Cancer Treatment and Pelvic Floor

So I wanted to jump in with some content on how cancer treatment can impact the pelvic floor and what you can do about it - whether it may help you, your patients, or your parents, being prepared can help you navigate the effects on your pelvic health.  This article goes out to my mum, a truly inspiring cancer survivor and amazing woman. This also goes out to all of the women’s health angels out there, your work and impact on the community and their families is incredible - Rosie xo

The symptoms of gynaecological cancers depend on where the tumour is situated, the size of the tumour and how quickly it is growing.

According to Cancer Australia, symptoms that may be caused by gynaecological cancers include:

• abnormal or persistent vaginal bleeding – for example, bleeding after menopause, bleeding that is not part of menstrual periods, or bleeding after sex
• unusual vaginal discharge
• pain, pressure or discomfort in the abdomen
• weight loss
• swelling of the abdomen
• change in bowel or bladder habits
• pain during sex
• itching, burning or soreness in the pelvic region
• lumps, sores or wart-like growths.

Please Note: There are a number of conditions that may cause these symptoms. If any of these symptoms are experienced, it is important that you talk to a doctor.

Women’s Health related Cancers - treatment and the pelvic floor

Unfortunately, women with bladder or anal cancer, women with gynecological cancers (endometrial, ovarian, cervical, vulvar and vaginal), and men with prostate cancer can all experience pelvic floor dysfunction (PFD). Gynaecological cancers make up 10.9% of female cancers, and are more likely to have overlay to pelvic floor health than general cancers, but the pelvic floor can also be affected by cancer treatments (for any type of cancer) and side effects as well - read on to find out why, and what you can do to reduce the impact and improve your or your patient’s quality of life during this trying time.

IUGA-ICS definition of the pelvic floor 

The terminology relating to the Pelvic Floor has changed considerably over time, and in 2017 the following ICS / IUGA definition was issued : 

The Pelvic Floor is considered to comprise “structures located within the bony pelvis, i.e urogenital and anorectal viscera, pelvic floor muscles and their connective tissues, and nerves and blood vessels” (2) (3)

The pelvic floor is therefore a complex region constituting not only muscles, but fascia, organs, neurovascular structures, and so when viewed this way is easier to understand the impact of surgery, chemotherapy and treatment - it’s not simply a sheet of muscles associated with continence, but a support system for our internal organs, passageway and sphincteric control of bladder and bowel movements, sexual intercourse, and much, much more.

In the context of cancer treatment, the pelvic floor can be affected by : 

• Surgical procedures involved in cancer treatment  - depending on the tumor size, location and stage, such as tumour debulking, Hysterectomy, Salpingo-oopherectomy (removal of fallopian tubes and ovaries). 
• Surgical procedures within the pelvic region can directly affect PFM through scar tissue restriction and swelling.(4)
• The hormonal impact of surgical procedures can also indirectly affect the pelvic floor muscles - similarly to the effect of hormones on connective tissue in pregnancy and breastfeeding - leading to a softening or change in the tissue properties with the propensity towards increased laxity
• Chemotherapy or Radiation treatment can also affect the pelvic floor. Radiation can lead to hardening (fibrosis) of the pelvic floor muscles which in turn can lead to shortening or narrowing of the vaginal canal in women - which can lead to urinary incontinence (UI), pelvic pain and sexual dysfunction.
• Chemotherapy and radiation treatment for all types of cancers (beyond pelvic health) can also have indirect affect on the pelvic floor, due to side effects of treatment which can include profuse vomiting and therefore repeated high pressure on the pelvic floor which may overload the current capacity of the pelvic floor and cause stress urinary incontinence at the time of treatment and for the immediate period afterwards.

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

Prevalence of Pelvic Floor related disorders in general cancers

Over 50% of women with gynaecological malignancies report stress urinary incontinence, and just over 10% report symptoms associated with prolapse.

