Introduction

Pelvic floor dysfunction (PFD) is a condition where the muscles that support the bladder, rectum and uterus do not work correctly. PFD can be caused by ageing, trauma, or childbirth and presents with bowel issues such as constipation, pelvic pain, and both urinary and bowel incontinence. Tenesmus is described as a persistent urge to urinate or have a bowel movement, with or without pain. PFD may result in tenesmus as it impairs the muscles’ ability to relax when using the toilet. Therefore, it is important to understand the connection between both conditions for appropriate diagnosis and management.¹

Pelvic floor dysfunction (PFD)

Anatomy and function of the pelvic floor muscles

The pelvic floor consists of connective tissues and muscles at the bottom of the pelvis. These muscles support vital organs such as the bladder, the rectum, the uterus in women, the prostate in men. They help regulate the expulsion of urine, faeces, and gas as well as sexual function. The pelvic floor muscles contract and relax together, providing optimal bladder and bowel control and supporting the pelvic organs during physical activity like walking and lifting,
or sneezing.²

Causes of PFD

Several factors can cause PFD, including:¹

• Vaginal childbirth, especially with extended labour, may overstretch or injure the pelvic muscles and nerves, causing dysfunction
• With increasing age, the strength of pelvic muscles declines naturally, resulting in loss of pelvic organ support
• Injury to the muscles or nerves in the pelvis, often caused by a fall or accident
• Surgery, especially pelvic surgery (e.g., prostate surgery or hysterectomy), can weaken or damage pelvic floor muscles
• Obesity can put additional strain on the pelvic floor, leading it to weaken over time

Symptoms of PFD

Symptoms of PFD vary but tend to present with:

• Leakage of urine during coughing, sneezing, or exercising
• Soreness or pain in the pelvis that increases with activity
• Inability to manage bowel movements, constipation, or a feeling of
  incomplete evacuation
• Painful intercourse or a feeling of pelvic fullness
• Prolapse: a feeling of pressure or bulging in the pelvis, typically indicating that pelvic organs are slipping

Understanding tenesmus

Tenesmus is the constant urge to pass stool or pee, even when the bladder or bowel is empty. This feeling is frequently accompanied by pain and trouble with complete emptying. There are two types of tenesmus: rectal and urinary. Urinary tenesmus is the urge to urinate even when the bladder is empty, whereas rectal tenesmus is the urge to pass faeces after having recently had a bowel movement.

Tenesmus is frequently caused by inflammatory bowel diseases (IBD), such as Crohn's disease or ulcerative colitis, which inflame the intestines and can result in rectal tenesmus.³ Tenesmus can also be brought on by illnesses that irritate the bladder or rectum, such as urinary tract infections (UTIs) or gastrointestinal diseases. Nerve impulses that regulate bladder and bowel movements can be disrupted by neurological disorders like multiple sclerosis or spinal cord damage. Tenesmus can also result from PFD, a condition in which weak pelvic muscles make it difficult to fully evacuate the bladder or bowel.

The relationship between PFD and tenesmus

With PFD, changes in muscle function such as weakness, tension or incoordination can result in tenesmus. These functional changes can create a feeling of incomplete evacuation, and difficulty in emptying of the bladder or bowel. Urgency and discomfort may increase if pelvic muscles are unable to relax when using the toilet. Tense pelvic muscles can also create a feeling of pressure, and therefore the need to use the toilet regularly.¹

Diagnostic devices for PFD

PFD can be diagnosed in the following ways:

• Pelvic floor testing: biofeedback or manual testing examines muscle coordination and strength
• MRI: provides pelvic floor muscle images to detect abnormalities or prolapse
• Manometry: evaluates pressure and function of the anal sphincter and pelvic muscles to identify bowel dysfunction

Diagnostic techniques for tenesmus

A clinician may diagnose tenesmus in the following ways:

• Rectal exam: diagnoses muscle tension or rectal abnormalities that cause rectal tenesmus
• Colonoscopy: examines the rectum and colon for illnesses like ulcerative colitis or Crohn's disease
• Bladder function tests: cystoscopy or urodynamics evaluate conditions of the bladder that lead to tenesmus of the urine

Importance of complete evaluation

Complete evaluation of both tenesmus and PFD is necessary for correct diagnosis and proper management. Since the two usually overlap, both need to be diagnosed to deliver focused therapy and improved outcomes.

