Pelvic Health: Pelvic Floor Disorders, Incontinence, UTIs, and Vaginitis

Introduction

Pelvic health encompasses the function of the pelvic floor muscles, bladder, bowel, and reproductive organs. Pelvic floor disorders affect approximately 25% of women in the United States, with prevalence increasing with age, parity, and obesity. These conditions significantly impact quality of life but are often underreported due to embarrassment.

Pelvic Floor Anatomy

Structure	Function	Innervation
Levator ani (pubococcygeus, iliococcygeus, puborectalis)	Main pelvic floor support; organ support, continence, sexual function	Pudendal nerve (S2-S4)
Coccygeus (ischiococcygeus)	Posterior pelvic floor support	S3-S4
External anal sphincter	Fecal continence	Pudendal nerve
Urethral sphincter	Urinary continence	Pudendal nerve (somatic); sympathetic/parasympathetic (autonomic)
Endopelvic fascia	Connective tissue organ support	N/A (passive)
Uterosacral/cardinal ligaments	Uterine and vaginal apex support	N/A (passive)

Pelvic Floor Disorders (PFDs)

Types of Pelvic Organ Prolapse (POP)

Type	Organ Affected	Location	Symptoms
Cystocele (anterior prolapse)	Bladder	Anterior vaginal wall	Bulge, pressure, incomplete bladder emptying, splinting to void
Rectocele (posterior prolapse)	Rectum	Posterior vaginal wall	Bulge, pressure, constipation, splinting to defecate
Enterocele	Small bowel	Posterior vaginal wall (apical)	Bulge, pressure, low back pain
Uterine prolapse	Uterus	Vaginal apex	Bulge, pressure, bearing down sensation
Vaginal vault prolapse	Vaginal cuff (post-hysterectomy)	Vaginal apex	Similar to uterine prolapse

POP Quantification (POP-Q)

Stage	Description	Leading Edge
0	No prolapse	>-3 cm above hymen
I	Most distal prolapse >1 cm above hymen	<-1 cm
II	Most distal prolapse between 1 cm above and 1 cm below hymen	-1 to +1 cm
III	Most distal prolapse >1 cm below hymen but <2 cm less than total vaginal length	+1 to (TVL-2) cm
IV	Complete eversion (total vaginal length)	>(TVL-2) cm

POP Risk Factors

Risk Factor	Relative Risk	Mechanism
Vaginal parity	Strong, dose-dependent	Muscle and connective tissue injury
Instrumented delivery (forceps)	2-3x	Pudendal nerve injury, levator avulsion
Age	Increases with age	Connective tissue weakening, menopause
Obesity	2-3x	Increased intra-abdominal pressure
Chronic constipation	1.5-2x	Repeated Valsalva
Heavy lifting	1.5-2x	Same
Genetics / connective tissue disorders	Variable	Weak collagen (Ehlers-Danlos, Marfan)
Hysterectomy	Moderate	Altered pelvic support
Smoking	1.5x	Reduced tissue quality

POP Treatment

Severity	Non-Surgical	Surgical
Asymptomatic	Observation	Not indicated
Mild-moderate (Stage I-II)	Pelvic floor physical therapy, behavioral modifications, vaginal pessary	May be considered
Moderate-severe (Stage II-IV)	Pessary (if surgery not desired or contraindicated)	Native tissue repair, mesh-augmented repair, sacrocolpopexy, colpocleisis (if no desire for vaginal intercourse)

Urinary Incontinence

Types

Type	Mechanism	Prevalence	Key Features
Stress urinary incontinence (SUI)	Urethral hypermobility or intrinsic sphincter deficiency; increased intra-abdominal pressure > urethral closure pressure	30-50% of UI	Leakage with cough, sneeze, laugh, exercise, lifting; no urge
Urgency urinary incontinence (UUI)	Detrusor overactivity (involuntary bladder contraction)	20-40% of UI	Sudden, strong urge with inability to reach toilet; may leak large volumes
Mixed urinary incontinence (MUI)	Combination of SUI and UUI	30-40% of UI	Both stress and urgency symptoms
Overflow incontinence	Incomplete bladder emptying leading to overflow	5-10% (more common in men with BPH)	Frequent dribbling, incomplete emptying sense
Functional incontinence	Physical or cognitive inability to reach toilet	10-20% (elderly)	Normal bladder function but impaired mobility/cognition

Diagnosis

Test	Purpose
Bladder diary (3-7 days)	Records frequency, volume, leaks, triggers
Cough stress test	Visualize urine loss with cough (full bladder)
Post-void residual (PVR)	Rule out overflow; normal <50 mL, abnormal >150-200 mL
Urinalysis	Rule out UTI, hematuria, glucosuria
Pad test	Quantify leakage
Urodynamics	Assess bladder filling and voiding function (pre-operative)
Cystoscopy	If hematuria, recurrent UTIs, or suspected pathology

