Pelvic Pain/ Pelvic Floor Dysfunction

Pelvic Floor Diagram

Our knowledge of treating the pelvic floor, and how its relationship to the rest of the body contributes to pelvic floor related conditions, ensures the cause of the problem is addressed. By engaging our patients in understanding the cause of their condition, they help facilitate their own return to health.

What is the Pelvic Floor?

The pelvic floor is made up of a group of muscles that attach to various points of the underside of the pelvis whose main function is to support the internal organs located in the abdomen. The pelvic floor creates a sling or hammock from the front of the pubic bone to the sacrum (the large fused bone at the bottom of your spine, just above the tailbone). It surrounds the vaginal, urethral, and rectal openings.

The pelvic floor is a complex structure that not only allows the passage of urine and stool at appropriate times, but also preserves continence daily. Bowel and bladder functions are controlled by contracting and relaxing these muscles. These muscles must relax to allow for urination, bowel movements, and, in women, sexual intercourse.

Anatomy of the Pelvic Floor
Anatomy of Pelvic Floor

Muscles of the Pelvic Floor:

  • Levator ani - comprised of 3 muscles. It is comprised of 30% type II (fast twitch) and 70% type I (slow twitch)
  • Puborectalis
  • Pubococcygeous
  • Iliococcygeous
  • Pirifomis
  • Obturator Internus - runs along the obturator

Other notable structures:

  • Gluteus Maximus
  • Gluteus Medius
  • Iliopsoas
  • Transverse Abdominus
  • Lower portion of the Rectus Abdominus
  • Mulitifidi

These structures in combination with the pelvic floor form the support structure for the pelvic ring.

The length and strength of these muscles will contribute to the presence of trigger points, hypertonia (excessive muscle tone), or hypotonia (lack of muscle tone) of the pelvic floor.

What is Pelvic Floor Dysfunction?

Pelvic floor dysfunction occurs when the muscles are unable to properly contract and/ or relax. Typically what we have found is that the pelvic floor muscles have a combination of tone, strength, and control. Pelvic Floor Tone means the density of the tissue. This is very different than the strength which means the power of the muscle. Control is referred to as quality of movement. When the any of these three aspects of the pelvic floor is disrupted, pelvic floor dysfunction will occur.

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The pelvic floor is what I consider the gateway. If its function is disrupted, then all that is attach to it, or systems that use it will eventually be affected. Here are some examples. Hip, back, abdominal, pelvic, or vaginal pain may result from improper muscle length/ tension of the pelvic floor (levator ani). If the pelvic floor is in spasm, the bladder may not void urine properly due to the urethra opening passing through the pelvic floor. The bladder will then tell the body it has to urinate more frequently because it can't void completely. If the bladder retains a residual amount of urine, the toxin may reabsorb itself into the bladder wall causing a breakdown in the lining (Interstitial Cystitis). A spasm of the back portion of the pelvic floor can cause a similar disruption of the bowel system. If the body cannot rid itself of waste it will continually back itself up the systems of the viscera. Constipation may result. Reflux may also result as the food cannot go down; the body pushes it back up. Irritable Bowel Syndrome (IBS) may result from the gall bladder trying to figure out a way to allow the waste to pass. The gall bladder secretes bile into the intestine so that food is broken down and waste can be formed after the body takes the nutrients from the food. If the body cannot pass the waste, the gall bladder may change the amount of bile it secrets in attempts to allow the pelvic floor to let the waste pass, creating IBS.

There are four main categories of pelvic floor dysfunction. These can occur on their own or in conjunction with one another.