Treatment options

There are several treatment methods for both PFD and tenesmus, ranging from physiotherapy, medications, behavioural modifications and surgery.

Physiotherapy for pelvic floor rehabilitation

• Biofeedback: using sensors to monitor muscle activity and deliver immediate feedback helps patients learn to control pelvic floor muscles better.
• Pelvic floor exercises: Kegel exercises strengthen and coordinate the pelvic floor muscles, helping control the bladder and bowel and alleviate symptoms of tenesmus.

Medications for controlling symptoms of tenesmus

• Anticholinergics: These medications can relax bladder spasms and urgency, relieving urinary tenesmus
• Pain relievers: NSAIDs or other analgesics can be used to relieve pain caused by tenesmus, especially in conditions like interstitial cystitis or IBD

Behavioral interventions

• Bowel training: Regular bowel schedules and timing relieve constipation and alleviate rectal tenesmus
• Dietary modification: Altering the diet to include more fibre or increasing fluid intake helps reduce constipation and enhances bowel function, thereby lessening symptoms of tenesmus

Surgical treatments

• Sacral Nerve Stimulation: a minimally invasive technique where a device placed under the skin of the buttocks delivers electrical impulses to the sacral nerves to improve pelvic floor muscle function and decrease tenesmus symptoms¹
• Pelvic Floor Surgery: in severe instances, surgery may be required to fix pelvic floor prolapse or repair damaged muscles¹

Multidisciplinary care role

Multidisciplinary care is required for the treatment of both PFD and tenesmus. A multidisciplinary team of gastroenterologists, urologists, and physiotherapists can offer integrative care, combining medical treatments, physiotherapy, and lifestyle change to treat both the underlying causes and symptoms of these conditions.⁴

Challenges in management

Complexity of treating comorbid PFD and tenesmus

It is not always easy to treat tenesmus and PFD simultaneously as their symptoms are similar. Since both conditions involve abnormalities in pelvic muscle function, identifying the primary issue and deciding which should be treated first can be challenging. Furthermore, treatments for one condition might not effectively treat the other, so a more individualised approach might be necessary.

Individual variation in treatment response 

Each patient responds uniquely to interventions, so it is important to implement interventions based on individual needs. Age, symptom severity, and co-morbid conditions (such as IBD or interstitial cystitis) are all factors that may influence the extent to how a patient responds to physical therapy, medication, or other interventions. ⁴

Patient education and ongoing monitoring

Patient education plays a critical role in the management of both disorders. Educating patients on proper pelvic floor exercises, dietary adjustments, and follow-up treatment as needed can increase compliance and improvement. Regular follow-ups must also be carried out to monitor progress and make adjustments to the treatments as indicated to ensure prolonged relief and relapse prevention. ⁴

Prognosis and outlook

Long-term management strategies

Treatment for tenesmus and PFD typically involves ongoing care. Medication, physiotherapy and behavioural therapies including bowel training and dietary changes, are all part of long-term treatment. It is possible to modify the treatment plan as necessary by following up with medical professionals. For more severe or chronic cases, pelvic floor surgery or sacral nerve stimulation may be provided.

Space for improvement through early intervention

Early intervention is necessary to improve outcomes. PFD and tenesmus symptoms can be significantly reduced, and the progression of muscular weakness can be stopped. Most patients who receive the right care see a noticeable improvement in their ability to regulate their bowels and bladder, which enhances their quality of life.

Importance of lifestyle changes and adherence to treatment regimens

Changes in lifestyle, such as maintaining a healthy weight, doing regular pelvic floor exercises, and adding fibre-containing foods to treat constipation, are essential for symptom management. Following treatment plans is crucial for a long-term prognosis since it prevents pelvic floor degeneration and relieves tenesmus symptoms.

Summary

• Tenesmus can be brought on by PFD, which interferes with bladder and bowel control and results in a chronic feeling of incomplete evacuation
• Physiotherapy, medication, behavioural adjustment, and surgery if required, are all part of the holistic treatment system
• To give patients the best care possible, further research is required to improve knowledge of PFD and tenesmus, as well as their diagnosis and treatment