Pelvic Floor Dyssynergia

The pelvic floor muscles are responsible for your posture, the function of your bladder and bowel, and intimate sensations. Pelvic floor dyssynergia is a loss of coordination between these muscles and others in the pelvis. Often leading to issues in the way your bladder and bowel work, issues with the related muscles and bones in your hips and back, and pelvic pain as a result. Pelvic floor dyssynergia is an unintentionally acquired behavioural issue, often referred to as a functional issue rather than a structural (i.e. damaged muscle), neurological (i.e. disease of the brain) or pathological issue (i.e. disease).

The most common outcome of pelvic floor dyssynergia is issues with defecation. For an efficient bowel movement, there are a number of complex voluntary and involuntary movements that need to occur. The puborectalis sling muscle (involuntary) and the anal sphincter muscles (voluntary) need to relax. At the same time the abdominal muscles push down. This changes the ano-rectal angle which allows for defecation.

When these actions do not coordinate the rectum can become obstructed, resulting in an uncomfortable and incomplete bowel movement. As pelvic floor dyssynergia can happen to varying degrees with the muscles doing different things, the issues of defecation can be further classified into a number of conditions; including:

  • Anismus - Involuntary spasm of the anal muscles during defecation.
  • Obstructive defecation - Inability for stool to move through the rectum.
  • Levator ani syndrome - Involuntary pelvic floor and rectal spasms.
  • Pelvic outlet obstruction - A perceived inability to empty the rectum.
  • Spastic pelvic floor syndrome - The pelvic floor contracts when it should relax to allow for defecation.
  • Paradoxical puborectalis contraction - Obstruction of the rectum by contraction of the sphincter muscles during straining.

Pelvic floor dyssynergia can affect both men and women, but a greater number of women are known to seek treatment. The condition often first occurs in childhood (31% of cases), and increases in prevalence with age (50% of those affected are between 30-60 years old). As with most intimate conditions, the prevalence of pelvic floor dyssynergia is likely to be under reported as many individuals will not seek diagnosis and treatment. Many individuals will not realise they are suffering from pelvic floor dyssynergia, and will be having limited success in treating the symptoms without this knowledge. It is believed that only 29% of people suffering from pelvic floor dyssynergia seek treatment.

Pelvic floor dyssynergia is not life threatening, however its symptoms reduce the quality of life of those suffering. Resulting in 17.9 days absence from work / school each year for the average sufferer.

To diagnose pelvic floor dyssynergia, your GP will rule out other conditions that may be causing your symptoms, such as slow-transit constipation. You may be asked to complete a bowel diary to provide an insight into your behaviour. An examination of your rectum, vagina and pelvic floor can determine if there are any obvious physical reasons why you are suffering. A defecography may be used to record the changes in your muscles and organs as you attempt to evacuate artificial stool (barium paste or a balloon of warm water).


What are the Symptoms of Pelvic Floor Dyssynergia?

The most common symptom of pelvic floor dyssynergia is constipation, causing 50% of all recorded chronic constipation cases. However, the loss of efficient function of the pelvic muscles can cause issues with all the pelvic organs and related muscles.

  • Constipation and related straining with an inability to fully empty your bowels
  • Hard stools
  • Less than 3 bowel movements a week
  • Pelvic pain that may be brief and occur infrequently, or it may be consistent and more dull - When the pain is a result of chronic constipation, it is often a tenderness and sensation of pressure high within the rectum.
  • Pain that gets worse when sitting
  • Pain during and after sex (dyspareunia)
  • Lower back pain
  • Pelvic muscle spasms
  • Urge urinary incontinence

When you suffer from the symptoms above, you will often begin to experience associated psychological symptoms which impair your quality of life further. These in turn exacerbate the experience of the physical symptoms listed above.

  • Anxiety
  • Depression
  • Obsessive compulsiveness
  • Hostility and distraction from personal relationships

Its important to be aware that pelvic floor dyssynergia often co-exists with rectal ulcers, enterocele (prolapse of the small intestine into the vagina) and rectocele (prolapse of the rectum into the vagina). The symptoms are similar to those experienced with inflammatory bowel syndrome (IBS), hemorrhoids and prostatitis (inflamed prostate gland).


What Causes Pelvic Floor Dyssynergia?

Pelvic floor dyssynergia is a behavioural disorder that is the result of an unintentional habit. It is often a habit of an ineffective posture and behaviour you have when you try and have a bowel movement.

To determine if there was a singular cause that led to your pelvic floor dyssynergia, or if multiple events played a part, your GP will discuss your medical history. Including any issues during the labour and delivery of any children, and any previous pelvic surgeries.

