Pelvic Floor Awareness and Adult Re-Toilet Training in the Treatment of Lower Urinary Tract Dysfunction

Abstract

Toileting habits are established early in life, during the process of toilet training. Children who overuse their guarding reflex can develop voiding dysfunction and incontinence, which they typically outgrow. However, unhealthy behaviors, such as enhanced holding and straining to void, are common in the adult general population, suggesting the persistence of old habits that have the potential to create symptoms throughout a woman’s life. Women with poor toileting habits frequently ignore bodily sensations, and use voiding postponement and abdominal straining to eliminate, without relaxing the pelvic floor. Continuous pressure on the pelvic floor tissues during elimination can create structural changes in the pelvic anatomy, particularly after childbirth. Educating women about pelvic floor function, bladder retraining, and full pelvic floor relaxation during voiding and defecating are the goals of treatment. In this chapter, we review a simple and strategic process in which the provider teaches relaxation of the puborectalis muscle, with the aid of diaphragmatic breathing, so that coordinated elimination can develop. Although pelvic floor awareness and education may not benefit all cases, women should be warned that chronic pelvic muscle clenching and straining are potentially destructive to the pelvic floor and sphincter muscle function.

1. Introduction

Female pelvic floor disorders are pervasive and costly problems leading not only to diminished quality of life, but severe health issues including overactive bladder, urinary incontinence, painful bladder syndrome, pelvic pain, dyspareunia, recurrent urinary tract infections, and pelvic organ prolapse. While we have come to understand the causes of these common conditions to be multifactorial, with contributions from childbearing, aging, genetics and lifestyle, little emphasis has been placed on the role of toileting habits. In the last two decades, there has been an increased understanding that women who exhibit unhealthy habits such as delayed voiding, straining to void or positional voiding have higher rates of lower urinary tract dysfunction (LUTD) including overactive bladder symptoms, incomplete bladder emptying, recurrent urinary tract infections and urinary leakage [1, 2, 3, 4]. A cross sectional study of the US population showed 76% of women admit to delayed voiding and 62% strain to void, leading the authors to conclude that “this work is important for the development of future public health interventions to encourage healthy toileting behaviors and equitable access to toileting environments that support bladder health” [5].

Many investigators have proposed that adult toileting behaviors are persistent learned childhood behaviors. Children who delay voiding also have a propensity for bowel dysfunction, which motivated the International Continence Society (ICS) to suggest the umbrella term, “bladder and bowel dysfunction (BBD)”, to describe these related conditions [6]. Many children with BBD display abnormal or unhealthy toileting habits which are highly sustained into adulthood [7, 8, 9, 10]. There is a significant association of lower urinary tract symptoms (LUTs) and a history of unhealthy toileting habits such as infrequent urination, postponement of urination, and urinary urgency in childhood [11]. Childhood dysfunctional voiding may predict adult bladder control problems particularly in women with urge incontinence [12]. Pelvic floor disorders and LUTs are approximately doubled in nulliparous women with a history of childhood bedwetting [13]. Nocturnal enuresis in childhood is predictive of nocturia and frequency in adult women [14]. The long-term follow-up of children with nocturnal enuresis in a large cohort of 516 patients and showed that, despite the resolution of bedwetting, a third of patients go on to experience nocturia and a fourth of them still report LUTs [15]. A recent study demonstrated that, according to ICS criteria, 40% of females who had extensive urotherapy for voiding dysfunction in childhood had persistent voiding dysfunction as an adult, 56% still experienced daytime incontinence and 28% had recurrent UTI’s. The results of these studies suggest that the resolution of childhood LUTs and incontinence does not necessarily indicate the resolution of the underlying pathological condition [16].

Other factors which contribute to toileting habits are occupational and lifestyle constraints [17]. Poor access to toilet facilities undoubtedly leads to prolonged holding which is beyond one’s control [18]. There is also the problem of lack of public education about what is considered “healthy toileting”. The majority of women are uninformed about how often they should be using the bathroom and how to position/posture themselves on the toilet to promote effective emptying [19]. Due to concerns about hygiene, many women hover or squat over public toilets, a position known to promote dysfunctional habits such as straining to urinate or “power peeing” [20]. Furthermore, women are surprisingly unaware of their own toileting behaviors and are known to be poor historians when asked specific questions about their voiding habits [21]. They also demonstrate a poor knowledge about the pelvic floor and related dysfunctional conditions, expressing a strong desire for more information [22, 23].

