What Should You Do About Pelvic Floor Problems?
Start with a pelvic floor physical therapy evaluation — this is the recommended first-line treatment for most pelvic floor disorders. Don't assume symptoms like incontinence are normal or inevitable. Talk openly with your healthcare provider, as effective treatments exist for all types of pelvic floor dysfunction.
Pelvic floor physical therapy (PFPT) is the gold standard first-line treatment for stress urinary incontinence, overactive bladder, and mild-to-moderate pelvic organ prolapse. A Cochrane review of 31 trials found that pelvic floor muscle training (PFMT) cured or improved stress urinary incontinence in 56-70% of women. PFPT goes beyond Kegel exercises to include biofeedback training, manual therapy, behavioral strategies, core stabilization, and education about bladder habits, fluid management, and lifestyle modifications.
Many women do Kegel exercises incorrectly — studies show up to 50% of women cannot correctly contract their pelvic floor muscles based on verbal instruction alone. A pelvic floor physical therapist uses digital palpation and/or biofeedback to confirm correct muscle activation. Some women have hypertonic (overactive) pelvic floors that need relaxation techniques rather than strengthening. This is why professional assessment is superior to self-directed exercises and should be recommended as the initial treatment.
A Cochrane review of 31 trials found pelvic floor muscle training cured or improved stress urinary incontinence in 56-70% of women
What Causes Pelvic Floor Dysfunction?
The pelvic floor is a group of muscles, ligaments, and connective tissue supporting the bladder, uterus, and rectum. Dysfunction occurs when these structures weaken or become damaged. Major causes include pregnancy and vaginal delivery (especially prolonged labor, forceps delivery, or large babies), aging, menopause, obesity, chronic constipation, and heavy lifting.
Pregnancy and vaginal delivery are the strongest risk factors. During vaginal delivery, the levator ani muscle can stretch to over 3 times its resting length, and avulsion (tearing from the pubic bone) occurs in 13-36% of vaginal deliveries. Forceps delivery significantly increases risk compared to spontaneous vaginal delivery or vacuum-assisted delivery. Multiple vaginal deliveries have a cumulative effect. While cesarean delivery reduces pelvic floor trauma, pregnancy itself causes pelvic floor changes through hormonal effects and mechanical load.
Estrogen decline during menopause contributes significantly to pelvic floor dysfunction in older women. Estrogen receptors are abundant in pelvic floor muscles, ligaments, and urethral tissues. Declining estrogen leads to tissue atrophy, reduced collagen content, decreased blood flow, and weakened support structures. This is why the prevalence of pelvic organ prolapse and urinary incontinence increases sharply after menopause. Vaginal estrogen therapy can partially reverse these changes.
What Treatment Options Exist for Pelvic Floor Disorders?
Treatment ranges from conservative (pelvic floor therapy, pessaries, medications, lifestyle changes) to surgical (sling procedures for incontinence, prolapse repair). Most women improve significantly with conservative management. Surgery is reserved for those not responding to non-surgical approaches or with severe prolapse requiring structural repair.
For stress urinary incontinence, the midurethral sling (TVT or TOT) is the gold standard surgical treatment with long-term cure rates of 80-90%. However, PFMT should be tried first for at least 3-6 months. Vaginal pessaries are silicone devices inserted into the vagina to support prolapsed organs and reduce incontinence — they provide immediate symptom relief without surgery and are appropriate for women who prefer non-surgical management or are not surgical candidates.
For overactive bladder and urge incontinence, behavioral therapy (bladder training, timed voiding) combined with pelvic floor therapy is first-line. Anticholinergic medications (oxybutynin, tolterodine, solifenacin) and beta-3 agonists (mirabegron, vibegron) are second-line. Tibial nerve stimulation and sacral neuromodulation are advanced options for refractory cases. For pelvic organ prolapse, surgical options include native tissue repair and mesh-augmented repair, with the choice depending on prolapse type, severity, and patient factors.
