopy with biopsy. Treatment: NSAIDs, hormonal contraceptives (continuous or extended cycle), progestins (norethindrone, DMPA), GnRH agonists (leuprolide — limited to 6 months to prevent bone loss), GnRH antagonists (elagolix, relugolix), aromatase inhibitors (off-label), and surgical excision or ablation of endometriosis (laparoscopic). Hysterectomy with bilateral salpingo-oophorectomy is definitive but reserved for severe cases in women who have completed childbearing.

ⓘ Information

Interstitial cystitis (IC/BPS) is a chronic condition characterized by bladder pressure and pain (worsening with bladder filling, improving with voiding), urinary frequency and urgency, and nocturia, in the absence of infection. The prevalence is 2-6 million women in the United States. Etiology is unclear — possible theories include urothelial glycosaminoglycan (GAG) layer dysfunction, mast cell activation, neurogenic inflammation, and autoimmune processes. Diagnosis is by clinical criteria; cystoscopy with hydrodistention may show glomerulations or Hunner’s ulcers (less common in women — more common in men with IC). Treatment is multimodal: behavioral (bladder retraining, dietary modifications — avoid acidic foods, caffeine, alcohol, artificial sweeteners, spicy foods), oral medications (pentosan polysulfate — the only FDA-approved oral drug, amitriptyline, hydroxyzine), intravesical instillations (DMSO, heparin, lidocaine), and sacral neuromodulation (InterStim) for refractory cases. Pentosan polysulfate can cause maculopathy — baseline and annual retinal exams are recommended. IC/BPS is also associated with the “evil twins” — concurrent fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, and vulvodynia.

Vulvodynia is chronic vulvar pain (burning, stinging, irritation, rawness) of at least 3 months’ duration without an identifiable cause (negative skin exam, negative cultures, negative biopsies). The prevalence is 7-8% of women. Subtypes: generalized (entire vulva) or localized (vestibulodynia — pain at the vaginal introitus, provoked by touch or intercourse). Evaluation: cotton swab test (touch test mapping out the vestibule), and exclusion of infections, dermatoses (lichen sclerosus, lichen planus), and malignancy. Treatment: vulvar care measures (gentle cleansing, barrier ointments, cotton underwear, avoid irritants), topical lidocaine 5% (applied 5-10 minutes before intercourse), pelvic floor physical therapy and biofeedback, low-dose tricyclic antidepressants (amitriptyline or nortriptyline 10-75 mg daily), gabapentin or pregabalin, CBT, and vestibulectomy (surgical removal of the painful vestibular tissue — 70-80% success rate for localized vestibulodynia).

Pelvic Floor Physical Therapy

Pelvic floor physical therapy is the cornerstone of conservative management for POP, UI, and CPP. Techniques include: biofeedback (electromyography or pressure sensors to teach correct pelvic floor muscle recruitment), manual therapy (external and internal soft tissue mobilization, trigger point release, myofascial release, scar mobilization for C-section or episiotomy scars), electrical stimulation (for detrusor overactivity), behavioral training (bladder and bowel retraining, urgency suppression, proper voiding and defecation mechanics), and home exercise programs (Kegels, relaxation techniques, core stabilization). Pelvic floor PT should be performed by a specially trained women’s health physical therapist.

Summary

Pelvic floor disorders are common but underreported. Pelvic organ prolapse (anterior, posterior, apical) stages 0-IV can be managed with PFMT, pessaries, or surgery. Urinary incontinence includes SUI (leakage with exertion — treated with PFMT and sling) and UUI (leakage with urgency — treated with bladder training and anticholinergics). Chronic pelvic pain includes endometriosis, IC/BPS, and vulvodynia — treatment is multimodal. Pelvic floor physical therapy is first-line for many pelvic floor disorders.