Toileting habits and lower urinary tract anatomy illustrate the dynamic relationship between function and structure, which interplay over the course of a lifetime. One of the key principles of functional anatomy is that this relationship is bidirectional—a behavior can change the structure of a body part, which in turn affects the function of that part [24]. In the case of toileting habits, there may be anatomic changes in the lower urinary tract caused by chronic straining to eliminate which change the structure of the system to accommodate the behavior. As we will discuss later in this chapter, stress urinary incontinence may start with straining behaviors causing anatomic changes in the pelvic floor which facilitate voiding by weakening the outlet. Additionally, the abdominal strain necessary to overcome the obstruction of a non-relaxed outlet can create an anterior vaginal wall defect, causing further outlet obstruction from pelvic organ prolapse [25]. Because of the variability of outcomes, establishing the relationship between toileting behaviors and pelvic floor disorders is challenging. The salient questions to answer are (1) will correction of toileting habits through extensive education make a difference in the prevalence of pelvic floor disorders? and (2) what is the most effective way to provide that educational support.? If we are able to look at the vast amount of evidence already present in the literature, spanning multiple fields including adult and pediatric urology, gastroenterology, neurology and behavioral psychology, we can develop a greater understanding of the scope of the problem and further insight into answering these questions. In this chapter we will review the process of acquiring bladder control and how dysfunctional habits develop. We will then discuss a theory for how toileting habits may be the primary underlying cause for adult pelvic floor disorders including urinary incontinence and pelvic organ prolapse. Lastly, we discuss re-toilet training techniques with an emphasis on pelvic floor awareness.

2. The development of lower urinary tract function and dysfunction (LUTD)

The principal role of the lower urinary tract is to allow for low pressure storage of urine and its complete expulsion from the urinary bladder without having to generate high pressures that could be transmitted to the kidneys. Although the anatomic structures, including the urinary bladder and the bladder outlet, are rich in peripheral nerve pathways, the coordinated activity of these structures is mediated by a complex neural control system located in the central nervous system. The initiation of micturition is achieved through voluntary relaxation of the striated urogenital sphincter complex, followed almost immediately by a detrusor contraction and complete bladder emptying [26]. Coordinated voiding is not present at birth so that neonates and infants have uncontrolled urination and do not empty their bladders completely [27]. Social continence is achieved through physiological maturation and parental guidance, which, in the United States, occurs between 3 and 5 years of age, when toilet training is usually complete [28]. At this milestone, the child is presumably (1) aware of inner body sensations that the bladder is full (2) able to initiate toilet finding behaviors in a timely fashion (3) able to contract the pelvic floor muscles until the toilet is found (4) able to empty the bladder in a coordinated fashion.

The process by which controlled urination occurs is not fully understood but is thought to be mediated by use and disuse of the “guarding reflex”. Children learn to purposefully inhibit reflex voiding and to consciously initiate desired voiding using the external sphincter as an “on and off switch” [29]. Voluntary contraction of the external sphincter, suppresses detrusor activity by stimulation of the sympathetic (holding) and inhibition of parasympathetic (releasing) responses of the lower urinary tract [26]. As children enter structured environments, such as school, they must navigate time schedules and circumstances which can distract them from noticing internal bodily sensations until they come on suddenly, necessitating extreme holding maneuvers such as leg crossing and “Vincent’s curtesy” to suppress the urge [30]. When holding behaviors are consistently prioritized at the expense of appropriate outlet relaxation during voiding, dysfunctional patterns emerge which create bladder outlet obstruction (BOO) [31]. While the majority of children acclimate with maturity, LUTD is the basis for 40% of all pediatric urology visits [32]. A study of 2856 school-age children, 5–20% had daytime/nighttime wetting with the female to male ratio of 3:1 [33]. In severe cases, such as Hinman’s syndrome, obstructive voiding patterns lead to incomplete emptying, chronically elevated bladder pressures causing reflux to the kidneys and the potential for renal loss [34]. Fowlers syndrome is another condition seen predominantly in young females with a poorly relaxing sphincter and reflexively acontractile detrusor muscle, resulting in urine retention. A key feature is decreased bladder sensation, with failure to process internal signals of fullness causing large capacity bladders [35].

