Sexual Aspects of Pelvic Floor Disturbances/Disorders

Abstract

This chapter will pay attention to the disturbances related to the pelvic floor, focusing on their sexuality-related consequences. It will start with the troubles during pregnancy, followed by the problems after childbirth. At the end of each topic, it will offer treatment recommendations.
The urinary disorders will cover stress urinary incontinence (SUI), urgency urinary incontinence (UUI), climacturia (losing urine during orgasm), and urinary tract infections. The defecation disorders will cover anal incontinence, flatal incontinence, and constipation. Pelvic organ prolapse (POP) does usually not happen in the first pregnancy, though the primigravid woman can have similar complaints.
Pelvic girdle pain (PGP) tends to start during pregnancy.
Pregnancy and vaginal birth are the most common risk factors for postpartum PF disorders: stress urinary incontinence, overactive bladder syndrome, pelvic organ prolapse, and anal incontinence. On the one hand, that may sound like pathologizing childbirth. On the other hand, healthcare providers should be aware that they tend to underestimate the rates of (anal) obstetric injuries, and most textbooks do not mention levator ani avulsion.
Aspects of pelvic floor muscle training (PFMT) receive ample attention in the treatment recommendations. In the postpartum part, the chapter pays extra attention to perineal pain, vaginal laxity, and overactive pelvic floor. Those are disruptive elements for intimacy and sexuality, just like all the other mentioned disturbances.
This chapter is part of ‘Midwifery and Sexuality’, a Springer Nature open-access textbook for midwives and related healthcare professionals.

Full text

185
16
Sexual Aspects of Pelvic Floor
Disturbances/Disorders
LiesbethWesterik-Verschuuren ,
MarjolijnLutkeHolzik- Mensink, MarleenWieffer-Platvoet,
andMinkevan der Velde
16.1 Introduction
Whereas Chap. 10 looked at the sexual aspects of the pelvic oor (PF) in healthy
pregnancy and postpartum, this chapter will address how various PF disorders inu-
ence sexuality. The chapter will successively pay attention to urinary problems,
defecation problems, pelvic organ prolapse, and pelvic girdle pain and how they
relate to sexuality. We start with the pregnancy-related situations and then the post-
partum situations.
16.2 Pelvic Floor Disturbances/Disorders During Pregnancy
16.2.1 Introduction
PF disorders are common during pregnancy. The increased intra-abdominal pres-
sure and the relaxation of the PF connective tissues can disturb micturition and
defecation and cause pelvic organprolapse [1]. Those are embarrassing complaints
L. Westerik-Verschuuren (*) · M. Lutke Holzik-Mensink
Bekkenfysiotherapie Twente, Expertise Center for Pelvic Floor Physiotherapy,
Enschede, The Netherlands
SOMT University of Physiotherapy, Master Pelvic Physiotherapy,
Amersfoort, The Netherlands
e-mail: l.westerik-verschuuren@somt.nl
M. Wieffer-Platvoet
Bekkenfysiotherapie Twente, Expertise Center for Pelvic Floor Physiotherapy,
Enschede, The Netherlands
M. van der Velde
Seksuologiepraktijk Twente, Center for Sexology, Enschede, The Netherlands
© The Author(s) 2023
S. Geuens et al. (eds.), Midwifery and Sexuality,
https://doi.org/10.1007/978-3-031-18432-1_16

186
that decrease quality of life, including sexual life. The range of disturbances goes
from a slight inconvenience to severe disorders. Factors such as shame in the woman
and her partner inuence the degree of impact on sexuality and sexual well-being,
just as the importance they attach to sexuality.
16.2.2 Urinary Disorders During Pregnancy
Both pregnancy and childbirth are risk factors for developing urinary incontinence.
Stress urinary incontinence (SUI) is the involuntary loss of urine on effort or
physical exertion. SUI can already develop before childbirth and happens in 38% of
nulliparous [pregnant] women [2]. With the potential damage caused by delivery
added, SUI occurs in 42% of multiparous women [3].
Urgency urinary incontinence (UUI or urine leakage at urgency1) also increases
during pregnancy but less frequently.
The amount of urine loss differs. Whereas some women lose some drops, the
bladder empties entirely in others. It can be experienced as embarrassing, dimin-
ishes the woman’s self-esteem and self-worth, and impairs her sexuality.
SUI and UUI can also happen during sexuality, with SUI occurring relatively
more frequently during penetration and UUI relatively more frequently at orgasm.