  1. Hypertonia Dysfunction: The word hypertonia refers to muscles that "tighten up" or "fire" more than usual. This dysfunction may result in pelvic pain with lifting, sitting, walking, intercourse, bowel/bladder voiding, or when wearing restrictive clothing.
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    • Levator ani Syndrome - spasm of the pelvic floor muscles
    • Coccydenia - Pain on or around the tailbone
    • Vestibulitis - Pain in the space between the labia minor into which opens the urethra and the vagina.
    • Chronic Pelvic Pain
    • Dyspareunia - Painful intercourse.
    • Urinary Frequency- Having to urinate more than every 2 hours
  2. Visceral Dysfunction: The internal organs of the abdomen or pelvis stop moving or functioning properly. As this occurs, the surrounding muscles may become irritated and pain may occur. Surgical scarring may also play a role.
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    • Endometriosis
    • Pelvic Inflammatory Disease
    • Dysmenorrhea - Pain with menstruation
    • Irritable Bowel Syndrome
    • Interstitial Cystitis - Chronic inflammation of the bladder
    • Urinary Retention- Inability to fully empty your bladder upon urination
  3. Incoordination Dysfunction: The muscles of the pelvic floor work in a specific order and timing with other muscles to carry out bowel, bladder, and sexual functions. Improper timing of muscle contraction may result in constipation or urine leakage with activities of daily living.
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    • Stress Incontinence - Inability to control urine leakage or flow with stresses such as coughing, sneezing, laughing, or exercise.
    • Urinary retention- Inability to fully empty your bladder upon urination
    • Constipation
    • Pelvic Pain
    • Detrusor Sphinctor Dyssynergia - incoordination resulting from a problem in the spinal cord.
  4. Supportive Floor Dysfunction: The muscles of the pelvic floor do not have enough integrity to support the pelvic organs. This may result in loss of urine with coughing, sneezing, or lifting. Pelvic pain may also occur with walking or exercise.
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    • Stress Incontinence - The inability to control urine leakage or flow with stresses such as a coughing, sneezing, laughing, or exercise.
    • Urinary Urgency- The urge to have to urinate without being able to hold it until you reach the bathroom. " I have to go and I have to go right now"
    • Pelvic Organ Prolapse -
      • Cystocele - Bladder prolapse into the vagina
      • Rectocele - Rectal prolapse into the vagina
      • Uterine Prolapse - Uterine displacement into the vagina
    How is Pelvic Floor Dysfunction Diagnosed?

    PFD can be diagnosed on physical examination by a physician and further assessed by a physical therapist that is specially trained in treating pelvic floor dysfunction (PFD). Using "hands-on" or manual techniques to evaluate the function of the pelvic floor muscles a physician or physical therapist can assess the strength, tone, and control of the pelvic floor as well as note compensatory patterns of movement (what the patient may be using instead of their pelvic floor). Typically an internal exam is done to assess tone, presence of trigger points or restriction, pain, and quality of a Kegal with the pelvis in neutral as well as in a relaxed position. The main considerations in determining what the underlying cause is so that a proper treatment plan can be established are in the proper assessment of the pelvic floor muscle tone, strength, and control. For example, the physical therapist may find the presence of trigger points along one side of the pelvic floor, but once they have been eliminated the therapist determines poor ability to relax after initiation of contraction. In this case it would be inappropriate to prescribe Kegal exercises as it will likely make the symptoms worse.

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    It is important to note that a comprehensive external examination of the lumbar, pelvis, abdominal, and hip regions are completed in order to determine associated weakness, muscle restriction, and faulty movement patterns that may be contributing to the dysfunction of the pelvic floor. Full resolution of systems may not result unless this is incorporated into the treatment plan.

    Body Awareness Physical Therapy has a unique program that can be considered a marriage of both women's health and orthopedics. Our pelvic program looks at the body as a whole. We assess how each region of the body is affecting the other (it is all connected after all), with the goal being to restore optimal alignment, muscle balance, proper sequencing of muscle recruitment and most of all function. Our licensed physical therapists are trained to complete an internal examination of the pelvic floor as well as a comprehensive orthopedic examination so that the big picture can be assessed and a treatment plan can be developed to ensure that all contributing factors are addressed for the best possible outcome and return to function.

    How is Pelvic Floor Dysfunction Treated?

