Pelvic Floor Physiotherapy in Female Voiding Dysfunction

Voiding dysfunction caused by functional bladder outlet obstruction (BOO) among women has received increasing attention. Inappropriate contractility of the urethral sphincter and/or pelvic floor muscles (PFMs) during voiding can cause functional BOO, and in the patients with intact neurologic function, it is called dysfunctional voiding (DV) (Haylen et al 2010; Chiang et al 2021).

Symptoms of nonrelaxing pelvic floor dysfunction are associated with DV (Faubion et al 2012). Pelvic floor spasm and associated voiding problems are heterogeneous in their pathogenesis and are therefore often underrecognized and undertreated; it is therefore essential that a therapeutic strategy needs to be personalized to the individual patient's requirements. Therefore, careful evaluation and assessment of individuals using a multidisciplinary team approach including a trained pelvic floor physiotherapist/nurse clinician is essential in the management of these patients (Kuo et al 2015). It is good to have in mind that DV can be caused by deep infiltrating endometriosis (DIE). DIE lesions can also be associated with non-relaxing pelvic floor muscle dysfunction (Mabrouk et al 2019; Spagnolo et al 2014).

Individuals with DV either never learned correctly how to void or acquired the functional disorder in adulthood through voluntary holding of urine or stool. This voluntary holding might be attributable to habit, lifestyle, occupation, or constant recruitment of muscles used to avoid bladder incontinence (Faubion et al 2012).

Providing education about the anatomy and function of the pelvic floor is important and should be a routine part of women’s health care. Pelvic floor physiotherapy has several treatment approaches such as manual therapy, EMG biofeedback, pelvic floor muscle training, relaxation techniques, uroflowmetry with EMG for training PFM relaxation during void among other methods, but little is currently known about the most effective combination of approaches or modalities. Further studies are needed to individualize interventions and to tailor them to more effectively address functional BOO.

As a side note, just some points about nomenclature: The term “nonrelaxing PFM” was previously used as a diagnosis, however, this term describes a sign, and is not recommended to be used as a diagnosis. This sign may be combined with symptoms to inform a clinical diagnosis.

References:

Chiang C-H, Jiang Y-H, Kuo H-C. Therapeutic efficacy of biofeedback pelvic floor muscle exercise in women with dysfunctional voiding. Sci Rep [Internet]. 2021 Dec 2;11(1):13757. Available from: http://www.nature.com/articles/s41598-021-93283-9

Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. Mayo Clin Proc [Internet]. 2012;87(2):187–93. Available from: http://dx.doi.org/10.1016/j.mayocp.2011.09.004

Frawley H, Shelly B, Morin M, Bernard S, Bø K, Digesu GA, et al. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment. Neurourol Urodyn [Internet]. 2021 Jun 12;40(5):1217–60. Available from: https://onlinelibrary.wiley.com/doi/10.1002/nau.24658

Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J [Internet]. 2010 Jan 25;21(1):5–26. Available from: http://link.springer.com/10.1007/s00192-009-0976-9

Kuo TLC, Ng LG, Chapple CR. Pelvic floor spasm as a cause of voiding dysfunction. Curr Opin Urol [Internet]. 2015 Jul;25(4):311–6. Available from: https://journals.lww.com/00042307-201507000-00008

Mabrouk M, Raimondo D, Parisotto M, Del Forno S, Arena A, Seracchioli R. Pelvic floor dysfunction at transperineal ultrasound and voiding alteration in women with posterior deep endometriosis. Int Urogynecol J [Internet]. 2019 Sep 2;30(9):1527–32. Available from: http://link.springer.com/10.1007/s00192-019-03963-4

Spagnolo E, Zannoni L, Raimondo D, Ferrini G, Mabrouk M, Benfenati A, et al. Urodynamic Evaluation and Anorectal Manometry Pre- and Post-operative Bowel Shaving Surgical Procedure for Posterior Deep Infiltrating Endometriosis: A Pilot Study. J Minim Invasive Gynecol [Internet]. 2014 Nov;21(6):1080–5. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1553465014002982