Enhanced holding behaviors appear to be influenced by psychological processes and emotional stress. In a cohort of 62 women with Fowler’s syndrome, 24% had medically unexplained somatic symptoms that included loss of consciousness, limb weakness, sensory disturbance, and memory impairment. Furthermore, almost a third (31%) had psychological comorbidities such as anxiety/depression or obsessive-compulsive symptoms [36]. The latter conditions were found in 29% of children with urinary incontinence vs. 6% in healthy controls [37]. Delayed voiding is associated with an increased rate of psychosocial difficulties as well as stressful childhood experiences. These include divorce, bullying, physical and sexual abuse, adoption, moving multiple times, and death of a family member [38]. In a large epidemiologic study of 8213 children aged 7.5–9 years, children with daytime wetting had significantly increased rates of psychological problems especially separation anxiety, attention deficit, oppositional behavior, and conduct problems [39]. Studies have shown that relapse of nocturnal enuresis in children can be induced by stressful life changes such as separation and divorce [40]. Similar patterns are noted in adults with histories of childhood voiding dysfunction indicating there is an ability to regress to immature voiding patterns during periods of increased psychosocial stress [41]. One study showed that nearly 50% of patients with OAB have anxiety and or depression, with 25% having severe symptoms [42]. Proposed mechanisms for anxiety causing bladder and bowel dysfunction are based on animal studies demonstrating stress related activation of the hypothalamic-pituitary axis, which releases cortisol and adrenaline in a sympathetic response, overly enhancing outlet tone and worsening LUTs [43]. Urinary incontinence can itself be the source of anxiety and depression, suggesting that the relationship is cyclical [44, 45]. Chronic sympathetic response initiates a vicious cycle in which an individual, distressed by their incontinence, has increased psychological disturbance which perpetuates the incontinence. Regardless of the underlying mechanism, undue psychological stress during development is a proven barrier to functional voiding.

3. Diagnosing LUTD in adult females

The obstructive mechanism of LUTD in adults is similar to that in children. Incomplete relaxation of the outlet during the voiding phase can result in typical overactive bladder (OAB) symptoms such as frequency, urgency, nocturia and urge incontinence. Women who have managed to effectively suppress bladder contraction with a strong muscular outlet can develop detrusor underactivity (DU), characterized by a normal or increased capacity with “contraction of reduced strength and/or duration, resulting in prolonged bladder emptying and/or a failure to achieve complete bladder emptying within a normal time span”. According to the ICS, underactive bladder (UAB) describes a slow urinary stream, hesitancy and straining to void with or without a feeling of incomplete bladder emptying, sometimes with storage symptoms [46]. Both OAB and UAB can present with storage and emptying symptoms, requiring pressure flow studies to make the distinction, although there are no standardized parameters to confirm either diagnosis.

UAB is a common finding in women with voiding dysfunction but there is little information on the true prevalence, although it is known to be more common in the aging population [47]. The diagnosis of UAB is made when LUTS such as frequency, urgency and incomplete bladder emptying are paired with decreased voiding pressures on urodynamic testing. Uroflowmetry may show a low flow with staccato interrupted pattern and elevated post void residual or a completely normal curve with complete emptying [48]. Nitti et al. demonstrated that it is typical for women to void using less than 10 cm of water pressure to completely empty with a good urinary flow rate using subtle maneuvers such as abdominal straining [49]. Straining is a common voiding pattern in women—with and without LUTs—seen in as much as 75% of the general population of women [48]. Strain patterns are easy to overlook on pressure flow studies especially when there is a normal bell-shaped flow curve. Someone who pushes or bears down to urinate can generate substantial flow rates to rapidly empty her bladder. Despite its efficiency, investigators have warned that abdominal straining during the entire micturition process can have deleterious outcomes [50]. In one study, half of women without subjective complaints of voiding difficulty (poor stream, straining to void, hesitancy or incomplete emptying) voided with abdominal straining as a compensation for a compressed or constricted urethral outlet [3]. Investigators have found that strain and postural changes are risk factors for recurrent UTIs, lower urinary tract symptoms, pelvic organ prolapse, incontinence and bladder outlet obstruction [51].

Straining to void is seen frequently in women with stress incontinence. In a large study of 1788 patients, those with DU were more likely to report stress urinary incontinence, reduced stream, straining to void, enuresis, absent or reduced sensation, previous urinary retention and use of antidepressants [52]. When urodynamic studies in patients with and without SUI were compared, significantly lower voiding pressures were noted in women evaluated for SUI than in the normal controls [53]. Similarly, eighty-four percent of women with genuine SUI voided without a detrusor contraction compared to none of the patents without SUI [54]. In women with SUI, dysfunctional patterns such as straining and staccato voiding may be hidden by an incompetent sphincter which could obscure the diagnosis of bladder outlet obstruction (BOO). Strain voiding rarely presents with bothersome voiding symptoms and women may only seek consultation for the accompanying SUI [55]. The underlying voiding patterns are important to consider when correcting SUI because straining to void is associated with higher rates of urinary retention and lower success rates after anti-incontinence surgery. Strain voiders are more likely to develop urgency after pubovaginal sling [56]. Women who go into retention after PVS may fail the surgery by loosening the sling through bearing down behaviors [57].