    Pelvic Floor dysfunction is treated best by obtaining a detailed medical history so that a possible line can be drawn as to progression of symptoms to the patient's current presentation at the time of evaluation. It is important that the patient disclose any emotional or physical trauma incurred including strains/sprains, surgical procedures, or instances of high anxiety, stress, or abuse. Once a complete history is obtained and an evaluation has been completed, we treat the whole person. Many different treatment techniques are available to help the physical therapist effectively deliver a plan of care. A combination of the following treatment techniques are used each visit. At each visit the physical therapist will determine what is appropriate for that particular session based on the subjective and objective findings. Patients are encouraged to remain consistent in attendance of their treatment session as each session builds upon the last to continue to peel the layers of the 'onion' away. One session of physical therapy generally lasts about one hour in length. Most women will need to commit to attending physical therapy 2 times per week for up to 12 weeks for optimal results and return to function.

    Common Treatment Techniques for Pelvic Floor Dysfunction:
    Soft Tissue Mobilization, Myofascial Release, and Trigger Point Release
    Adhesions may develop as a result of muscular overuse or chronic shortening from sustained postures or repetitive activity. Release of these regions/points is essential in alleviation of painful referral patterns as well as restoring normal tissue mobility.
    Joint Mobilization
    Mobilization of chronically adhered structures is crucial to ensure proper spine and soft tissue movement. Stiff or ridged joints in one region of the body will cause another region to develop excessive mobility. This compensation will manifest as a movement dysfunction and predispose to pain and injury.
    Neuromuscular Re-education
    Neuromuscular re-education is an essential part in the rehabilitation process. This education includes training proper alignment of the pelvis with leg and trunk movements. Pelvic floor, low back, hip and abdominal musculature re-education is imperative to pain relief and increased function.
    Postural Alignment
    Neutral pelvic alignment must be established in order to obtain a successful outcome. In order to accomplish neutral pelvis, the therapist must also consider the alignment of the shoulders, rib cage and spine.
    Activities or Daily Living
    Incorporation of proper muscle sequencing with activities of daily living such as sit to stand, sitting, computer work, walking, lifting, bowel and bladder retraining, and any other specific activities related to your daily function.
    Biofeedback Training
    Biofeedback is used to perform assessment and/or neuromuscular reeducation of the pelvic floor musculature. Electronic and hand held biofeedback devices are available. Biofeedback is used in conjunction with myofascial and trigger point release, joint mobilization and specific muscle reeducation for best patient outcomes.
    Proper Breathing and Relaxation Techniques
    Incorporation of proper breathing and relaxation techniques allows the abdominal cavity and viscera to relax and re energize and is helpful to allow patients a tool for self management.
    Visceral Manipulation
    Visceral manipulation is a form of manual therapy that focuses on the internal organs, their environment, and the potential influence on many structural and physiological dysfunctions. The visceral system relies on the interconnected synchronicity between the motions of all the organs and structures of the body.
    What is a Kegal?

    A Kegal exercise is the recruitment of the pelvic floor musculature.

    When is appropriate to perform a Kegal?

    One should be able to perform a Kegal throughout a lifetime. Poor pelvic floor muscle tone can result in incontinence (stress or urge), pelvic pain, abdominal pain, sacral and tailbone pain, and/or low back pain. A Kegal should be done daily throughout pregnancy and starting at 4-weeks postpartum.

    Kegal exercises should not be performed if one experiences pain or an increase in frequency of urination, or constipation. Occasionally the pelvic floor can become overactive, resulting in trigger points and spasm. Should you experience painful intercourse, or pain after abdominal/internal surgery, please consult your physician for a referral to a physical therapist that is knowledgeable in women's health. This is treatable with physical therapy and the earlier it is detected the faster relief can be achieved.

    How do I perform a Kegal correctly?

    The pelvic floor musculature is the same muscles used to stop the flow of urine. It is performed by tightening the vagina opening and then lifting upward as if to "cork" the opening. Think of tightening from the front (pubic bone) to the back (rectum) without any movement of your pelvis. Once contracted, think of lifting the muscles straight up. Pull you belly button toward your spine at the same time for a stronger contraction. This will recruit your transverse abdominus- the lower abdominal wall. No movement of the body should occur, only muscle recruitment.

    What if I cannot perform a Kegal?

    If you cannot perform a Kegal or are not sure if you are performing it correctly, you may be a candidate for physical therapy. A knowledgeable physical therapist will be able to assist you in the re-education process. Biofeedback and electrical stimulation are also available for more severe dysfunction.