The last, called ‘climacturia’, is especially disturbing during cunnilingus (oral sex
to the woman’s genitalia), a standard part of the sexual script for couples in many
parts of the globe.
Urinary tract infections (UTI) affect up to 10% of pregnant women. Although
some people consider sexual intercourse to cause recurrent UTIs, (un-)hygienic
measures and dysfunctional voidingseem more relevant. Some women appear to
avoid sexuality to prevent UTIs with dysuria and the continuous urge to void as
additional reasons to abstain from penetrative sex.
16.2.2.1 Treatment Aspects
During pregnancy, urinary incontinence (UI) is associated with an underactive pel-
vic oor, and isa risk factor for developing postpartum UI.So the woman should
train her PF muscles (PFMT as described in Chap. 10), focusing on contraction
(increasing strength and endurance), relaxationand coordination. The most impor-
tant aspect of PFMT is learning to squeeze the PF muscles when the abdominal
pressure increases and consciously relax them when no contraction is needed. A
correct function and good awareness of the PF will allow penetration and intensify
sexual feelings.
In case of recurrent urinary tract infections, adequate toilet technique needs
attention.
With a completely relaxed PF, voiding can take place spontaneously without
pressing. The woman should also take time to empty the bladdercompletely.
1 Urgency is ‘having difculty to postpone a sudden or unstoppable sensation to urinate or
defecate’.
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16.2.3 Defecation Disorders During Pregnancy
In pregnancy, defecation disorders include anal incontinence, involuntary loss of
faeces or atus, and constipation. Anal incontinence and constipation are highly
distressing and negatively impact sexuality.
Although pregnant women rarely report the involuntary loss of solid or liquid faeces
(out of shame?), the research found incidences between 2% and 9.5% [4]. Involuntary
loss of atus (‘atal incontinence’) affects 12–35% of pregnant women and is espe-
cially embarrassing during intercourse. As a result, some women seem to avoid sexual-
ity, others avoid genital contact, and nearly all abstain from receptive oral sex.
The causes of constipation during pregnancy are manifold. In constipation, def-
ecation is infrequent or incomplete, or there is a need for frequent straining or digi-
tal assistance to defecate. The relaxation of the connective tissues of the bowels
increases the ‘colon transit time’, increasingly solidifying the stool. The woman
then strains to defecate, which can cause haemorrhoids and painful and incomplete
evacuation. Oral anaemia-related iron supplementation can aggravate this process.
Constipation can cause abdominal pain, reduced appetite, and reduced well-
being, negatively affecting sexuality. In addition, the rectum lled with faeces can
cause an unpleasant sensation of urgency during sex.
16.2.3.1 Treatment Aspects
In case of anal or atal incontinence, PFMT (pelvic oor muscle training) is recom-
mended (as described in Chap. 10). In case of constipation, osmotic laxatives can
soften the stool.Furthermore the position during a bowel movement is important.
For proper defecation, the position is essential. The knees should be placed
higher than the hips. In this ‘squatting’ position, the PF (especially the puborectal
muscles) relaxes and enhances free passage (Fig.16.1).
16.2.4 Pelvic Organ Prolapse During Pregnancy
Pelvic organ prolapse (POP) is the descent of the anterior vaginal wall, posterior
vaginal wall, uterus, or combinations. Since the connective tissues relax and the
intra-abdominal pressure increases, one may expect a descent of the pelvic organs
during pregnancy. In contrast, there is a cranial shift from the pelvic organs from
mid- to late pregnancy [5]. So, a pelvic organ prolapse is not expected in the primi-
gravid woman. Pregnant women, however, report a heavy, dragging sensation in the
vaginal area. Most probably, circulatory changes, particularly reduced venous back-
ow with perivaginal varicose and venous congestion, are responsible for this heavy
sensation. Combined with the increased vaginal blood circulation of sexual arousal,
this can increase the feeling of prolapse. In some women, that might be a reason to
avoid sexual activities. The decreased function of the pelvic oor muscles might be
another part of the explanation for the ‘prolapse sensation’.
Be aware that in threatening premature labour, the woman can also experience
the sensation of prolapse.
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188
Fig. 16.1 Position for easily passing stool.
(Illustration by Corine Adamse)
16.2.4.1 Treatment Aspects
Without other signs of threatening premature labour, it seems relevant to reassure
pregnant women that the sensation of prolapse is just part of the pregnancy and that
sexual activities, including penetration, will not worsen this condition. On the other
hand, the woman could diminish the sensations by limiting her standing time to
decrease the pressure on the lower belly.