Straining maneuvers are also a risk factor for pelvic organ prolapse (POP) [58]. Forty-one percent of women with POP have DU, voiding symptoms and incomplete emptying, with larger defects having a greater likelihood of underlying DU and voiding dysfunction [59]. Chronic constipation is highly associated with all degrees of POP. In one study, after controlling for important covariates, straining at stool remained associated with anterior vaginal wall and perineal descent [60]. When researchers compared urodynamic patterns of patients with SUI, with and without anterovaginal wall prolapse, women with prolapse had higher urethral resistance during the voiding phase, even with cystocele reduction. The authors concluded that patients with prolapse have DU with elevated BOO that is not related to a structural abnormality [61]. The generation of POP is a good demonstration of the complex interplay between structure and function. Women who have obstructed elimination patterns develop weakness in their vaginal walls through straining which then worsen the obstruction by further compressing the opening. Without knowing the “pre-prolapse” voiding pattern, clinicians may assume the obstruction is caused by the prolapse, and not the reverse.

4. Understanding pelvic floor function and dysfunction (PFD)

The pelvic floor muscles work in tandem with the anal and urethral sphincters to control urination and defecation. The levator ani muscles—the pubococcygeus (PCM) and iliococcygeus (ICM) muscle—comprise the deep floor. The superficial muscles, which are caudal to the deep floor, are the urethrovaginal sphincter (UVS), compressor urethrae (CU) muscle, the ischiocavernosus, and bulbospongiosus muscles complex [62]. The puborectalis (PR), often considered part of the superficial floor, is a muscular sling with two well-developed parallel fascicles that insert anteriorly in the pubis, and fuse together behind the rectum at the top of the anal canal. The traction of the PR maintains anorectal angulation and places pressure on the opening of the anus, urethra and vagina to constrict these openings against the pubic bone [63]. The deep muscles of the pelvic floor serve to support the pelvic organs, working synergistically with the thoracic diaphragm and abdominal wall to maintain low intrabdominal pressure (IAP). The superficial muscles, including the UVS and CU components of the external urinary sphincter (EUS) and the PR muscle are concentrically placed and work in tandem to compress the three openings of the pelvic floor—the urethra, the vagina and the rectum—during elevated IAP. This constriction is often involuntary, as during positional changes, creating a high pressure zone of the vagina [64]. As in the case of the lower urinary tract, higher cortical functions are needed to balance voluntary control with the involuntary contraction necessary for activities and positional changes [65].

Pelvic floor dysfunction is a generalized term which describes a group of muscular conditions characterized by either hypotonic (weak) or hypertonic (overly tense) muscles. The classic teaching is that women with hypotonic muscles have SUI and POP whereas women with hypertonic muscles have irritative symptoms and pelvic pain syndromes, although this may be an oversimplification. In 2021, the ICS published an updated list of terms which are used in the neuromyofascial assessment and diagnosis of pelvic floor muscle disorders to aid teaching and standardization of terminology in this field. Hypertonic pelvic floor disorders are defined by increased “resting tension clinically determined by resistance to passive movement” [66]. Elevated pelvic floor tone and myofascial levator tenderness is seen in 87% of patients with chronic pelvic pain and IC/PBS [67]. The development of myalgia maybe related to the degree of spasm with higher tone causing higher pain levels. Chronic elevated resting tension is often cited as the basis for the majority of pelvic floor pain and dyspareunia, causing local impairment of blood circulation and the exchange of oxygen and metabolites, leading to dysmorphic changes in muscle structure and neuropathic pain [68].

While many clinicians are familiar with pelvic floor “tension”, chronic pelvic muscle clenching (CPMC) is an unconscious, habitual overuse of the guarding reflex. The ICS has acknowledged the need for a new term, “involuntary contraction” which is defined as “pelvic floor contraction which occurs reflexively or automatically, without volition or conscious control” [66]. Involuntary movements in the pelvic floor help support continence and elimination, however a significant portion of activity may also be utilized to manage emotional states. Psychological stress leads to chronically high tone in the pelvic floor [69, 70]. Women are typically unaware of increased pelvic tone nor do they associate the state of their pelvic muscles with their symptoms. Some women continuously tighten their muscles for fear of losing urine or stool. The cycle of increased outlet tone causing worsening BOO and LUTs, leading to reflexive increase in voluntary pelvic muscle clenching to prevent leakage is a common occurrence. Clenching is also used as a protective response to pain in the visceral area, or if pain is anticipated causing further tightening and further discomfort [68].

