Pelvic Floor Dysfunction and Cancer Treatment

Original Editor - Laura Ritchie, posting on behalf of Lily Xiong, MPT Class of 2021 at Western University, project for PT9585.

Top Contributors - Laura Ritchie, Temitope Olowoyeye, Sehriban Ozmen, Kim Jackson, Khloud Shreif, Kirenga Bamurange Liliane and Nupur Smit Shah

Introduction

The pelvic floor is a dome-shaped structure that extends from the pubic bone to the tailbone. See Pelvic Floor Anatomy. It provides several key functions, which can be summarised by the "4S” acronym:

1. Support: of pelvic organs (bladder, bowel; female: uterus and vaginal canal; men: prostate)
2. Sphincteric: control and relaxation for continent and urination/defecation, respectively
3. Sexual: superficial muscles of PF support clitoral and penile erection and arousal
4. Stabilisation of hip, pelvis, and lower back (LB)

Pelvic Floor Dysfunction

Pelvic floor dysfunction (PFD) occurs when the PF musculature cannot be properly relaxed, coordinated, or controlled. It can also be a primary or secondary condition expressed as incontinence, leaking, and/or pelvic organ prolapse. Other manifestations of PFD include pain during or after sex or erectile dysfunction in men.

Cancer and the Pelvic Floor

Individuals with bladder or anal cancer, women with gynaecological cancers (endometrial, ovarian, cervical, vulvar, and vaginal), and men with prostate cancer and penile cancer can all experience PFD. Penile cancer is uncommon, affecting less than 1 in 100,000 men in the U.S. and leading to roughly 2,200 new cases and 440 deaths annually. Survival rates are low, highlighting the need for specialized, multidisciplinary treatment approaches.

Surgical procedures involved in cancer treatment can affect the pelvic floor depending on the tumor size, location, and stage. Surgical procedures within the pelvic region can cause damage to the muscles and other structures of the pelvic floor. Moreover, surgical procedures can affect pelvic floor musculature indirectly, such as through hormonal mechanisms after oophorectomies. More specifically, common surgical procedures that affect the PFM include:

1. Tumor debulking (removal of cancerous tissue)
2. Hysterectomy (extraction of uterus)
3. Salpingo-oophorectomy (removal of ovaries and fallopian tubes)

Adjuvant therapies like chemotherapy and radiation may also impact the pelvic floor. Radiation (external beam or internal brachytherapy) during cancer therapy can lead to fibrosis (hardening) of the pelvic floor musculature, which may lead to shortening or narrowing of the vaginal canal in women. This same hardening of the pelvic floor (men and women) and the vaginal canal (women) can lead to incontinence and/or urgency of the bowel and bladder, pelvic pain, and sexual dysfunction. According to multiple long term cross sectional studies and systematic reviews on effects on pelvic floor musculature after surgeries and adjuvant therapies in gynecologic cancer survivors, there was an increase in reports of lower libido, changes in sexual response, altered body image, and distress related to sexual health.

In addition, the extraction of pelvic lymph nodes can also lead to lymphedema, or chronic swelling in the abdomen, genitals, and legs. Genital lymphedema in the pelvic region can impact bladder function and sexual wellness.

Despite the abundance of studies and evidence presented on cancer treatment’s effect on pelvic floor health, the degree of these treatment effects varies on a case -by- case basis. Some patients will have no PFD symptoms, and some may have mild to severe symptoms immediately after treatment or develop overtime.

Prevalence

More than half of women with gynecologic malignancies report baseline urinary incontinence (UI) and 10.9% felt a pelvic organ prolapse. Moreover, women with benign hysterectomies had poorer quality of life and increased PFDs compared to women who had not undergone surgery. Survivors of gynaecological cancer also experience significantly more pelvic floor symptoms and an associated reduction in quality of life.

There is limited PFD prevalence data in male cancer survivors, however, PFM training with or without biofeedback reduces time to continence in men after radical prostatectomy. Furthermore, PFM exercises resulted in improved erectile function in men after radical prostatectomy.