Improving the PF function will create better support for the pelvic organs and
be, in that way, effective. Training of the PF muscles, performed in the supine
position, will activate the muscle pump and relieves by diminishing the venous
congestion.
16.2.5 Pregnancy-Related Pelvic Girdle Pain (or
Pregnancy- Related Low Back Pain)
The denition of pelvic girdle pain (PGP) is: pain experienced between the poste-
rior iliac crest and the gluteal fold, particularly in the vicinity of the sacroiliac joint.
The pain may radiate in the posterior thigh and occur in the symphysis [6]. It gener-
ally develops during pregnancy or the rst 3 weeks postpartum. PGP affects up to
45% of pregnant women and causes multiple limitations in daily life activities [7].
Musculoskeletal pain can limit sexual activities as well [8].
Furthermore, PGP can be considered a motor control impairment of the lumbar
spine and the pelvis, leading to several compensation strategies. One of those com-
pensation strategies is using the pelvic oor muscles to improve motor control.
Many women unconsiously develop an overactive pelvic oor. Such PF muscle
overactivity can cause dyspareunia [9].
16.2.5.1 Treatment Aspects
Counselling, explaining the pain, and training to improve motor control of the lum-
bar spine and the pelvis can reduce this pain and be sufcient to resume sexual
activities. Here, it can be helpful to recommend trying adapted positions for
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189
Position APosition B
Fig. 16.2 Sexual positions to be recommended in Pelvic Girdle Pain. Position A: woman supine,
man on his side, penis towards the vagina. Position B: sciccors position. (Illustration by
Corine Adamse)
penetrative sex, for instance, the man on his side and the woman on her back with
knees bent and vagina towards the penis(position A) (Fig.16.2a). The woman’s
pelvis is spared in this position, just as in the ‘scissors position’ (position B). When
advising couples on such pelvis-sparing positions for penetration, it is necessary to
be very concrete and detailed to minimize any hesitation to implement these tips at
home because of doubts about the ‘How?’. Here, hand-out illustrations can be
benecial.
16.3 Pelvic Floor Disturbances/Disorders
inthePostpartum Period
16.3.1 Introduction
Pregnancy and vaginal birth are the most common risk factors for postpartum PF
disorders: stress urinary incontinence, overactive bladder syndrome, pelvic organ pro-
lapse, and anal incontinence [1]. This might sound like pathologizing birth. However,
HCPs tend to underestimate the rates of obstetric (anal) injury, and in most textbooks,
levator ani avulsion is not even mentioned. In an Australian study with 483 patients,
only 33–40% of primiparous women achieved an atraumatic normal vaginal birth [10].
These disorders develop by various combinations of damaged PF muscles, dam-
aged PF nerves, and damaged connective tissues, all potentially inuencing sexual-
ity. This part will rst address perineal pain, vaginal laxity, and overactive pelvic
oor, followed by urinary incontinence, anal incontinence, pelvic organ prolapse,
and pelvic girdle pain.
16.3.2 Perineal Pain
Perineal pain can happen because of episiotomy, lacerations, or (over)stretching of
the perineum. Nine out of ten women report this pain, with a third of the women
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190
experiencing moderate-to-severe pain and one in seven women still suffering 9
weeks after childbirth [11]. Perineal pain can limit daily life activities. It can also
impair sexual life and sexual pleasure with, especially in couples with poor com-
munication, the risk that dyspareunia develops into long-standing sexual and rela-
tionship problems.
16.3.3 Vaginal Laxity
One of the effects ofchildbirth PF injuries is a reduced strength of the PF muscles.
When the strength has decreased too much, the woman cannot close the genital
hiatus sufciently. This symptom is called vaginal laxity.With such laxity, there is
no or little friction between the penis and the vagina during penetration. This laxity
diminishes sexual pleasure for both partners. Furthermore, it can cause vaginal
noise or ‘vaginal atus’ during intercourse, which is embarrassing for most people.
Because of the entrance’s insufcient closure, air enters the vagina and is noisily
pushed out by the intercourse movements. Though laxity does not physically hurt,
it means, for some couples, a serious sexual disorder needing counselling with prac-
tical recommendations on how to avoid vaginal atus during penetrative sex.
Couples could try another position. Unfortunately, literature does not offer solu-
tion of ‘noise-free’ positions. One could try minimally moving the penis after pen-
etration and use other stimulation like kissing, caressing the breasts, stimulating the
clitoris, or whatever a couple prefers. Some couples use loud music and orchestrate
penetration on the beats of the music.