For reasons not clearly understood, sensorimotor control of the pelvic floor muscles is underdeveloped in many women. Only a minority of women are able to correctly engage their muscles despite confidence that they are exercising correctly [71]. Multiple reasons for the diminished proprioception seen in women with and without pelvic floor disorders have been proposed, including an inability to visualize or “map” the pelvic floor muscles, lack of information about pelvic floor anatomy, and conflicting messages given to women from a very young age. There is also considerable cultural, racial and generational differences in women’s comfort levels with discussion on the subject of urogenital functions [23]. Unawareness of the pelvic floor muscles is closely associated with pelvic floor disorders. Fifty-three percent of women with SUI are unable to perform coordinated pelvic floor movements with simple verbal instructions [72]. When women with and without functional constipation were compared, those without obstruction had a better ability to identify and relax their pelvic floor muscles [73]. Regardless of their condition, clinicians routinely counsel women to perform Kegel’s or pelvic floor tightening exercises without emphasizing pelvic relaxation [74]. Women with high tone pelvic floors can experience increased pelvic pain and worsening organ dysfunction if they engage in unsupervised strengthening exercises [75]. Rigorous exercise programs such as cross fit, which emphasize core strengthening, can have the adverse effect of enhancing pelvic spasm by incorporating the pelvic floor [76].

The challenge for the clinician is to be able to diagnose high tone PFD and when there is extreme variability in its presentation. Female pelvic muscle strength is difficult to assess, particularly when there is an overall weakness in the vaginal walls, as in the case with POP. Some women with pelvic muscle tears, weakened deep levator muscles and widened genital hiatus can still have high tone/outlet pressure even though there is little resistance to the examiners finger on palpation. Some women who appear to have weakened strength have so much muscle tension at “rest” that they are unable to further contract to execute an effective squeeze around the examiner’s finger. While a physical examination of the myofascial structures can show elevated resting tone of the puborectalis muscle, as determined by digital palpation, there is poor reliability [77]. Numerous scoring systems have been developed which rely on subjective quantification of tone and function and have not been validated [78]. Other assessment techniques, including transperineal ultrasound, manual muscle testing, and squeeze pressure measurements, have similarly produced unreliable results [79]. Levator tenderness is a sufficient but not a necessary criteria for high tone PFD as many cases do not result in pelvic floor myalgia or allodynia [80]. Due to the likelihood of discoordination of the pelvic floor muscles in LUTD, high tone PFD and CPMC are the diagnoses to be excluded in all patients with LUTs and incontinence.

5. A functional theory of SUI

LUTD leads to strain assisted voiding patterns which have the potential to cause distortion in the vaginal wall including bladder neck hypermobility and pelvic organ prolapse, particularly after childbirth. Even small amounts of continuous pressure on the weakened pelvic support tissues may prevent damaged fascia, ligaments and muscles from regaining their nulliparous structure [81, 82]. Delancey proposed that stress urinary incontinence develops from damage to the support of the urethra which requires a strong backboard to maintain function [83]. As described by Petros and Ulmsten in their integral theory, the mechanism is made possible by several anatomical structures. Most importantly, the pubourethral ligaments (PUL) attach the pubic bone to the midurethra and the external urethral ligaments (EUL) affix the muscular components of the distal urinary sphincter—the CU and UVS—to the undersurface of the symphysis pubis. The vaginal hammock is a fascial condensation extending between these two ligamentous structures. The integrity of the PUL allows the distal muscles of the EUS to approximate with the urethral crest (UC), the cavernosal type tissue of the distal urethrovaginal septum which is analogous to the verumontanum in males. When the CU and UVS contract, they exert a downward force on the lumen of the urethra, compressing this tissue and creating a strong seal for continence. The configuration is important in that it implies that the closure of the urethra by the EUS is done slit-wise by compressing the ventral part against the dorsal part instead of closing in a purely circular way. The authors referred to this mechanism as the ‘first closure mechanism’ (Figure 1) [84].

Figure 1.

External urinary sphincter closure mechanism. (1) Open EUS during pelvic floor relaxation and functional urination and (2) downward force of EUS muscles on urethral crest creates continence seal.

