Share ThisIn our Ask a Doc series, we sit down with physicians and other clinical experts, including those at Allegheny Health Network (AHN), for a chat on an important health topic. In this interview, we feature three AHN clinicians sharing insights on pelvic floor health.
Erasing the stigma and embarrassment around certain health conditions can help rectify them. This can be especially important for women’s health, as we noted in a previous article on irritable bowel syndrome (IBS). We’ll delve into that further with this article on pelvic floor health.
Pelvic floor dysfunction includes a range of causes and symptoms, and impacts approximately 25% of American women. While pelvic floor disorders become more common as women get older, our clinical experts emphasize that issues can be treated and should not be ignored as “just part of aging.”
To learn more, I spoke with three Allegheny Health Network clinicians who have specialties that include treating patients with pelvic floor disorders: Saad Javed, MD (neurogastroenterology and motility); Lindsay Turner, MD (urogynecology); and Taryn Hassinger, MD (colorectal surgery).
Megha Pai: Can you explain at a high level what the pelvic floor is and how it influences, and can be impacted by, other parts of the body?
Dr. Saad Javed: The pelvic floor is a group of muscles at the lowest part of the abdomen, between the hip bones. It supports pelvic organs such as the rectum, uterus and urinary bladder. One of its most important functions is efficient bowel evacuation. When that “hammock” of muscles supporting the pelvic organs becomes weak or damaged, it can lead to fecal incontinence, pelvic organ prolapse, and obstructive or dyssynergic defecation — the inability to pass stool through the anus. Pelvic floor dysfunction can manifest as impaired rectal contraction or inadequate anal relaxation.
Dr. Taryn Hassinger: When we’re talking about the pelvic floor, we're talking about all the musculature that contributes to both the support and function of the pelvis and its associated organs. Pelvic floor issues can be present for men and women, but women have a much higher incidence of issues based on our anatomy, and having children can be a factor, too. Some of the muscles involved are ones you might not necessarily have conscious control over. They’re like the muscles in your lower back that contribute to posture — but when these muscles get out of whack, there’s potential for a lot of structural and functional problems, including with bladder function.
Dr. Lindsay Turner: I’ll add that many people think pregnancy and childbirth are the only causes of pelvic floor dysfunction, but we see women with issues completely unrelated to pregnancy and childbirth. Pelvic floor issues are multifactorial — multiple things can lead to dysfunction.
Megha Pai: How can women maintain good pelvic floor health? Are there any myths to be wary of?
Dr. Lindsay Turner: One myth to watch out for is that Kegel exercises fix everything. That's not necessarily true. Kegels can make things worse for people who are experiencing high tone pelvic floor problems, for example, because the exercises are further engaging the already overly tight muscles.
Dr. Taryn Hassinger: In terms of maintaining good pelvic floor health and preventing issues, obesity can contribute to pelvic floor problems, so weight loss can help. Chronic coughing brought on by smoking can also cause pelvic floor problems, so quitting smoking can help with that. Taking measures to reduce stress and anxiety can help the pelvic floor as well, because women tend to hold that tension in their pelvic floor.
Dr. Saad Javed: In addition to these suggestions, I regularly remind my patients to avoid spending extended amounts of time sitting on the toilet. Prolonged sitting (for example while scrolling on your phone), with a lot of straining can not only precipitate and worsen hemorrhoids but can also contribute to worsening outlet dysfunction.
Megha Pai: Pelvic floor dysfunction can manifest in many ways. What are some symptoms and health concerns related to the pelvic floor?
Dr. Taryn Hassinger: I mostly see people who are having issues with the posterior compartment, like the rectum, so the issues include rectal prolapse and patients having problems with bowel movements. Pelvic floor dyssynergia or dysfunction can cause obstructive defecation syndrome (ODS), so that’s mostly patients who present with constipation. The issue is not necessarily that stool is moving slowly through their colon, it's more that the stool gets to the bottom and can't get out. That is a very common manifestation of pelvic floor dysfunction that I see in my practice.
Dr. Lindsay Turner: Vaginal prolapse can by caused by pelvic floor dysfunction and can involve the bladder, bowels and uterus. Pelvic floor dysfunction presents differently depending on whether the pelvic floor is too weak or overly engaged. If you have a weak pelvic floor, you can develop prolapse and leakage of urine related to coughing, laughing or sneezing or that “gotta go to the bathroom” feeling. If you have an overly engaged, high tone pelvic floor, it can also include that “gotta go to the bathroom” feeling, but you’ll often see obstructed defecation and/or painful sex as well. Some patients also have urinary retention, where they physically can't empty their bladder because of such a high tone pelvic floor.
Dr. Taryn Hassinger: Fecal incontinence — not being able to control bowel movements — is also an issue I see which is often related to pelvic floor dysfunction. Weakness of the pelvic floor, or more specifically, weakness of the sphincter complex, can sometimes mean multiple issues at once. I think more people experience fecal incontinence than those who seek treatment for it, because it’s an uncomfortable topic for patients to broach with their physicians. That’s why it’s best for us to specifically ask patients about it.
Megha Pai: Being uncomfortable talking about a symptom is a barrier to care. Can you talk about the range of barriers women encounter in addressing pelvic floor health issues?
Dr. Lindsay Turner: Overcoming the stigma surrounding pelvic floor health issues and making sure people don’t dismiss certain discomforts as things they have to live with, are both important in helping people seek the treatment they need. Sometimes, people think that bowel leakage or painful sex are just things that happen, especially if they’ve recently had a child, so they don’t seek help.