Vaginal laxity is frequently linked to an avulsion of the levator ani muscle, mean-
ing that the muscle is partly (and sometimes wholly) torn away from the pubic bone.
In a multicentre study on women with rst deliveries, the prevalence of levator ani
avulsion was 18.8% (with 8% in spontaneous, 29% in vacuum-assisted, and 51% in
forceps–assisted delivery) [12].
16.3.3.1 Treatment Aspects
PFMT, creating a kind of hypertrophy of the puborectal and pubococcygeus muscle,
will decrease the cross-sectional area of the genital hiatus and thus improve the
closure of the genital hiatus and increase the friction between the vaginal wall and
the penis with a more intense sexual sensation [13].
16.3.4 Overactive Pelvic Floor
Overactivity is the opposite of laxity. The PF has an increased toneand isnot able
to relax when needed. This can be caused by perineal pain and fear of (urinary or
anal) incontinence or prolapse. The overactivity causes the PF nods and closes the
vagina, resulting in a short and narrow vagina, as described in Chap. 10. The conse-
quences are difcultiesin penetrating, dyspareunia, and the risk of developing a
vicious circle of ‘dyspareunia → no desire → dyspareunia’.
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16.3.4.1 Treatment Aspects
PFMT should focus on relaxation and coordination. In perineal pain, the woman
needs reassurance that squeezing the PF will not cause harm. On the contrary, alter-
nately, maximum squeezing and complete relaxation of the PF will decrease the
pain. Especially here, be aware of the risk of developing long-standing vicious cir-
cles of pain, poor sexual pleasure, and relationship problems. Having couples avoid
all potentially painful sexual activities is often considered an excellent start to treat-
ment and a way of preventing the development of more permanent pain associa-
tions [11].
16.3.5 Urinary Incontinence
Urinary incontinence affects up to a third of women in the rst 3months after child-
birth. Unfortunately, 1year after birth, that has barely changed.
Urinary incontinence is a burdensome condition affecting the quality of life,
often causing shame and loss of one’s self-perceived sexual appeal.
Vaginal birth is particularly associated with stress urinary incontinence (SUI). It
is caused by injuries to the PF muscles (reduced strength), connective tissues (weak-
ened support of the bladder neck), and the pudendal nerve. SUI limits all‘abdomi-
nal pressure increasing’ activities like coughing, running, jumping, bending, and
carrying the baby. During sex, it occurs with pressure on the belly and when the
penetrating penis pushes against the bladder. So urinary incontinence can affect
personal, work, and leisure activities.
There is no difference between vaginal and caesarean delivery regarding urgency
urinary incontinence [14].
Urinary incontinence can also lead to coital incontinence (as described in Chap.
10), diminishing sexual activity in some couples.
16.3.5.1 Treatment Aspects
Part of these injuries will heal but not recover completely. Well-functioning PF mus-
cles can partly compensate for this damage [15].
They can improve the closure of the urethra.
To close the urethra optimally, a contraction of the diaphragmpelvisand the
urogenital diaphragm, in particular the external urinary sphincter, is required.
Actually, the external urethral sphincter is not really a sphincter, but a
horseshoe- shaped muscle that closes the urethra by pressing it against the
fascia.
The closure of the urethra should be emphasised. With your palpating nger
against the bladder neck, ask the woman to contract her PF.A proper contraction
will lift the urethra ventralward (‘bladder neck elevation’).
Following the advice given in Chap. 10, (healthy) women can expect improve-
ment by PFMT after 6weeks. Recovery of the pelvic oor muscles will take more
time in the breastfeeding woman because of her low oestrogen levels.
Practical aspects: empty the bladder before sexual activity.
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192
Adjust urine production to desired sexuality (food that makes the urine smell,
timing, the diuretic effect of caffeine, et cetera).
16.3.6 Anal Incontinence
Anal incontinence is a rather embarrassing condition, more bothersome and burden-
some than urinary incontinence. After vaginal childbirth, 14% of women suffer
from anal incontinence [16].
Anal incontinence is associated with third- and fourth-degree anal sphincter tears
[17]. Women with anal sphincter tears often have injuries to the perineal muscles
(pubovaginalis, puborectalis) and the pudendal nerveas well. Like urinary inconti-
nence, anal incontinence limits all ‘abdominal pressure increasing’ activities. With
a sphincter tear, women have less resumption of sexual activities [18]. Because of
the extent of the injury, there can be a decrease in sensations during sexual activi-
ties. Fear of losing stool or gas does neither make a woman feel feminine nor
attractive.