Women with chronic DU who use straining against a narrow outlet to void are at risk for developing sphincter damage and SUI after a vaginal delivery. Loss of urethral support through vaginal distortion compromises the alignment of the CU and UVS over the UC which prevents the occlusive seal needed to prevent leakage when the IAP rises. A closer look at this mechanism is demonstrated in Figure 2. The EUS muscles are stabilized by the EUL which remains relatively unharmed by childbirth. In contrast, the UC is part of the distal anterior vaginal, normally stabilized by intact PULs which are primarily injured in vaginal delivery. In women with SUI, during cough or valsalva, there is rotational movement of the external meatus around the intact EUL causing the UC to become displaced (Figure 2(2) and (3)). When the EUS muscles clamp down to make contact with the UC, the target is missed causing an insufficient occlusive seal. The amount of movement required to produce leakage depends on multiple factors such as striated muscle atrophy as seen with aging, estrogen deficiency, genetic tissue quality, urethral scarring, fibrosis and denervation of the EUS muscles. Purportedly, the MUS procedure works to realign the sphincter component by preventing the rotational motion that destabilizes the EUS complex.

Figure 2.

External sphincter complex misalignment. (1) Pre-cough position—compressor urethrae (CU) and urethrovaginal sphincter are aligned with urethral crest (UC), (2) sphincter misalignment with cough. EUL = external urethral ligament, PUL = pubourethral ligament, SSU = striated sphincter urethrae, (3) 90 degree muscle misalignment during cough causing leakage of urine and (4) reconstruction of EUS with polyacrylamide hydrogel.

In the current model, poor apical support would also compromise EUS alignment, and therefore, the function of the first closure mechanism. In the integral theory, the “second closure mechanism” relies on both functioning PULs as well as apical support of the vaginal wall. Poor proximal urethra support, as exists when there is significant apical prolapse, prevents the necessary backward motion of the levator plate which then fails to stretch the proximal urethra at the zone of critical elasticity (ZCE), impairing bladder neck closure. This plate stretching may also be important for EUS alignment. The authors stated that “an intact first closure mechanism is an important prerequisite for the proper functioning of the second closure mechanism” [84]. Elevating the apical anterior vaginal wall in patients who have significant bladder neck hypermobility, would potentially reduce the separation of the UVS and CU, and pull the urethral crest back into approximation with the EUS muscles. In patients with prolapse and SUI undergoing mid-urethral sling, patients with tighter USL repairs had better continence outcomes than those with loose USL repairs [85]. The idea of apical support facilitating EUS closure seems counterintuitive when one considers the similarly appearing but entirely distinct mechanism of unmasking occult stress incontinence in patients who have apical prolapse repairs. In these scenarios, prolapse correction unobstructs the bladder neck, increasing the flow to and unveiling a weakly functioning EUS. Therefore, EUS closure is also dependent on substantial tissues for creating a seal. Realignment of the EUS through vaginal suspension alone will not work to cure incontinence in the setting of striated muscle damage.

As we further delineate the pathophysiology of SUI, potential new treatment modalities emerge. For example, urethral injection therapies or bulking agents have been variably effective in decreasing stress incontinence symptoms in patients with SUI, but they are routinely placed in the proximal urethral/bladder neck. An alternative technique would be to inject the muscular components of the external sphincter muscles and urethral crest to create an artificial seal of the sphincter complex without the need to surgically correct the support defect (Figure 2(4)). In patients with severe misalignment defects, injecting the EUS with enough of the agent to create a seal may not be possible without drawing back the anterior vaginal wall and posterior urethra by addressing apical prolapse. Understanding the role that voiding dysfunction, specifically strain voiding, plays in the generation of SUI is crucial to the success of this type of injection. Women with SUI generally do not relax their pelvic muscles to void and rely on the incompetency of the EUS to facilitate emptying. Enhancing the closure strength of the EUS could potentially cure SUI but also cause retention or LUTs in women who have not learned to relax their PR muscle and voluntarily open the EUS during voiding. Persistent post injection pushing behaviors could displace or dislodge a product before its full incorporation into the tissues, necessitating repeat treatment. Fortunately, women are easily incentivized to reverse their toileting habits when they are (1) alerted to the existence of the behaviors, and educated on their contribution to the leakage condition (2) told of the importance of correcting behaviors in order to have successful treatment outcomes and (3) taught how to voluntarily relax the PR muscle.

