Pelvic Floor Dysfunction (Non-relaxing type)

 

Introduction

Non-relaxing pelvic floor dysfunction (NR-PFD) is a functional cause of bladder outlet resistance and complex lower urinary tract symptoms in patients without anatomic or neurologic obstruction. Patients present with hesitancy, weak or intermittent stream, incomplete emptying, frequency, nocturia, pelvic pain, or sexual dysfunction. Early recognition is vital because routine urologic tests may be non-diagnostic and conservative rehabilitation is usually the mainstay of therapy.

Important concepts

NR-PFD: inability of pelvic floor muscles to sufficiently relax during voiding, producing a functional bladder outlet obstruction. 

Hypertonic pelvic floor: a subtype where resting pelvic floor tone is increased but NR-PFD can occur with normal resting tone. 

Dyssynergic voiding (DSD): NR-PFD occurs in neurologically intact patients and is distinct from detrusor-sphincter dyssynergia caused by suprasacral spinal lesions. 

Myofascial contributors: trigger points and chronic guarding can perpetuate non-relaxation and pelvic pain. 

What we know

• Video urodynamics with pelvic floor surface EMG and a focused pelvic examination are central tools to identify NR-PFD. 
• Urodynamics define functional outlet obstruction by correlating pressure-flow data with EMG activity and imaging; surface EMG mainly measures levator ani behavior. 
• These diagnostics help distinguish NR-PFD from urethral stricture, poor external sphincter relaxation, or neurogenic causes. 
• Conservative pelvic floor physical therapy (PFPT) is the recommended first-line therapy. 
• PFPT commonly includes neuromuscular re-education, diaphragmatic breathing, manual myofascial release, and biofeedback. 
• There is evidence of substantial symptomatic and objective improvement with PFPT and biofeedback in both sexes, including improvements in flow, post-void residuals, symptom scores, and quality of life. 
• For patients refractory to PFPT, adjunctive options include trigger point injections (TPIs), botulinum toxin A (BTX) injected into pelvic floor muscles, sacral neuromodulation (SNM), and integrative approaches (acupuncture). 
• The evidence is heterogenous: some series show good response for TPIs and SNM.
• Randomized trials of BTX show reduction in EMG activity but inconsistent pain or long-term clinical benefit. 
• Multidisciplinary, individualized care is pivotal part of managing such cases. 

Important numbers

• 82% — women with functional defecatory symptoms reporting ≥2 urinary symptoms (hesitancy, straining, interrupted stream, incomplete emptying). Interpretation: urinary symptoms commonly coexist with defecatory disorders and suggest pelvic floor incoordination. 
• 57% — same cohort reporting four or more urinary symptoms. Interpretation: many patients have multiple LUTS, raising suspicion for NR-PFD. 
• 29% (men) and 32% (women) — rates of reported physical abuse in a dyssynergic defecation cohort; 22% reported sexual abuse. Interpretation: past trauma is common and should be screened sensitively. 
• 51.2% — proportion of women with voiding symptoms found to have pelvic floor obstruction on videourodynamics in one series. Interpretation: videourodynamics often identifies pelvic floor–related obstruction among symptomatic patients. 
• 80% — of patients reported ≥50% improvement symptom/QOL after sacral nerve modulation in a cohort of refractory patients. Interpretation: SNM can benefit selected refractory patients but is invasive and off-label for isolated NR-PFD. 
• 97% — men with chronic pelvic pain who had decreased NIH-CPSI score after biofeedback PFPT in one series. Interpretation: biofeedback PFPT can produce marked symptom improvement in men with pelvic floor spasm. 
• 81% — women achieving clinical and uroflowmetric improvements after 3 months of biofeedback-assisted PFPT in a study. Interpretation: high short-term success of conservative therapy in women with dysfunctional voiding. 
• 72% — improvement ≥50% after levator ani TPIs in a small series. Interpretation: TPIs can provide meaningful short-term pain relief in selected patients. 
• 33% — by 8 weeks, proportion with ≥33% pain reduction after BTX vs placebo (20%) in a randomized trial (no consistent long-term superiority). Interpretation: BTX reduces EMG activity but clinical benefit is inconsistent.  

Clinical clue 

1. History — screen for voiding (hesitancy, straining, weak/interrupted stream, incomplete emptying), storage (frequency, nocturia), pelvic pain, bowel symptoms, sexual dysfunction, and past trauma. 

2. Physical exam — trauma-informed external genital, vaginal (if female) and rectal exam to assess resting tone, trigger points, tenderness, and contract-relax ability; palpation may reproduce pain. 

3. Initial tests — urinalysis with culture, basic blood tests (CBC, BMP) when indicated, and uroflowmetry with post-void residual measurement. 

4. Objective assessment — if suspicion persists or initial tests inconclusive, perform multichannel pressure-flow urodynamics with pelvic floor EMG; video-UDS adds anatomical correlation. 

5. Adjunct imaging — pelvic ultrasonography to view bladder neck descent or wall changes; dynamic MRI for complex anatomy or prior pelvic surgery. 

The Urologist’s Summary: 

(1) Focused history and trauma-informed pelvic exam is importnant initial part of patient evaluation.

(2) UA, uroflowmetry + PVR are important primary tests 

(3) Refer for PFPT + biofeedback as first-line while arranging urodynamics if no improvement. 

The Point

Think functional, not structural, when LUTS occur without anatomic or neurologic cause. Early PFPT and biofeedback give the best chance for recovery, and objective testing (EMG/UDS) helps confirm NR-PFD in complex or refractory cases. Start conservative therapy early and coordinate multi-disciplinary care including physiotherapy and psychology when needed for best outcomes always. 

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The Urologist

By:

Dr. Ahmed M. Bakr, MD, FEBU

Reference: Sadeghi Z, Afyouni AS, et al. Urologic Manifestations of Nonrelaxing Pelvic Floor Dysfunction. Curr Urol Rep. 2025.