Treatment

Type	First-Line	Second-Line	Third-Line
SUI	Pelvic floor physical therapy (Kegels), lifestyle (weight loss, smoking cessation)	Vaginal pessary, urethral bulking agents	Mid-urethral sling (surgery)
UUI	Behavioral (bladder training, timed voiding), pelvic floor PT	Anticholinergics (oxybutynin, tolterodine, solifenacin, darifenacin) or beta-3 agonists (mirabegron, vibegron)	Sacral neuromodulation (InterStim), percutaneous tibial nerve stimulation (PTNS), onabotulinumtoxinA (Botox) injection
MUI	Treat predominant component first	Sequential treatment if needed	Combined approach

Anticholinergic Medications for UUI

Drug	Dose	Half-life	Metabolism	Side Effects
Oxybutynin	5 mg BID-TID; ER 5-30 mg daily	2-3 hours (IR); 12-16 (ER)	CYP3A4	Dry mouth (most common), constipation, dry eyes, cognitive impairment
Tolterodine (Detrol)	2 mg BID; ER 4 mg daily	2-4 hours (IR); 6-10 (ER)	CYP2D6, 3A4	Less dry mouth than oxybutynin
Solifenacin (Vesicare)	5-10 mg daily	45-68 hours	CYP3A4	Constipation, dry mouth
Darifenacin (Enablex)	7.5-15 mg daily	12-19 hours	CYP2D6, 3A4	Constipation (most common); less cognitive effect (M3 selective)
Fesoterodine (Toviaz)	4-8 mg daily	4-6 hours (active metabolite)	CYP2D6, 3A4	Dry mouth, constipation

Beta-3 Agonists

Drug	Dose	Mechanism	Side Effects
Mirabegron (Myrbetriq)	25-50 mg daily	Beta-3 receptor agonist (relaxes detrusor)	Hypertension, headache, UTI, constipation
Vibegron (Gemtesa)	75 mg daily	Same as mirabegron	Hypertension, headache

Kegel Exercises (Pelvic Floor Muscle Training)

Proper Technique

Step	Instruction
1	Identify correct muscles: stop urine flow mid-stream (do NOT do this regularly; just to identify) or insert finger into vagina and squeeze
2	Empty bladder before exercising
3	Contract pelvic floor muscles (lift up and in)
4	Hold contraction for 3-10 seconds
5	Relax completely for equal time
6	Repeat 10-15 times per session
7	Perform 3+ sessions per day
8	Progress to quick contractions (1-second squeeze/relax)
9	Do NOT hold breath, tighten thighs/buttocks, or push down

Common Mistakes

Mistake	Correction
Bearing down (Valsalva) instead of lifting up	Think “stop the flow of urine” or lift up vaginally
Holding breath	Breathe normally; inhale to relax, exhale to contract
Squeezing buttocks/thighs	Isolate pelvic floor; hand on buttocks to monitor
Overdoing	Rest between contractions; muscles need recovery

Biofeedback and Devices

Tool	Description
Digital feedback	Therapist finger in vagina to confirm contraction
EMG biofeedback	Surface or vaginal sensor measuring muscle activity
Vaginal weights/cones	Graded weights held by pelvic floor contraction
Electrical stimulation	Low-level current activates pelvic floor
Vaginal trainers (Kegel devices)	Smartphone-connected sensors (Perifit, Elvie, KGoal)

Urinary Tract Infections (UTIs)

Classification

Type	Location	Symptoms
Acute uncomplicated cystitis	Bladder (non-pregnant, healthy, no anatomic abnormality)	Dysuria, frequency, urgency, suprapubic pain
Complicated UTI	Bladder with anatomic, functional, or medical abnormality	Same + possible systemic symptoms
Pyelonephritis	Kidney	Flank pain, fever, chills, nausea, vomiting
Asymptomatic bacteriuria	No symptoms with positive culture	No treatment needed (except pregnancy, pre-urologic surgery)
Recurrent UTI	3+ episodes/year or 2+ in 6 months	Treat acute, then prophylaxis

Common Pathogens

Pathogen	Percentage of UTIs	Features
Escherichia coli	75-95%	Most common; increasing resistance
Staphylococcus saprophyticus	5-15%	Young, sexually active women
Klebsiella pneumoniae	5-10%	May indicate resistance
Enterococcus faecalis	3-5%	Complicated UTI
Proteus mirabilis	2-5%	Forms struvite stones, alkaline urine
Pseudomonas aeruginosa	1-2%	Complicated, nosocomial