Physiotherapy Management

Education

Physical therapists (PT) play a key role in educating both male and female cancer patients/survivors regarding the effects of cancer treatment on PFM function and health. This will encourage patients to “buy in” to active PFM rehabilitation to address PFD and unwanted symptoms. Education regarding the PFM can be sensitive, and here are some tips for patient education for PTs:

1. Referring to PFM as “internal hammock” that functions to support the pelvic organs
2. Explain the function of this “internal hammock” in the context of the patients’ lives (occupation, hobbies, exercise, etc)
3. Using the “tightening the tab” analogy for leakage and urinary incontinence issues
4. “If there is an issue, there is a tissue”: be mindful of not just the musculature but the biopsychosocial aspect of the patient that may impact or be impacted by PFD

Pelvic Floor Physical Therapy

The right PF physical therapy can entirely decrease or eliminate symptoms of PFD. In addition to education, PF physical therapy includes a combination of pelvic floor muscle training, exercise (PFM and core), manual therapy, and biofeedback therapy are techniques used to strengthen and restore normal function of the PFM.

Subjective history taking: this involves sitting down with the patient and taking an extensive history of the pain, symptoms, bowel and bladder functions, diet composition, biopsychosocial factors, occupation, stress levels, pregnancy history, trauma, medications, etc.

1. Postural examination: in both standing and sitting as posture changes, skeletal alignment will affect the length and tension of PFMs. Addressing postural misalignments, habits, relaxing, stretching tight muscles, and strengthening weak muscles can directly change PFM function.
2. Movement analysis looks at the quality of movements and whether patients exhibit movement pattern impairments. For example, if a mother gets incontinence whenever she picks her kid’s toy off the floor, the therapist will ask her to mimic picking of a toy off the floor and address her movement pattern dysfunction through teaching proper squatting or lifting techniques.
3. Orthopedic assessment: as a specialized branch of physical therapy, PF physical therapist will also look at the patient’s spine, sacroiliac joints, hip joints, rib cage and analyze breathing patterns before the internal exam is done.
4. Pelvic floor assessment: includes an external and internal examination of the vagina and/or rectum. The external examination usually includes a skin and external musculature examination of the perineum, for issues like skin irritation and external PFM atrophy/asymmetry. The perineum is examined for any prolapse (vaginally or rectally). For the internal assessment, the PFM’s strength, length, and quality are evaluated. The internal assessment also includes trigger points and tension examinations.
5. Patient education: is crucial in PF physical therapy, as many patients have gone through ringer prior to seeing a PF PT. Frustration, depression, and helplessness are common mental health findings when patients start the process of PF physical therapy.
6. Treatment: PF physical therapy intervention/treatment includes:

• Trigger point release to PFM
• Joint mobilization for: hips, coccyx, lumbar or thoracic spine
• Muscle energy techniques
• PFM re-education (manual feedback, electrical stimulation)
• Biofeedback: to assist in relaxation of the PFM or contraction/strengthening of PFM

Occupational Therapy Management

Physiotherapy and Occupational therapy (OT) plays a significant role in oncology by addressing the physical, emotional, cognitive, and psychosocial challenges that individuals with cancer and their families face throughout their cancer journey. While both services may have similar goals to improve the overall quality of life and function of patients, there may be different approaches taken to accomplish them.

Physical therapy addresses impairments causing functional limitations, while occupational therapy in oncology aims to enable patients to achieve maximum functional performance in daily living skills, regardless of their life expectancy, both physically and psychologically.

OT starts by evaluating an individual's physical, cognitive, and emotional abilities, daily routines, and roles, and collaborating with the patient to set personalized goals to maintain or improve their functional independence and quality of life.

Cancer side effects like fatigue, pain, weakness, cognitive difficulties, anxiety, depression, and self-esteem can be addressed through interventions aimed at restoring function, modifying activities, and adjusting environments. The Scope of Practice for Occupational Therapy includes activities of daily living (ADLs), education, and instrumental activities of daily living (IADLs), which include self-care activities, learning, and multistep care for self and others, such as household management, financial management, and childcare.