Dr. Paulo Vieira de Sousa 

General Surgeon and Coordinator of the Surgery Department
Clinical Director of HPA Gambelas
President of the Medical Council

The role of general surgery in pelvic floor dysfunction   

HPA Magazine 23 // 2025

Pelvic floor dysfunction affects both men and women and can manifest through various symptoms, with urinary, gynaecological, and defecatory complaints being the most common. It significantly impacts quality of life, causing issues such as loss of control over urination and bowel movements, pain, limited mobility, emotional instability, social isolation, and sleep disturbances.
Some studies suggest that its impact on health and daily functioning is comparable to chronic diseases like stroke, cancer, diabetes, or dementia. It is a prevalent condition, with approximately 50% of women over 55 experiencing problems related to pelvic floor dysfunction, including urinary and/or faecal incontinence and prolapses.
Despite these statistics, only a small percentage of patients seek help, often due to reluctance to discuss their symptoms or lack of awareness about available treatments.
In recent years, there has been increased awareness among patients and healthcare providers regarding pelvic floor dysfunction, driven by advancements in therapeutic options, particularly in surgical techniques that are now more streamlined and personalized.
Treatment should be approached by a multidisciplinary team and tailored to each patient's specific needs and condition, which may involve dietary adjustments, targeted
exercises, physiotherapy for perineal rehabilitation, medication, devices, or minimally invasive surgical procedures that are safe and highly effective.

WHAT IS THE PELVIC FLOOR? 
 The pelvic floor refers to the set of muscles, fascia, and ligaments located in the lower part of the abdominal cavity. It supports the pelvic organs, maintaining them in their anatomical position and ensuring their proper function. The pelvic floor is crucial for urinary and faecal continence, as well as sexual performance. Working in conjunction with other muscle groups, such as the diaphragm. The pelvic floor also plays a vital role in lumbopelvic stability.
Therefore, it is important to view the pelvic floor as a dynamic system that requires ongoing maintenance throughout life. Dysfunction of the pelvic floor can result from weakness or injury to its muscular or neurological components, leading to issues with urinary, defecatory, and sexual functions.

WHAT SYMPTOMS AND PROBLEMS MAY BE RELATED TO THIS DISORDER?
There may be different symptoms depending on the type of dysfunction. A weak and loose pelvic floor may be accompanied by urinary incontinence, prolapse of the pelvic organs (such as the uterus, bladder, or rectum), or a feeling of heaviness, pain, or decreased sensation during sexual intercourse. Changes in orgasm, gas or faecal incontinence. may also be present.
On the other hand, increased muscle tension leads to stiffness in this region, resulting in chronic pelvic pain, pain when emptying the bladder, urinary incontinence, pain during sexual intercourse, constipation, false urges, or difficulty or pain when evacuating.
 
 
WHAT ARE THE RISK FACTORS FOR PELVIC FLOOR DYSFUNCTION?
Factors such as postural changes, obesity, smoking, asthma, chronic cough, strenuous sports, jobs involving heavy lifting, prolonged standing, chronic constipation, and straining during bowel movements can contribute to dysfunction due to increased pressure.
Pregnancy and childbirth are common risk factors, as they can lead to postural changes and increased intra-abdominal pressure during pregnancy, as well as pelvic consequences from childbirth, especially in cases of vaginal delivery, prolonged or complicated labour, or the use of forceps or suction cups.
Inadequate postpartum recovery and premature resumption of heavy tasks can also contribute to pelvic floor dysfunction.
Age is a risk factor due to the natural decrease in collagen tissue quality, leading to ligament laxity and muscle weakness, which can manifest as incontinence, prolapse, or changes in sexual sensations.
Other causes of pelvic dysfunction include recurrent infections, trauma, abdominal or pelvic surgery, neurological disorders, among others.
 

