Pelvic Organ Dysfunction

What is Pelvic Organ Dysfunction?

Many men and women suffer from urinary frequency and urgency, sometimes even urinary incontinence. Others may have difficulty urinating and may even go into urinary retention. These symptoms are occasionally associated with chronic pain involving the pelvic organs such as bladder, or suprapubic pain, vaginal pain and painful intercourse in females, testicular discomfort, groin and prostate pain in males. Occasionally there is also bowel dysfunction with intermittent diarrhoea or constipation and haemorrhoids. Patients are sometimes labelled to have irritable bowel syndrome, interstitial cystitis, overactive bladder, chronic prostatitis, recurrent urinary tract infections. This constellation of symptoms is also sometimes associated with sexual dysfunction such as decreased libido, erectile dysfunction, premature ejaculation, and in females orgasmic problems and painful intercourse. These symptoms may occur in isolation or may be associated with many of the other symptoms mentioned.

Often no obvious cause can be found and patients go from doctor to doctor seeking relief.

However, these people can achieve significant improvement and require a special approach.

The Pathophysiology

The bladder, rectum and their sphincter muscles(located within the pelvic floor group of muscles) have essentially only 2 functions : to store and to empty their contents at appropriate times. To achieve this, however, involves a highly complex neural system comprising a network of nerves, muscles, neurotransmitters, hormones, and receptors. These different components are thoroughly integrated, are delicately balanced and “talk” to each other via a sophisticated system of reflexes. It is therefore not surprising that many external and internal factors such as diet, toxins, stress, anxiety, poor toilet habits as well as poor general health and other disease processes may adversely affect the functioning of the pelvic organs. In addition the different organ systems within the pelvis profoundly influence each other. For example, problems with the bowels may adversely affect bladder performance, and visa versa; sexual dysfunction can lead to chronic pelvic pain syndromes.

How do we make the diagnosis of Pelvic Organ/Pelvic Floor Dysfunction(POFD)?

The patient is firstly very carefully assessed by taking a careful history and examination and only including special tests when necessary. Very often the picture becomes clear in the first interview.

It is important to rule out obvious organic pathology such as urinary tract infections, kidney stones, tumours involving the pelvic organs, organic bowel pathology or neurologic problems such as early diabetes or multiple sclerosis, previous pelvic organ surgery(hysterectomy), vitamin deficiencies, spinal cord problems and to treat those conditions appropriately. Special investigations such cystoscopy(looking inside the bladder), ultrasound examinations or Xrays may be necessary. Patients with POFD may fit into the following profile: These men and women are often goal oriented achievers, who admit to significant stress and anxiety. They may have developed poor habits regarding diet, tobacco, alcohol, inadequate exercise and recreation, irregular toilet habits, and insufficient attention to a healthy sex life. They usually have several symptoms related to the pelvic organs and require the comprehensive holistic approach which we outline below.

Of course people with few symptoms may not fit into the above profile and respond to a more simplified treatment regimen.

Approach to Management

Once we have confidently ruled out obvious organic causes, the pathophysiological nature of this pelvic organ dysfunction is explained to the patient with the aid of slides and diagrams, including the role of the pelvic floor muscles. This is not an imagined or “psychosomatic” condition. These patients have very real symptoms probably on the basis of subtle neurological dysfunction.

The treatment approach is tailored to the person’s particular dysfunction or symptoms, but in general, the following principles are followed:

Firstly is the common sense, practical approach to general health. The pelvic organs, like other tissues and organ systems in the body are profoundly affected by the person’s health or ill health, mental and physical. Therefore, we encourage attention to diet, exercise, stress relief, discourage toxins such as tobacco and excess alcohol, and certain foodstuffs known to irritate the lower urinary tract. Patients are urged to consider the practice of yoga, or other meditative – type exercises, as these generally incorporate an overall healthy life style and remind us to be mindful of our bodies, including the pelvic floor and pelvic organs.

Attention is then directed at specific exercises and routines involving the pelvic floor and pelvic organs. These give the patient the tools to directly improve their symptoms.

The goal is to give the patient the understanding and practices to improve their overall health and specifically the functioning of their pelvic organs. Initially we try to avoid medication and other more invasive options, especially in early cases with mild symptoms.

When the symptoms are more severe

The dysfunction may be so well established, with persistent urinary and/or bowel symptoms, pelvic pain etc., that other methods of management need to supplement the above holistic approach. Excellent medication is available which has been developed to target specific organs and symptoms. For example, the newer antimuscurinic agents act on specific receptors within the bladder and are effective in reducing urinary frequency and urgency. Analgesics are available which act on neurologic pain and may be effective in pelvic pain syndromes.

Occasionally patients are referred to Physiotherapists who specialize in pelvic floor rehabilitation or trigger point release.

There are more invasive options for patients with very severe bladder symptoms, such bladder hydrodistension, and the instillation of special substances into the bladder. The injection of Botox into the bladder can be effective in very refractory cases of “overactive bladder”.

Sacral Nerve Stimulation is an option for patients with very severe bladder symptoms and/or bowel problems/pelvic pain not adequately responding to the more conservative approach or who are unable to tolerate the medication. This involves the placement of a fine wire lead through the skin and tissues of the sacral area, so that it lies next to one of the sacral nerves. Stimulation of the sacral nerves results in neuromodulation of the dysfunctional reflexes within the pelvis and pelvic floor, with significant improvement in up to 75% of these people who are nearly crippled by their symptoms.

In Summary

We have outlined our holistic and comprehensive approach to people with Pelvic Organ/Pelvic Floor Dysfunction and welcome the opportunity to consult on these patients. We also welcome any comments/suggestions. Please email seppel@urologycapetown.co.za