In our latest Nursing in Practice 365 CPD eLearning module, continence nurse specialist Jane Simpson explains how pelvic floor dysfunction contributes to urinary continence and other health problems in women, and advises on evidence-based approaches to pelvic rehabilitation and improving pelvic floor health.
Learning objectives
This module will support you to:
- Gain a better understanding of the function of the female pelvic floor.
- Recognise the different problems that affect the pelvic floor over a women’s life.
- Be aware of the latest treatments for pelvic floor re-education available.
- Know where to access self-help resources to provide patients with.
- Know the recommended medications for urinary incontinence and genitourinary syndrome of the menopause.
Pelvic floor dysfunction is a global health problem: data from a survey carried out on behalf of the Royal College of Obstetricians and Gynaecologists in 2023 showed that over 60% of UK women have at least one symptom of poor pelvic floor dysfunction, 1 and nearly one in four women have never done any pelvic floor exercises that could prevent and improve their pelvic floor function. The data also reveal a lack of awareness about pelvic floor health, including symptoms of a weakened pelvic floor and the benefits of pelvic floor re-education.
Nurses in primary care will be familiar with the kind of patient concerns I hear day to day: ‘I am so ashamed, I wet myself’; ‘I just couldn’t get to the toilet in time’; ‘I don’t dare to do any star jumps’; ‘I have an awful dragging feeling in my vagina by the end of the day’; and ‘I’ve stopped having sex because it’s so painful and dry’.
What and where is the pelvic floor?
The pelvic floor is made up of a group of muscles that stretch from the tailbone (coccyx) at the back to the pubic bone at the front and between the bones that we sit on. These muscles work a bit like a piece of elastic or a trampoline. They can move up and down as needed, depending on levels of activity. The muscles relax to allow urination and bowel movements, and contract to stop the leaking of urine when coughing or sneezing and to prevent the passing of wind. They are the bottom of the core muscles that support and stabilise the spine and pelvis.
What causes pelvic floor dysfunction?
Childbirth and decreasing oestrogen at the menopause are the most common causes of pelvic floor dysfunction. Women are living longer, exercising harder, having babies at a later age; on average they will spend about a third of their lives in the post-menopausal stage. Life expectancy in women has increased over the last 200 years from 45 years in 1840 to 83 years in 2025.2 The menopause is therefore far more relevant.
Related Article: CPD: How to put the new NICE menopause guidance into practice
Other causes of pelvic floor dysfunction are obesity, constipation, heavy lifting, a chronic cough, hypermobility and hysterectomy; hereditary factors may also contribute.
What happens when your pelvic floor is not working properly?
Stress incontinence
NICE guidelines note that the prevalence of stress incontinence is about 24%; other studies say it is between 25-45%.3 However the true figure may be higher as many women are still too embarrassed to admit small amounts of urinary incontinence and to seek help.
Stress incontinence is an entirely physical issue: it is not related to stress or anxiety. It usually happens on coughing, sneezing, laughing, running, trampolining or skipping. How many of your patients have given up the idea of running or trampolining?
Stress incontinence varies in severity but whether it’s a little or a lot it still needs treating. (See section below on pelvic rehabilitation.)
Overactive bladder and urge incontinence
About one in 6 women in the UK have overactive bladder symptoms.4 This manifests as urinary frequency (passing urine more than 6-8 times in 24 hours), a sudden or urgent desire to pass urine that’s hard to control and sometimes leads to not being able to get to the toilet in time (urge incontinence).
It is caused by involuntary contractions of the bladder that cause the urgent need to pass urine. This can be a complication of bladder tumours or stones, and neurological conditions like stroke, Parkinson’s disease and multiple sclerosis. Hormonal changes at the menopause, urinary tract infections, constipation and diabetes can also be underlying causes, as can cognitive changes in older age, and medications that cause the body to produce more urine. Learned behaviour or going to the toilet ‘just in case’ may also be a factor.
The first line of treatment for the overactive bladder is bladder retraining. The goal is to reduce the number of times the patient passes urine to between six and eight times in a 24-hour period.
Related Article: How to manage genitourinary symptoms of menopause
Pelvic floor rehabilitation (either pelvic floor exercises or in the case of a hypertonic pelvic floor, pelvic floor relaxation) is also important to improve pelvic floor health (see relevant sections below).
For bladder retraining follow the steps below:
- Start a bladder diary. Ask the patient back to the clinic to review the diary; it is very useful and often very revealing. It also gives your patient a chance to talk through the issues they are experiencing. They only need to do the diary for a few days. Ask them to record what they are drinking (recommended water intake is about 1.5L per day) and make a note of how often they go to the toilet.
- Advise a reduction in caffeine, alcohol, fizzy drinks and spicy foods.
- Ask them to steadily lengthen the time between visits to the toilet; tell them to ‘put yourself back in charge of your bladder’.
- Offer self-help tips including to avoid constipation, obesity and the habit of going to the toilet ‘just in case’.
If none of these simple steps are effective, a more medical approach may be necessary.
Firstly, medication may help in the form of anti-cholinergic or anti-muscarinic drugs, and if appropriate vaginal oestrogen (all prescribed by the GP or nurse practitioner).
The use of percutaneous tibial nerve stimulation (PTNS) can be done in an outpatient setting and sometimes now at home. Lastly, if all the other treatments have failed, a hospital referral can be made for either Botox injections into the bladder or sacral nerve stimulation.
To complete the full module and log 1.5 CPD hours visit Nursing in Practice 365
Related Article: NHS launches UTI awareness campaign ahead of winter
Jane Simpson is a continence nurse specialist and author of The Pelvic Floor Bible
References
- Royal College of Obstetricians and Gynaecologists (RCOG). RCOG calling for action to reduce number of women living with poor pelvic floor health. 2 February 2023
- Office of National Statistics. Healthy life expectancy in England and Wales between 2011 to 2013 and 2021 to 2023 2024
- Hunskaar S et al. The prevalence of urinary incontinence in women in four European countries. BJU Int 2004; 93:324–330
- Coyne K et al. The impact of overactive bladder on mental health work productivity and health-related quality of life in the UK and Sweden: results from EpiLUTS. BJU Int 2011 Nov;108(9):1459-71