HOW ARE PELVIC FLOOR DYSFUNCTIONS DIAGNOSED AND CLASSIFIED?
The diagnosis is made based on a detailed clinical history, physical examination, complementary tests appropriate for an accurate diagnosis, and also on the evaluation necessary for the rehabilitation of the pelvic floor.
The classification is made according to the manifestations.
Urinary dysfunctions:
· Stress urinary incontinence - is the loss of urine caused by increased abdominal pressure, in situations of effort, such as sneezing, intense coughing, laughing, jumping, running, among others;.
· Urge incontinence or overactive bladder - imperative and, at times, uncontrollable urge to urinate, with or without loss of urine, with urinary frequency whether day or night.
Mixed urinary incontinence:
· Loss of urine associated with urgency and also effort.
Anal dysfunctions:
· involuntary loss of both faecal material and gases, or faecal urgency.
Pelvic organ prolapse:
· Descent of one or more pelvic compartments and/or organs (bladder, uterus, rectum).
Sexual dysfunctions:
· these are disturbances in physical sexual responses, causing suffering and interpersonal difficulties, which may consist of changes in sexual desire or interest, loss of orgasm, vaginismus, or dyspareunia.
Chronic pelvic pain:
· non-menstrual pelvic pain without another clinical cause, lasting more than six months, intense enough to interfere with activity and quality of life.

WHAT ARE THE THERAPEUTIC OPTIONS?
Treatment should be decided after a meticulous evaluation, preferably by a multidisciplinary team. Physiotherapy plays an important role in the rehabilitation of the pelvic floor, whether alone or associated with other therapeutic modalities, notably after surgery.
Therefore, the patient may be indicated for:
1. Conservative Treatment:
· Physiotherapy/Pelvic Floor Rehabilitation: It is the first-line treatment in most situations, especially in the absence of prolapses. It may consist of specific physical exercises, re-education through biofeedback, electrotherapy, etc.
· Use of medications: muscle relaxants, psychotropic drugs, laxatives, or others, especially useful in cases of overactive bladder, constipation, chronic pain, and vaginismus.
· Others: use of medical devices such as vaginal pessaries to keep the uterus in position, eating habits, etc.
2. Surgical Treatment:
The goals of surgery are to eliminate symptoms, correct anatomy, and restore the function of each organ. It is particularly indicated for the correction of prolapses. In recent decades, preference has been given to minimally invasive approaches, which provide a great improvement in quality of life, are well tolerated, and have fewer complications. The selection of the surgical technique depends on the type of pathology, the morphotype, the patient's expressed wishes, and the scientific evidence on its results, always balancing the risk-benefit factor.
 

IF INDICATED, WHAT ARE THE BENEFITS AND SURGICAL OPTIONS?
The two classic groups of surgical techniques are:
1. Techniques for repairing the perineum, the anterior wall of the vagina, or the posterior wall of the vagina.
2. Suspension techniques, called pexias, which allow organs to be kept in their anatomical location. In recent years, other variations of these techniques have been introduced, called:
• Slings: simpler, which correct the clinical manifestation using the patient's tissues or synthetic material, which, when properly applied, present few complications and very high success rates, around 95%.
• POPS (Pelvic Organ Prolapse Suspension): a minimally invasive procedure that allows an intra-abdominal and trans-anal approach in a single operation, performing a complete correction with excellent therapeutic results.
3. Other surgical techniques are:
• Injections with filling agents: correct the coaptation defect either via the trans-urethral or trans-perineal route. It allows a transient improvement in symptoms; therefore, its effectiveness requires repeated injections.
• Vaginal and sphincter plasties: more complex surgeries that consist of the reconstruction of the injured component.
• Sacral neuromodulation: a minimally invasive technique that consists of nerve stimulation of the sacral roots through an electrode introduced percutaneously. It has revealed excellent results in the treatment of patients with anal incontinence, achieving success in more than 90% of cases.

The HPA Saúde Group offers a comprehensive approach to the diagnosis and treatment of this condition and all the manifestations associated with it, with a focused multidisciplinary team, integrating specialists in General Surgery, Urology, Gynaecology, Radiology, and Physical Medicine and Rehabilitation.
If necessary, make your appointment. We are at your disposal to clarify and take care.