6. Correcting voiding dysfunction and CPMC

Most women with and without pelvic floor disorders would likely benefit from a tutorial on pelvic floor awareness and healthy toileting habits. Multiple professional societies have developed evidence-based guidelines for the evaluation and treatment of female UI, including the American Urological Association (AUA), the Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction (SUFU), the American College of Obstetricians and Gynecologists (ACOG), and the American Urogynecologic Society (AUGS), as well as international societies, such as the International Urogynecological Association (IUGA) [86, 87]. Behavioral management including dietary considerations, bladder retraining and pelvic floor exercises and/or pelvic floor therapy are the first line treatment of all pelvic floor disorders yet there is no standardized approach to these modalities nor are providers routinely trained on these techniques. Furthermore, referrals to outpatient pelvic floor therapists have poor attendance rates [88]. Ideally, the initial comprehensive visit should incorporate an introduction to pelvic floor awareness to ensure there are sensorimotor skills necessary for healthy toileting.

6.1 Manual therapy

During routine pelvic exam, the provider can guide the patient in her execution of three achievable pelvic floor positions and confirm her proprioceptive understanding. The ability to relax and contract the muscle layers of the pelvic floor—the levator ani muscles and the PR muscle—is critical to the assessment of pelvic floor function [89]. Proper patient positioning on the exam table is crucial—supine recumbent with pressure off the buttocks onto the sacrum, and the legs bent with the soles of her feet flat on the table, is ideal for pelvic muscle assessment. The examiner gently inserts their finger into the vaginal opening and tests for sensation including discomfort. Normally, women will be in “clench” upon initial insertion. The highest/tightest position is “superclench” or Kegel, which is contraction of the lower abdominal muscles, the transversus abdominal, the gluteal muscles and the deep levator ani muscles to move the rectum and vagina forward against the bladder by elevating the levator plate [90, 91]. In this position, the superficial muscles, including the PR muscle, are also contracted (Figure 3(1)). Superclench involves core strength which is difficult to sustain due to muscle fatigue, but can be improved with core exercise therapy. The middle position is “clench” in which the deep muscles are relaxed but the PR and superficial muscles are contracted (Figures 3(2) and 4(1)). Clench of the PR produces an anorectal angle which puts pressure on the openings of the urethra, vagina and anus to help store stool and urine and is the resting position for most women [92]. Both clench and superclench involve contraction of the PR but superclench adds the elevation of the levator plate. In order to urinate, defecate, or have comfortable sexual intercourse, women must release both the levator plate and the PR tension on these structures and move into the relaxed position (Figures 3(3) and 4(2)). In general, resting tone in the pelvic floor refers to the tone of the PR in clench, and strength refers to the grip strength of superclench.

Figure 3.

Three positions of pelvic floor. (1) “Super clench”. Elevated pubococcygeus (PCM), iliococcygeus (ICM), levator plate (LP). Contracted puborectalis (PR) and urethrovaginal sphincter (UVS). Kegel exercise. (2) “Clench”. Relaxed PCM, ICM, levator plate. Contracted PR and UVS. Walk around position and (3) “relax”. Relaxed PCM, ICM, LP. Relaxed PR and UVS. Position for micturition/elimination.

Figure 4.

Clench and relax—puborectalis release. (1) “Clench”. Patient in semi supine with sacrum on the table. Puborectalis (PR) in raised position, (2) “relax”. Position needed for elimination/micturition. Relaxed PR.

Manual therapy serves the dual purpose of teaching proprioception and facilitating coordinated muscle motion through feedback provided by the examiner. Superclench is tested first and she is given feedback regarding holding strength. Gentle pressure on the back of the vagina over the PR muscle teaches her to voluntarily relax it, a technique described by Thiele in the 1960s [93]. Diaphragmatic breathing helps to relax the PR and can be taught even prior to exam. When the PR is released, the examiner tells her that she should be in this position during urination and defection (Figure 1(1)). Once the patient learns full relax, she is instructed to move from position to position gaining feedback from the examiner to confirm understanding. Myofascial puborectalis release has been shown to be effective in improving overactive bladder symptoms, and interstitial cystitis/PBS in multiple studies [94, 95, 96]. Adding a course of a pelvic floor relaxant such as vaginal Valium, or trigger point injections using various compounds including Botox have been shown to be effective in refractory cases. PRMT with or without biofeedback can reinforce learning how to operate the muscles in patients desiring more intensive training [97]. Biofeedback therapy has traditionally been used to treat dysfunctional voiding with good success in the pediatric population [98]. In a study of 958 postpartum women, instructional biofeedback was shown to have a beneficial effect in 73.6% [99]. It has also been shown to be useful in the correction of long term voiding dysfunction and recurrent urinary tract infections in adult women [100]. The most recent Cochrane review on the subject reported level 1 evidence that PFMT is successful in the conservative management of urinary incontinence [101].

