Pelvic Floor Dysfunction & Urinary Issues

Stephanie Prendergast is cofounder of The Pelvic Health and Rehabilitation Center and was the first physical therapist to be President of the International Pelvic Pain Society. Let’s Talk Menopause spoke to her recently about pelvic floor dysfunction and how it affects people in menopause and beyond.

Let’s start at the beginning. What is the pelvic floor? 

The pelvic floor muscles run from the pubic bone to the tailbone and are responsible for supporting pelvic organs as well as controlling urinary, bowel, and sexual function. Most muscles have a sensory capacity to feel things and motor capacity to move. The pelvic floor has an additional autonomic innervation which keeps our pelvic floor muscles ‘on’ automatically, much like our lungs. If our pelvic floor muscles did not have this unique innervation, we’d be incontinent and unable to support our organs and core. As the bladder fills or as stool or gas enter the rectum, the pelvic floor muscles reflexively tighten to keep things where they should be until it's time to use the bathroom. The pelvic floor also plays a major role in sexual function by keeping blood flow in the area, and orgasms are rapid contractions of the pelvic floor muscles. 

What is Pelvic Floor Dysfunction and What are the Signs?

Pelvic floor dysfunction is a common condition in which the muscles become too tight, too weak, or lack proper neuromuscular control. The signs and symptoms are many and, sadly, very few sufferers and providers initially realize these symptoms are connected to the pelvic floor. Symptoms may be intermittent or constant and include: 

Painful sex
Urinary tract infections
Urinary urgency or frequency 
Pelvic pain or tightness
Urinary leaks
Painful sex
Diminished/absent orgasm
Clitoral pain, vulvar pain, and itching 
Perineal or anal pain 
Hypersensitivity to wearing underwear or pants
Pain with sitting
Hip and back pain

Why are recurring urinary tract infections a leading cause of pelvic floor dysfunction (PFD)? 

Urinary tract infections cause the pelvic floor muscles to tighten or “guard” in response to pain. Over time and with repeated infection, the pelvic floor muscles become unable to return to their normal resting length after the infection is gone. This impairs the bladder’s capacity to fully empty causing one to be more likely to get another infection. In addition, tight pelvic floor muscles can mimic UTI symptoms in the absence of infection. 

What happens to the pelvic floor during the menopause transition and after?

Our pelvic organs, specifically the vulva and vestibule, urethra and bladder, and our somatic structures such as pelvic floor muscles and connective tissue are hormonally dependent structures that are affected by menopausal hormonal decline. As a result, our pelvic floor muscles and connective tissues become compromised as we age. The result is urinary and bowel symptoms, painful sex, and diminshed orgasms. Furthermore, hormonally deficient organs can become painful and a breeding ground for vaginal and bladder infections, both of which can further impair pelvic floor function. 

You believe that pelvic floor physical therapy (PFPT) and medical management go hand in hand. What does that look like?

Women in menopause often suffer from infections and hormonal deficiencies. These conditions require medical management from a doctor. However, pelvic floor dysfunction is also usually present and can be treated by PFPTs. Pelvic floor physical therapists are trained to evaluate the somatic structures of our patients’ bodies and develop an assessment of their function. This includes linking their history to their symptoms and their physical findings, followed by short-term and long-term goals as well as a treatment plan. 

Many women have never heard of Genitourinary Syndrome of Menopause (GSM). What do they need to know?

Do you know how many providers haven't heard of GSM either? Women need to know that unless providers seek out specific and current training in menopause management they may be misinformed or under-informed about the safety of hormone therapy. Genitourinary Syndrome of Menopause is an umbrella term used to describe the genital, sexual, and urinary symptoms that arise from estrogen decline. Most doctors are not familiar with pelvic floor dysfunction; thus, they do not know the importance of recommending pelvic floor physical therapists. While it is never too late to start, all women should be referred to a pelvic floor PT after having a baby, when entering menopause, or if they have urinary or bowel dysfunction or pelvic pain. We advise working with doctors who have undergone ISSWSH or NAMS training and not to forget a pelvic floor physical therapist to improve their pelvic health!

What else should people know? 

All things that burn and itch are not necessarily infections. If your UTI cultures are negative, there can be other things happening within your pelvic floor. It's also completely insane to me that people don't have pelvic floor rehab after things like pelvic organ prolapse surgery and hysterectomies. We have physical therapy after an ankle sprain, and that is nowhere near as complicated as pelvic surgery. Lastly, people should be aware of the sizable connection between pelvic floor issues and hip and back pain as a recent study found that 97% of people with hip and back pain also had pelvic floor dysfunction. 

Where can people find skilled pelvic floor physical therapists?

Women entering perimenopause and menopause can benefit from a evaluation with a PFPT to eliminate pain and dysfunction and restore sexual pleasure and pelvic health. Please, please visit the organizations below to find a provider near you.

American Physical Therapy Association: Pelvic Health

Herman and Wallace Find a Provider

Pelvic Guru

Stephanie A. Prendergast, MPT is co-founder of the Pelvic Health and Rehabilitation Center. She has authored numerous publications in peer-reviewed journals and textbooks. She and PHRC co-founder Liz Akinicilar co-authored the popular book, Pelvic Pain Explained. In 2020, Stephanie and Liz developed a virtual health/telehealth platform and are now available to anyone anywhere in the world interested in a pelvic health consultation and mentoring for other pelvic health professionals. You can find Stephanie on Twitter and the Pelvic Health and Rehabilitation Center on Instagram, YouTube, TikTok, Facebook, and Pinterest.