Hysterectomy can cause increased risk of prolapse even in benign cases, when compared to women who have not undergone the surgery,  According to PhysioPedia, “Survivors of gynecological cancer also experience significantly more pelvic floor symptoms and an associated reduction in quality of life.” (4)

Symptoms of pelvic floor disorders 

Gynaecolocical cancers and associated treatments can be catalysts for pelvic floor symptoms, which include

• Pelvic pain, 
• Urinary retention (difficulty voiding)
• Leaking / incontinence (urinary and fecal), 
• pain on intercourse
• Change in discharge
• Hormonal changes and onset of menopause symptoms (6)

Support - Education and Physiotherapy

Physiotherapists can play a key role in educating both male and female cancer patients on the effects of cancer treatment on pelvic floor health. It can be helpful to:

• Think of the pelvic floor as an “internal hammock” that functions to support the pelvic organs, which supports you to go about your day to day activities and sports
• Learn the connection to pelvic floor and breath, and how you can support the pelvic floor naturally through correct breathing mechanics: - inhale to prepare for load, exhale to support the pelvic floor as you / lift/ cough/stand up (as examples)
• Incorporate pelvic floor muscle activity into daily movement - when you get up and down from a chair, put effort into picking something up from the floor, sit up out of bed
• Learn how to do “the knack” (preemptive pelvic floor contraction
• Ensure you have adequate emotional and psychological help - speaking with a trained (psychologist, for example professional in cancer treatment and rehabilitation
• Incorporate mindfulness into your day - we love insight timer - Richard Millar’s IRest for connecting to, and appreciating your body

Treatment

Physiotherapy treatment from a well trained women’s health physiotherapist may entirely decrease or completely eliminate symptoms of pelvic floor dysfunction.

Physiotherapy for the pelvic floor may include:

• Internal examination of the vagina +/- rectum, to assess pelvic floor function (length, strength, quality and endurance of muscle contraction, pelvic floor tightness, and prolapse
• Pelvic floor and core muscle training and education,using either or both manual and biofeedback therapy techniques to strengthen and restore normal function of PFM. ition, biopsychosocial factors, occupation, stress levels, pregnancy history, trauma, medications etc.
• Assess and address postural and movement imbalances which can contribute to reduced pain, and improved pelvic floor health
• Assess and address breathing patterns 

As part of treatment with a trained women’s health physiotherapist you may recieve:

• Trigger point release to PFM
• Joint mobilization for: hips, coccyx, lumbar or thoracic spine
• Muscle energy techniques (muscle release techniques)
• Pelvic Floor Muscle re-education (manual feedback, electrical stimulation)
• Biofeedback: to assist in relaxation of the PFM or contraction/strengthening of PFM
• Recommending support garments to assist muscle function and support continence and prolapse

Support Resources

Here is a brief list of Cancer support resources:

Cancer support organisations | Cancer Australia

Gynaecological | Cancer Council

Home – Australian Gynaecological Cancer Foundation (agcf.org.au)

Support and Services | Cancer Council

References

1. Cancer incidence, mortality and survival in Australia | EdCaN
2. An International Continence Society (ICS) report on the terminology for pelvic floor muscle assessment - PubMed (nih.gov)
3. IUGA-ICS Joint Report on the Terminology for the Assessment of Sexual Health of Women with Pelvic Floor Dysfunction
4.  Ccgynonc. Cancer and the Pelvic Floor [Internet]. Colorado Gynecologic Oncology Specialists. 2018 [cited 2021Jun30]. Available from: https://ccgynonc.com/cancer-and-the-pelvic-floor/
5. Neron M, Bastide S, Tayrac Rde, Masia F, Ferrer C, Labaki M, et al. Impact of gynecologic cancer on pelvic floor disorder symptoms and quality of life: an observational study. Scientific Reports. 2019;9(1).
6. Menopause | Living Well After Cancer | Cancer Council NSW

This information is educational in nature and does not replace medical advice from your practitioner.