6.2 Deep diaphragmatic breathing (DDP)

Normal breathing, also known as deep diaphragmatic breathing (DDP), involves synchronized motion of the upper rib cage, lower rib cage, and abdomen. Abnormal breathing, known as thoracic breathing, involves breathing from the upper chest, evidenced by greater upper rib cage motion, compared to the lower rib cage [102]. The pelvic floor muscles physiologically act as expiratory muscles in synergy with the anterolateral abdominal muscles, contracting during expiration and relaxing during inspiration. These coordinated movements facilitate blood flow and oxygen exchange without significant expenditure of energy during restful breathing [103]. When DDP is performed correctly, by inhaling through the nose, contracting the diaphragm and expanding the lower abdomen, there is an automatic release of the pelvic floor musculature, and external sphincters. Teaching patients to perform DDP while urinating and defecating is a useful modality to ensure complete pelvic floor and sphincter relaxation to facilitate unobstructed elimination. Patients can also be taught hypoopressive exercises (HE) which promote synergistic muscle movements of the diaphragm and abdominal wall utilizing DDP. One study showed that an 8-week HE program provided benefit in perineal function and decrease symptoms related to PFD and UI. In addition, HE had no adverse effects and treatment adherence was high (97%) [104].

6.3 Adult re-toilet training

Childhood toileting habits are deeply stored in primitive brain structures and unless they are pointed out and corrected, they are likely to persist. Women may not be cognizant of their voiding habits and should be asked to observe themselves to gain insights to their own patterns. Information on the negative effects of abdominal strain to void and defecate should be emphasized as this information is not widely available. Encouraging women to pay attention to and prioritize their own bodily needs is often the first step to developing bladder control. The main goal of bladder retraining is to learn to urinate without using an involuntary bladder contraction to void. In order to do so, women should monitor their fluid intake to be able to time her voiding episodes so she can void before the urge is strong [105]. She will train herself to relax the PR to initiate the bladder contraction and facilitate full emptying. Diaphragmatic breathing techniques can be used to voluntarily open the striated outlet muscles during voiding to allow the bladder to empty without pushing or straining. Depending on the degree of detrusor dysfunction, as bladder outlet obstruction is mindfully corrected, bladder stability can be restored. The process takes time and can be facilitated by overactive bladder medications if necessary. In cases where conservative methods have been unsuccessful, second line therapies such as Botox of the EUS/pelvic floor and neuromodulation, modalities used in pediatric patients with refractory BBD, can be considered [106, 107].

7. Conclusions

Unhealthy toileting habits are behavioral conditions which are established early in childhood and have the potential to manifest symptoms throughout the course of a woman’s life. Depending on multiple factors, such as childbirth, hormonal status and psychosocial stress, the chronic failure to relax the pelvic outlet results in obstructed elimination and a wide spectrum of structural changes in the lower urinary tract anatomy which then become the focus of surgical treatment. Because these behaviors are unconscious, patient education to make her aware of the condition is integral to the process. In the absence of an underlying neurological condition, most women can reverse the dysfunctional toileting behaviors just by becoming informed of their existence. For some women, there is a need to have visceral feedback to understand the problem. These patients often demonstrate partial or complete sensorimotor dissociation from their pelvic floors muscles, unable to feel sensations or only to feel aberrant sensations and unable to exercise muscular control in this region. There is a need for validated and clear cut instructions on how to perform behavior therapies and exercises to help women learn to control the pelvic muscles, without the need for intensive pelvic floor therapy. On the toilet, deep diaphragmatic breathing techniques open the external sphincter to facilitate unobstructed voiding. Education on toileting habits by public health initiatives, pediatricians and gynecologists, prior to the onset of childbirth, will potentially avert structural changes later in life. Although pelvic floor awareness, education and re-toilet training may not benefit all cases of CPMC, motivated women can be taught to develop their interoceptive and pelvic motor skills, and observe their own toileting habits to correct their LUTD. This is especially important to undertake before any surgical procedure for urinary incontinence or prolapse is performed.

Conflict of interest

The author declares no conflict of interest. To all my teachers, most importantly the many patients who showed me what needed to be learned.

Notes/thanks/other declarations

C.G. Jung—‘Until you make the unconscious conscious, it will direct your life and you will call it fate.’