  • Chronic straining - If you are frequently constipated you will find yourself straining each time you have a bowel movement. This can cause a loss of muscle coordination - especially of the puborectalis muscle which needs to relax in order for a bowel movement to occur.
  • Behaviour disorder - A habit of bad posture and ineffective behaviour when on the toilet. It can be due to mistakes made when younger that have become routine.
  • Sexual abuse - If a patient has experienced sexual abuse, they are most likely to suffer from anismus. Where the anal sphincter muscles involuntarily contract during straining.
  • Pregnancy and childbirth - Your pelvic floor is vulnerable to weakening throughout your pregnancy, due to the weight of the growing baby and your hormones telling your pelvic floor to relax in preparation for a vaginal childbirth. Injuries to the pelvic floor muscles are common during vaginal delivery, which can lead to an imbalance in their contractions.
  • Trauma from high impact exercises - The pelvic floor can experience trauma from high impact exercises, where both feet are off the ground at the same time such as during football or gymnastics, or during an injury.
  • Pelvic surgery - Undergoing a pelvic surgery can alter your behaviour as a result of any damage that the muscles experienced.
  • Bulimia or anorexia nervosa - Eating disorders can result in a negative relationship with defecation and a change in behaviour.

To read about other causes of pelvic pain, visit the Causes and Diagnosis of Pelvic Pain page.


How to Treat Pelvic Floor Dyssynergia

If you have been suffering with pelvic floor dyssynergia for 6 months or more, your doctor will offer a programme of treatments which provide relief from the symptoms whilst you work to resolve the behaviour that is causing the symptoms. Its important to be aware that you will be unable to get permanent relief from the symptoms unless you resolve the pelvic floor dyssynergia itself. This requires determination and commitment from yourself.

  • Biofeedback techniques to change behaviour - Learning how to correct the coordination of the pelvic floor and abdominal muscles is essential to treating pelvic floor dyssynergia, and is successful for 72% of patients. Often led by a Physiotherapist, this can be done with a series of tools and techniques. Including using an ano-rectal manometry probe, inserted into the anus, which can display the change in structures as the patient attempts to defecate to show what can be improved. The important things to learn are:
    • The correct posture for defecation; where the legs are apart and you are at the correct angle. A toilet stool can be used to ensure this.
    • How to strain to effectively empty the bowels; using the abdominal muscles together with relaxing the pelvic floor. You will practice expelling a water filled balloon that is placed in the rectum to learn these techniques.
    • How to breath correctly during bowel movements.
    • The best diet to avoid constipation.
  • Neuromuscular electrical stimulation (NMES) of the sacral nerve - The sacral nerve is a group of 31 nerves that begin at your lower back and reach to the muscles of the pelvis; including the pelvic floor, rectum, bladder and sphincter muscles. These nerves are responsible for the control you have over these muscles and therefore are essential to continence. The sacral nerve can be stimulated by electrodes placed on the skin at the lower back, connected to an NMES toner. The NMES exercises the muscles that the nerves connect to, in order to strengthen them for you to regain control. A permanent sacral nerve stimulator can be implanted under the skin in a surgical operation, if the patient suffers from a condition that prevents the exercising of these muscles voluntarily i.e. spina bifida.
  • Injections of botulinum toxin (Botox) - There are several pelvic muscle groups that can receive Botox injections in order to relax them. These include the anal sphincter muscles, puborectalis muscle and the pelvic floor muscles. This can provide temporary minor relief from constipation, however, the effects usually deteriorate after just 3 months and the Botox injections need to be repeated. This treatment, therefore, is often used to reduce constipation whilst a permanent resolution to the pelvic floor dyssynergia is found. It is also used to confirm the diagnosis that the pelvic floor dyssynergia is the result of the uncoordination of the puborectalis muscle.
  • Sitz baths - Sitz baths with warm water are increasingly used to relieve anorectal pain. Often used alongside massages and muscle relaxants such as Epsom salts.
  • Psychological counselling - As pelvic floor dyssynergia is a behaviour, counselling can offer an opportunity to discuss why you are suffering and prevent it from recurring. A considerable number of women that suffer, do so following sexual trauma, which is seldom discussed and can otherwise remain a concern.
  • Surgery - As with most pelvic surgeries, surgery to treat pelvic floor dyssynergia has low success rates. Therefore, although mentioned here, it has a limited role in resolving pelvic floor dyssynergia and is appropriate for only 20% of patients.
    • Myectomy of the anal sphincter - This procedure is the removal of part of the anal sphincter muscle in order to allow for easier bowel movements as there is less of a contraction. It improves bowel movements in 10-30% of patients, but can lead to faecal incontinence.
    • Ileostomy (external bag) - If there is permanent damage to the pelvic floor and/or bowels, you may be offered a ileostomy to work around the issue. This is where the small bowel is diverted to an external bag, through an opening in the abdomen. This surgery can be reversed, however, it does come with a risk of permanent damage to the bowels.
    • Implanted sacral nerve stimulator - A sacral nerve stimulator can be placed under the skin of the lower back to consistently exercise the muscles of the pelvic floor, bowel and bladder. This is a reversible surgery if the stimulation is no longer required. This treatment has a 79% success rate and is often preferred over other surgeries as it can be reversed.
    • Partial myotomy of the puborectalis muscle - This surgery aims to partly relax the puborectalis muscle permanently to aid for easier bowel movements. It has a 67% success rate immediately with a small decline in success after a year.

To read about other treatments available for pelvic pain, visit our pelvic pain treatment page.


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