16.3.6.1 Treatment Aspects
Practical aspects: Work with quality and timing of food intake and defecation train-
ing towards regular daily bowel movements. With such regularity, the rectum will
be empty for the rest of the day, andone will not lose stool. Training of strength and
coordination of both the anal sphincter and the puborectal muscle is vital to main-
tain anal continence. Both aspects will improve sexuality as well.
16.3.7 Pelvic Organ Prolapse
Over her lifetime, pelvic organ prolapse (POP) affects 50% of all women who have
had at least one vaginal birth [19]. Women with prolapse experience various pelvic
oor symptoms depending on the localization and prolapse stage. The most appar-
ent sign of POP is a bulge descending into the vagina. This bulge can be the descend-
ing bladder, uterus, or rectum. Sometimes, the vagina seems blocked by the bulge.
However, during sexual activities, the bulge can easily be pushed aside.
Damage to the PF muscles and connective tissues causes the prolapse.Sometimes
the pudendal nerve is damaged as well. Many women with POP cannot sufciently
close the genital hiatus. During childbirth, the PF muscles, specically the pubo-
vaginal and puborectal muscles, have to stretch with a factor of 3–4. Since striated
muscles cannot stretch more than a factor of 1.5, it is not surprising that these PF
muscles get injured during childbirth. Such anoverstretching can result in a partial
or complete avulsion of the levator ani muscle or traumatic overstretching. Levator
ani muscle avulsion is not reversible and has a 13–36% incidence [20]. After a rst
vaginal birth, the next vaginal deliveries are unlikely to cause avulsion [12].
An open or insufciently closed genital hiatus can lead to vaginal noise or ‘vagi-
nal atus’ and low friction between the vagina and the penis [21]. POP affects the
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quality of life, particularly the woman’s self-image or self-esteem. Mechanically,
sexual intercourse is, in general, not impaired. In other words: penetration stays
possible.
16.3.7.1 Treatment Aspects
For sexual contact and intercourse, the couple can choose positions in which gravity
does not push the prolapse into the vulva, which makes penetration easier. In uro-
genital prolapse, training of the PF muscles (PFMT) is the rst treatment option.
Another frequently used strategy is a pessary [3]. PFMT will improve the closure of
the hiatus and will increase the friction between the vagina and the penis creating a
more intense sexual sensation [22]. The levator ani, bulbospongiosus, and ischio-
cavernosus muscles are important in sexuality by clasping what enters the vagina,
increasing the clitoral circulation, and experiencing orgasm contractions.
If PFMT, a pessary, or the combination does not yield effect, the next option is
surgery, aiming to repair the disturbed anatomical structures.
16.3.8 Pelvic Girdle Pain (PGP)
Though postpartum PGP prevalence decreases, it still affects a quarter of women
1year postpartum [9]. Pelvic girdle pain (formerly sometimes called pelvic instabil-
ity) is usually caused by impaired motor control of the lumbar spine and the pelvis.
Since the PF muscles connect the pelvic bones and can increase the abdominal
pressure, they can give an increased feeling of motor control. When experiencing a
lack of motor control, the woman will unconsciously compensate for this with her
pelvic oor. Though that will partly contribute to the stiffness of the predominantly
bony pelvic ring, it does not lead to optimal motor control. As a result, the PF
muscles gradually become overactive without improving the pain. Then, a vicious
circle can develop with the pain stimulating the PF muscles to keep trying improved
motor control. The overactive pelvic oor impedes sexual reexes and nods and
closes the vagina. Sexual well-being is thus harder to attain.
16.3.8.1 Treatment Aspects
Teach proper techniques to improve motor control without excessively squeezing
the PF.After achieving effective motor control, one should learn PF relaxation. See
also Chap. 10 or refer to a PF physiotherapist. As in prepartum PGP, being aware of
specic positions for penetrative sex is valuable.
16.4 Conclusion
Sexual disorders related to pregnancy and childbirth can be due to PF disorders and
dysfunctions. Women need more information about their PF muscles and their
changes during pregnancy and after birth [23]. Increasing PF muscle awareness and
improving PF muscle function can contribute to more satisfying sex. Though
16 Sexual Aspects of Pelvic Floor Disturbances/Disorders

194
sexuality will always be different after childbirth, it does not mean that a woman
cannot enjoy sex anymore. On the contrary, the woman who, in the course of the
pregnancy, becomes more aware of her pelvic oor and learns how to use those
muscles as ‘love muscles’ can benet tremendously.
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