Diagnosis

Test	Sensitivity	Specificity	Notes
Urinalysis: nitrite	30-50%	>95%	Bacteria convert nitrate to nitrite (not all bacteria do this)
Urinalysis: leukocyte esterase	75-90%	80-95%	WBC activity
Urinalysis: microscopy (WBCs, bacteria)	80-90%	80-90%	Gold standard for point-of-care
Urine culture	100%	100%	Reserved for complicated, recurrent, or failed treatment

Treatment (Uncomplicated Cystitis)

Medication	Dose	Duration	Notes
Nitrofurantoin (Macrobid)	100 mg BID	5 days	First-line; avoid if CrCl <30
Trimethoprim-sulfamethoxazole (TMP-SMX, Bactrim)	1 DS tab (160/800) BID	3 days	First-line if local resistance <20%
Fosfomycin (Monurol)	3 g single dose	1 dose	Second-line; increasing resistance
Cephalexin (Keflex)	500 mg QID	5-7 days	Alternative
Beta-lactams	Variable	5-7 days	Lower efficacy than first-line

Recurrent UTI Prevention

Strategy	Regimen	Evidence Level
Continuous antibiotic prophylaxis	TMP-SMX SS (40/200) daily or nitrofurantoin 50-100 mg daily or cephalexin 125-250 mg daily	Strong
Post-coital prophylaxis	Single dose of TMP-SMX SS, nitrofurantoin 50-100 mg, or cephalexin 250 mg after intercourse	Strong
Cranberry products	36 mg PAC/day (proanthocyanidins)	Moderate (controversial)
D-Mannose	2 g daily	Moderate
Increased fluid intake	>1.5 L/day	Moderate
Vaginal estrogen (postmenopausal)	Vaginal estradiol cream/ring	Strong for postmenopausal women
Methenamine hippurate	1 g BID	Moderate

Interstitial Cystitis (Bladder Pain Syndrome)

Feature	Description
Definition	Chronic (>6 weeks) pelvic pain, pressure, or discomfort perceived to be related to the bladder, with urinary symptoms (frequency, urgency)
Prevalence	2-7% of women (estimated)
Peak age	30-50 years
Etiology	Unknown; proposed: epithelial dysfunction, mast cell activation, neurogenic inflammation, autoimmune
Associated conditions	IBS, fibromyalgia, chronic fatigue, migraine, vulvodynia, endometriosis

Diagnosis

Criteria	Details
Symptoms	Pain/pressure/discomfort with bladder filling, relieved by voiding; urinary frequency (small volumes); nocturia
Exclusion	UTI (negative culture), carcinoma (cystoscopy if >50 or risk factors)
Cystoscopy	Glomerulations (petechial hemorrhages), Hunner ulcers (ulcerative subtype)
Potassium sensitivity test	Pain with intravesical KCL (not commonly done)

Treatment

Category	Options
Behavioral	Avoid triggers (caffeine, alcohol, acidic foods), timed voiding, stress reduction
Oral medications	Amitriptyline (10-75 mg qHS), cimetidine, hydroxyzine, pentosan polysulfate (Elmiron)
Intravesical	DMSO (Rimso-50), lidocaine, heparin, hyaluronic acid
Procedural	Hydrodistention (diagnostic and therapeutic), neuromodulation
Surgical	Rare: cystectomy (last resort)

Vaginitis

Types

Feature	Bacterial Vaginosis (BV)	Candidiasis (Yeast)	Trichomoniasis
Pathogen	Gardnerella vaginalis, anaerobes (overgrowth)	Candida albicans (85-90%), C. glabrata, C. parapsilosis	Trichomonas vaginalis (protozoan)
Symptoms	Thin, gray/white discharge; fishy odor; may be asymptomatic	Thick, white, “cottage cheese” discharge; pruritus; erythema; dysuria; dyspareunia	Frothy, yellow-green discharge; pruritus; dysuria; odor; strawberry cervix
pH	>4.5	<4.5	>4.5-5.0
Wet mount	Clue cells, few WBCs	Pseudohyphae, budding yeast, WBCs	Motile trichomonads, WBCs
Whiff test (KOH)	Positive (fishy odor)	Negative	May be positive
Treatment	Metronidazole 500 mg BID x5-7d or vaginal metronidazole gel x5d or clindamycin cream x7d	Fluconazole 150 mg PO single dose or topical azoles (clotrimazole, miconazole) x3-7d	Metronidazole 2 g PO single dose or tinidazole 2 g PO single dose (treat partner)
In pregnancy	Symptomatic: treat (metronidazole); asymptomatic: treat if prior preterm birth	Topical azoles only (clotrimazole, miconazole)	Metronidazole (safe); treat to prevent preterm labor
Recurrence	Recurrent BV: metronidazole gel 2x/week for 4-6 months; boric acid 600 mg vaginally	Recurrent Candida: fluconazole 150 mg weekly; boric acid 600 mg vaginally; check for diabetes, antibiotics, immunosuppression	Re-infection (partner not treated)