Dr. Sassetti Coimbra

Gynecology and Obstetrics Service

Pelvic floor dysfunction
What is it and how to prevent it?

HPA Magazine 23 // 2025

The pelvic floor refers to the group of muscles, ligaments, and tissues that support the organs located in the pelvis. In women, these organs include the bladder (which stores urine), the uterus (located above the vagina), and the rectum (where faeces are stored).
You can think of the pelvic floor as a web of intertwined fibres. When this web fails to support these organs effectively, it leads to what we call pelvic floor dysfunction. This dysfunction can manifest in different ways: urinary incontinence (difficulty retaining urine), genital prolapse (commonly known as "uterine prolapse"), or faecal incontinence (difficulty controlling bowel movements).
Although this topic may be uncomfortable for many women to discuss, pelvic floor dysfunction is quite common. It is estimated that one in four women will experience one of these problems, and one in five will require surgical correction.

Why does this happen?
There isn’t a single cause of pelvic floor dysfunction. Imagine the pelvic floor as a Jenga tower: over time, several "blocks" (such as muscular, genetic, or physical changes) are removed, eventually causing the structure to lose its ability to support the organs. Factors such as age, pregnancy, childbirth, genetics, smoking, a sedentary lifestyle, and obesity are well-known contributors to pelvic floor damage. Among these, vaginal childbirth is the principal modifiable risk factor, with around 20% of women who undergo vaginal deliveries sustaining severe and irreversible damage to the elevator ani muscles, which are crucial for pelvic support.

The importance of medical judgement and guidelines
Over the years, clinical assessment, medical judgement, and international guidelines have been the main tools used by healthcare professionals in managing pelvic floor risks. Evaluating factors such as the baby's weight, the baby's position during labour, and the woman's pelvic anatomy allows obstetricians to identify high-risk cases and take appropriate action.
Based on these assessments, doctors have adapted their approaches to minimise complications. Decisions around inducing labour, evaluating labour duration, and carefully managing interventions such as episiotomies have all been crucial in protecting women’s pelvic health during childbirth.

Modern tools for risk prediction:
UR-CHOICE
Despite the invaluable role of clinical judgement and experience, modern medicine is evolving towards a patient-centred model, encouraging shared decision-making between doctor and expectant mother. This is where modern risk prediction tools, like the UR-CHOICE calculator, come into play.
Launched by the International Urogynaecology Association in 2014, this tool was developed using data from over 9,000 women. It takes into account specific variables such as age, number of children, and type of delivery to provide an individualised risk of pelvic floor dysfunction for each pregnant woman. This allows doctors to inform women of their risk of developing pelvic floor dysfunction 12 or 20 years after delivery, enabling them to make informed decisions about the type and timing of delivery.
This tool helps personalise advice, reassuring women at low risk while enabling more targeted preventative measures for those at higher risk.
 

Preventing complications
Prevention of pelvic floor dysfunction can begin during pregnancy. Maintaining an appropriate weight, engaging in specific pelvic floor exercises, and, in some cases, opting for labour induction from 39 weeks are measures that can help reduce the risk of injury. During childbirth, there are various strategies to protect the pelvic floor, such as using warm compresses on the perineum or performing selective episiotomies.
In the weeks following childbirth, whether vaginal or caesarean, engaging in pelvic floor rehabilitation exercises is essential for muscle recovery. These exercises function like physiotherapy for injured muscles, helping prevent future issues. In the long term, healthy lifestyle habits, including a fibre-rich diet, regular physical exercise, and maintaining a healthy weight, are crucial for pelvic floor health.

Treating pelvic floor dysfunction
When prevention is not enough, the treatment of pelvic floor dysfunction depends on the type and severity of the condition, as well as its impact on the woman's quality of life. Treatment options include medication, specialised pelvic floor physiotherapy, laser treatments, or, in more severe cases, surgery. Treatment is generally very effective, but prevention remains the best approach.

Referências/References:
Bugge, C., Strachan, H., Pringle, S. et al. Should pregnant women know their individual risk of future pelvic floor dysfunction? A qualitative study. BMC Pregnancy Childbirth 22, 161 (2022). https://doi.org/10.1186/s12884-022-04490-9
Jelovsek JE, Chagin K, Gyhagen M, Hagen S, Wilson D, Kattan MW, Elders A, Barber MD, Areskoug B, MacArthur C, Milsom I. Predicting risk of pelvic floor disorders 12 and 20 years after delivery. Am J Obstet Gynecol. 2018 Feb;218(2):222.e1-222.e19. doi: 10.1016/j.ajog.2017.10.014. Epub 2017 Oct 19. PMID: 29056536
Wilson, D., Dornan, J., Milsom, I., & Freeman, R. (2014). UR-CHOICE: can we provide mothers to-be with infor-mation about the risk of future pelvic floor dysfunction? International Urogynecology Journal, 25(11), 1449–1452. doi:10.1007/s00192-014-2376-z