Background: In pelvic physical therapy practice, therapists intend to treat pelvic floor complaints holistically. The most common pelvic floor complaints in premenopausal women include urinary and fecal incontinence, micturition and defecation problems, pelvic organ prolapses, pelvic pain, and painful intercourse. Pelvic floor complaints tend to negatively affect women’s daily, social, and sexual function and their intimate relationships and are often accompanied by sexual and psychological distress. Pelvic floor complaints are also known to be associated with pregnancy and parity. Not all women experiencing pelvic floor complaints receive pelvic physical therapy treatment, implying that there are more contributing factors to receiving treatment than pelvic floor complaints alone.

Aim: This study investigated the predictive value of pelvic floor complaint severity, sexual function problems, and psychological distress of premenopausal pregnant, parous, and nulliparous women, aged between 18 and 45 years, who were receiving pelvic physical therapy treatment.

Study Design: To better understand the psychological burden of women with pelvic floor complaints two mixed-method studies were performed. Forty-eight women with pelvic floor complaints, who did and did not receive pelvic physical therapy treatment were interviewed about the restrictions and distress they experienced in their daily, social, and sexual functioning, as well as in their intimate relationships. Text mining analyses were performed to create a more comprehensive overview of women’s restrictions and distress with pelvic floor complaints. The group concept mapping method was used to develop a conceptual model of psychological distress. In addition, psychometric analyses were performed using statements from the interviews to develop a new instrument to measure women’s psychological burden with pelvic floor complaints. In a file review study, twenty-two pelvic physical therapists provided data about 366 women in their practices. This data included recorded pelvic floor complaints, types of distress, and pelvic floor muscle function in the files of pregnant, parous, and nulliparous premenopausal women receiving their treatment to gain more insight into combinations of complaints and distress from pelvic physical therapists’ perspectives. To explore pelvic floor complaint only and combined pelvic floor complaint and distress profiles, latent class analyses were performed. To include women’s experiences, an online survey was held to examine the predictive value of pelvic floor complaint-related, sexual, and psychological factors for receiving pelvic physical therapy treatment. More than 600 women with and without pelvic floor complaints participated in this survey. More than 400 women also completed the Implicit Association Test that was specially designed for this research. In the Implicit Association Test, aspects of intrinsic motivation were examined and operationalized as the strength of women’s implicit associations between pursuing help and sexual function problems. The predictive value of these variables for receiving pelvic physical therapy was analyzed using binary logistic regression analyses.

Results: A comprehensive overview and conceptual model of women’s sexual and psychological distress, and an instrument to measure women’s psychological burden with pelvic floor complaints were developed. Seven types of distress were most characteristic for pregnant, parous, and nulliparous women with pelvic floor complaints. The conceptual model indicated six clusters of distress around the edges, including ‘loss of control’, ‘feeling wronged’, ‘feeling helpless’, ‘feeling angry’, ‘feeling disappointed’, and ‘sexual distress’. The seventh cluster of ‘feeling insecure’ was positioned in the center of the model, indicating a pervasive association with the other types of distress (see Figure 1) (1). Psychological burden as measured with the new Pelvic Floor Complaint-related Psychological Burden Inventory was a stronger predictor of receiving pelvic physical therapy treatment than pelvic floor complaint severity. Women’s level of sexual function was not predictive, although it was significantly lower in women with pelvic floor complaints (2). However, at an implicit level, a more positive intrinsic motivation to pursue help for sexual function problems was also predictive of receiving pelvic physical therapy treatment. Four statistically and clinically relevant pelvic floor complaint profiles were identified from the data from the patient files. One profile, including a high probability of pelvic pain, was most likely encountered among pregnant patients. Two profiles, of which one with higher probabilities of fecal incontinence and defecation problems, and the other including higher probabilities of urinary incontinence and pelvic organ prolapses were likely to be encountered among parous patients. The fourth profile, including high probabilities of micturition problems and painful intercourse, was most likely found among nulliparous patients (see Figure 2). Distress was sparsely recorded, hindering the analyses of combined complaints and distress profiles. Increased pelvic floor muscle tone was the most commonly encountered pelvic floor muscle function (3).

Interpretation of results: The psychological distress that women with pelvic floor complaints experience appears subgroup- and context-related. The finding that psychological burden was a stronger predictor of receiving pelvic physical therapy treatment and that psychological distress is sparsely recorded in patient files by therapists might indicate a gap in the intended holistic treatment approach in pelvic physical therapy. Sexual function problems based on the sexual response cycle alone were not predictive of receiving pelvic physical therapy. However, when painful intercourse was included as a sexual function problem in the context of intrinsic motivation, sexual function problems were also predictive of receiving treatment. Psychological factors are important reasons to receive pelvic physical therapy, but the question arises if these are being addressed appropriately to the benefit of the patients. The role of sexual function problems in pelvic physical therapy is complex, because of the many influencing and contributing factors to these problems, and more research is needed to better understand their impact on the women who receive pelvic physical therapy treatment.

Conclusion: More in-depth insight into the combinations of and associations between pelvic floor complaints, sexual function, and psychological distress, added to a better understanding of characteristic features in the pregnant, parous, and nulliparous premenopausal women who received pelvic physical therapy. This knowledge may help healthcare providers to better inventory and explain their patient’s complaints, and integrate pelvic floor, sexual and psychological factors into their working procedures. Intertwining and combining pelvic floor, sexual, and psychological functioning in pelvic healthcare may ultimately improve holistic pelvic healthcare in this group of patients. More research is needed to answer the many follow-up research questions that arose during this research. Furthermore, the extent of combined competencies that are needed by pelvic health professionals needs to be assessed, to optimize care and collaboration with other pelvic health providers to benefit their patients.

Brand, A.M., Rosas, S., Waterink, W., Stoyanov, S., van Lankveld, J.J.D.M.: Conceptualization and Inventory of the Sexual and Psychological Burden of Women With Pelvic Floor Complaints; A Mixed-Method Study. Sexual Medicine 10(3), 100504 (2022). doi:https://doi.org/10.1016/j.esxm.2022.100504
Brand, A., Waterink, W., van Lankveld, J.: Sexual functioning is not, but psychological burden is predictive for seeking help in pelvic physical therapy practice: A cross-sectional study. Open Research Europe 3(141) (2023). doi:10.12688/openreseurope.16138.1
Brand, A.M., Waterink, W., Kavelaars, X., Van Lankveld, J.J.D.M.: Pelvic Health Problems in Young Adult Women; A File Review Study in Pelvic Physical Therapy Practices in the Netherlands [Manuscript submitted for publication].

Continence 12S (2024) 101613
DOI: 10.1016/j.cont.2024.101613