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The Pelvic Floor Is Often Ignored

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She’s the reason I pee when I sneeze. She’s the reason I fart when I walk. And yet, I would give birth to my daughter again, a thousand times over. And that, I think, is the crux of the cross we bear as mothers — the bearing of children and, specifically, bearing down. 

As a resident, I attended the Pelvic Floor Symposiums held by my institution. They were fascinating discussions led by mostly surgeons who were women, but these symposia were completely ignored by most other surgeons. As an attending surgeon, I was careful not to let myself be pigeonholed into the niche of treating pelvic floor dysfunction in women. Colorectal surgeons treat a lot of pelvic floor-related disorders, but I was always warned that pelvic floor patients are time-consuming, non-surgical, and, often, “crazy.” 

But aren’t those all just buzzwords for why clinicians don’t need to take women’s health concerns seriously? Because urinary and fecal incontinence, rectocele, pelvic organ prolapse, proctalgia fugax, anismus, dyspareunia, and obstructed defecation, to name a few, are all very real disorders. 

As a colorectal surgeon who spends the majority of her time addressing anorectal pathology, plenty of patients with pelvic floor concerns cross my path. Recently, a woman in her 60s came to me because she wanted her hemorrhoids fixed. She had been having occasional leakage for over a year, but not just the occasional mucous. There was fecal matter involved and “accidents” during both day and night. 

When I asked her about urinary incontinence, she raised an eyebrow as if questioning why I asked her about urine when she was there for her butt. I quickly explained that her symptoms went slightly beyond what I would expect with straightforward hemorrhoidal prolapse, and asking about urination often gave me additional insight about overall pelvic floor dysfunction, since between 30-50% of adults with fecal incontinence also have urinary incontinence

She was well educated and articulate and was positive that her hemorrhoids were the source of her leakage, but then cautiously offered that she was diagnosed with “Lock Key” syndrome, where she often barely made it to the bathroom in time before urine came out. She also had a connective tissue disorder, she said, that caused laxity in many of her tissues. I nodded, adding this information to my mental algorithm. 

When I did her digital rectal exam, it was obvious to me, even without anal manometry testing, that her external sphincter tone was non-existent. I went into the fecal incontinence (FI) discussion that I often have, and that patients are often surprised by: By standard guidelines, we first manage FI with diet, medications, and behavior modifications, pelvic floor PT and biofeedback, and, after other options are exhausted, a sacroneuromodulator implant, which would help her sphincter muscle control. I told her that I could address her hemorrhoids and it may help a little bit, but overall it would not change her muscle tone. I could just have easily treated her hemorrhoids and NOT addressed anything else, but that’s not in my nature. The patient seemed somewhat overwhelmed and dubious about all this information because she came in for a hemorrhoid problem and left with a pelvic floor problem, but I later found out that she took my recommendation and went to pelvic floor PT and will be following up with me soon. 

It is believed that the true incidence of fecal and urinary incontinence is unknown because both are underreported. In the U.S., FI is estimated to have an incidence of about 10% and urinary incontinence has an incidence of about 20%. One study in Spain showed a urinary incontinence rate of 50% and a pelvic organ prolapse rate of 40%, though only 10% of women reported symptoms. At three months postpartum, the rate of urinary incontinence after being in active labor for two hours is double that of being in labor for less than 60 minutes, and is higher overall in vaginal delivery than in C-section. I will tell you, not a single one of my OBs mentioned that fact in any of my prenatal visits. My wife often says, Would it have made a difference? And I reluctantly respond, No, I would’ve still given birth vaginally. Would I have kept pushing for six hours? I don’t know. Even though the doctor came in the next morning and said, Oh, so you’re the one who pushed for six hours! I didn’t get a medal for it; I did get an amazing daughter, though. I have spoken to many of my friends who have had babies in the past two years, and none of them reported a discussion about pelvic floor dysfunction in their prenatal visits, and all of them have some symptoms of pelvic organ prolapse that they’re managing with a hodgepodge of PT and medications. The quality of life is significantly further impacted with third or fourth-degree perineal lacerations. Isn’t that wild?

Women are overrepresented when it comes to specializing in pelvic floor disorders, and probably not coincidentally. Maybe it’s because we know these problems exist, having experienced one or two ourselves. I’m using childbirth as an example because it is by far the most common cause, but also the one most commonly ignored. But these problems aren’t limited to women. Men have pelvic floor dysfunction due to trauma, inappropriate bowel habits, or spine disease, but men with iatrogenic sphincter injuries or radiation are more likely to seek medical attention. I find that unless someone has dealt with it personally, either as a clinician or patient, pelvic floor dysfunction is often not at the top of a differential diagnosis, even though it has far-ranging effects. There is also an element where both physician and patient may be embarrassed or not know how to discuss pelvic floor dysfunction. I mean, how many people want to talk about pooping their pants or wetting their bed?

But we should, and we need to. As physicians, we need to start the conversation and have a low index of suspicion whenever someone says, “Oh, I have a little leakage/wetness/smearing.” That is often how patients will present, as if they are not concerned, when in fact they are VERY concerned. I mean, wouldn’t you be concerned to find a little smear in your underwear after sneezing? So we have to be the ones to say, “I would like to ask a few more questions about that, if it’s OK with you.” Assess the frequency, timing, and impact on quality of life. Some patients will say they don’t even want to go out anymore because they’re worried they have to run to the bathroom. But if we could screen and catch patients earlier, perhaps we can find a solution sooner. 

Pelvic floor disorders tend to be a “woman’s concern” and therefore are not thoroughly addressed. Authors in the U.K. have proposed more subspecialty pelvic floor training and interdisciplinary pelvic floor meetings between urology, colorectal surgery, and gynecology. I think we need more than that. All clinicians should be aware of the range of pelvic floor disorders and the impact these may have on overall health, and be able to make referrals as appropriate. After all, unless you’re a baby, no one should have to live in diapers.

Do you think all physicians should be able to address pelvic floor disorders? Share in the comments.

Dr. Carmen Fong is a writer, artist, and double board-certified general and colorectal surgeon who moved from New York City to Atlanta, Georgia, with her wife and two cats. They recently welcomed a baby daughter. She is the author of Constipation Nation (Rowman & Littlefield, forthcoming 2024), and is currently in private practice as Co-Director of Hemorrhoid Centers of America. Her work has been published online in, The Apothecary, The Bookends Review, the polyphony, The GoatPol, and She can be found on social media, mostly on Instagram @drcarmenfong, on Substack @hongkongfong, and on Twitter @Carmen_FongMD. When she is not writing or working, she enjoys cooking, drawing cartoons, and reading about the mysteries of the universe. Dr. Fong was a Stony Brook Children’s Literature Fellow and a 2022–2023 Doximity Op-Med Fellow, and continues as a 2023–2024 Doximity Op-Med Fellow.

Image by GoodStudio / Shutterstock

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