There are practical barriers, too. Childcare is a big one — I have a lot of women who can't get to appointments with me or with physical therapy because they can’t find or afford childcare or because they can’t take time off work. And another barrier is not knowing where to go — many patients say to me that they didn’t even know my specialty (urogynecology) existed. There’s a knowledge gap about the care that’s available.Dr. Taryn Hassinger: Patients also might not realize that there are effective interventions available to treat their issues.
Megha Pai: Right, they may not even be sure where to start.
Dr. Lindsay Turner: I think a good starting place is a patient’s OB-GYN or PCP. Those doctors can refer patients who have more complex issues. For example, at Allegheny Health Network, we built an algorithm surrounding urinary incontinence to ensure that patients are getting early access to treatment for that condition. We developed a pathway available to PCPs to assist with treating straightforward incontinence, and mechanisms to provide referrals to patients that may be better served by a specialist. If a patient’s symptoms can be resolved with a simple treatment or medication, we can avoid having them wait for an appointment and additional copay costs associated with seeing a specialist.
Dr. Saad Javed: Whether it’s an OB-GYN, PCP, or specialist, a thorough understanding of each patient's history is vital. Traumatic vaginal delivery with perineal injury during childbirth, history of complicated abdominopelvic surgeries and radiation treatments, sexual abuse and PTSD, and other sensitive factors can all be involved with pelvic floor disorders. It is exceedingly important to foster a strong patient-physician bond that allows patients to entrust their provider with these clues.
Megha Pai: Each of you has emphasized that it’s important for people with pelvic floor issues to realize that interventions and treatments are available. Can you provide examples of how that might play out and really make a difference in someone’s life?
Dr. Saad Javed: During the evaluation of patients with chronic constipation or fecal incontinence, I rely heavily on anorectal manometry to give me vital information regarding the anal sphincter function at rest and then during defecatory maneuvers. We obtain parameters like rectal sensation and compliance, relaxation of the internal anal sphincter, and manometric patterns produced upon attempted expulsion. In a small subset of patients, we might also consider an MRI of the dynamics of defecation; MR-defecography. This helps evaluate global pelvic floor anatomy and dynamic sphincter morphology during defecation. Once our patient is diagnosed with dyssynergic defecation, a primary treatment is robust pelvic floor physical therapy and biofeedback response. The goal is to properly engage the abdominopelvic muscles and relax the anal sphincter muscles. Biofeedback involves measuring pressures from the anal canal and providing the patient with real-time feedback. AHN's Physical Therapy and Rehabilitation team offers this form of neuromuscular training at multiple locations, and it has shown to improve outcomes in a sizable majority of our patients.
Dr. Taryn Hassinger: The large number of therapy sites means we can meet the needs of patients in their own communities. A typical regimen would combine weekly in-person therapy with an at-home treatment plan to help the person continue building on those sessions. Our physical therapists are specially trained in pelvic floor muscles and are very good at putting patients at ease, which is important since it’s an intimate type of therapy. It’s critical for strong rapport and trust to be built with the patient before delving into this therapy, so that patients are comfortable.
Our approach works — we get glowing feedback about our physical therapy team. If surgery is needed to fix pelvic floor issues, we do that as well, but in many cases physical therapy and other non-operative measures can improve pelvic floor health and help people get their lives back on track. With some patients, something as simple as starting a fiber supplement might have a huge impact.
Dr. Lindsay Turner: There are definitely quality-of-life improvements for patients after seeking treatment for pelvic floor issues. People don't realize how often women are avoiding social activities due to these conditions. We regularly have patients tell us that “they got their life back” because they got help for their pelvic floor dysfunction.
Taryn E. Hassinger, MD, MS, is a colon and rectal surgeon with AHN Surgery Institute, specializing in surgery of the colon, rectum, and anus.
Dr. Hassinger completed both medical school and residency in general surgery at the University of Virginia School of Medicine in Charlottesville, Virginia. She completed her fellowship in colon and rectal surgery at the University of Minnesota Medical School in Minneapolis, Minnesota.
Dr. Hassinger is certified by the American Board of Surgery in General Surgery. She sees patients ages 16 and older.
Saad Javed, MD, is a gastroenterologist with AHN Medicine Institute, specializing in the diagnosis and treatment of diseases and problems of the gastrointestinal tract. His clinical interests center on functional and motility disorders of the GI tract, including chronic abdominal pain and IBS.
He went to medical school at King Edward Medical University in Lahore, Pakistan. He did his residency in internal medicine and his fellowship in gastroenterology at Lahey Clinic in Burlington, Massachusetts. Dr. Javed completed his advanced fellowship in neurogastroenterology and motility at the University of Pennsylvania in Philadelphia, Pennsylvania.
Dr. Javed is certified by the American Board of Internal Medicine. He is affiliated with the American College of Gastroenterology, the American Neurogastroenterology and Motility Society, and the American Gastroenterological Association. Dr. Javed speaks English, Urdu, Punjabi, and Hindi and sees patients ages 18 and older.
Dr. Javed strives to provide compassionate and conscientious care to each patient; all the while working together, with the patients and colleagues from different specialties, in a collaborative and communicative spirit. Outside of the office, you can find Dr. Javed hiking, baking, reading to his young son and volunteering at the local animal shelter.
Dr. Lindsay Turner specializes in female pelvic medicine and reconstructive surgery.
Dr. Turner earned her medical degree from Loyola University. She completed her obstetrics and gynecology residency at Magee-Women’s Hospital of UPMC in Pittsburgh, where she was chief resident. She continued at Magee-Women’s Hospital to complete a fellowship in female pelvic medicine and reconstructive surgery. During her fellowship, she completed a master’s degree in clinical research.
She is a member of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society. She is well-published in various medical journals, including the International Urogynecology Journal and the American Journal of Obstetrics and Gynecology.
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