Pelvic floor dysfunction refers to a wide range of symptoms that occur when the muscles of the pelvic floor are not functioning properly.
The pelvic floor is a group of muscles, ligaments, and connective tissue that are located at the bottom of the pelvic bones. The pelvic floor muscles are dome shaped and attach to the pubic bone, coccyx, and sit bones (ischial tuberosities). The pelvic floor functions to provide support to the pelvic organs, offer stability to the low back and hip joints, maintain continence for the bowel and bladder, and serves to optimize sexual sensation and arousal.
The pelvic floor muscles function optimally when they are able to dynamically relax and contract. Pelvic floor dysfunction occurs when the muscles of the pelvic floor present with abnormal tension (either high or low tone), weakness, and/or a person lacks the conscious ability to properly coordinate activation and relaxation of these muscles.
In situations where the pelvic muscles are too tight/tense and unable to relax, the muscles are weak and symptoms of pelvic floor dysfunction may arise. Conversely, excessively low tone (hypotonic) pelvic floor muscles are also weak and lack the endurance and power needed to support the pelvic organs within the pelvic cavity as well as support normal bowel, bladder, and sexual function.
What are the most common symptoms of a hypotonic/underactive pelvic floor?
1 Pelvic Organ Prolapse (POP): POP occurs when as a result of weakness in the supportive tissues and muscles of the pelvic floor, the bladder, bowel, uterus, and/or small intestine shift downwards and descend toward the vaginal/rectal opening. There are five types of prolapse:
when the bladder descends and bulges into the front vaginal wall
when the rectum descends and pushes into the rear vaginal wall
when the uterus shifts downwards through the vaginal canal toward the opening of the vagina
Vaginal vault prolapse
when the vaginal walls cave in on themselves following a procedure that removes the uterus (hysterectomy)
this can occur most commonly following a hysterectomy and is when the small intestine descends and pushes through toward the lower pelvic cavity
The combinations of POP vary greatly and therefore, symptoms can be very unique for each individual. Most often, POP may include a heaviness/dragging/pressure sensation within the vagina, urinary incontinence, urine retention, persistent constipation, vaginal/rectal pain, inability to retain a tampon, fecal incontinence, dyspareunia, and decreased sexual sensation.
2 Urinary incontinence (UI): UI occurs when the pressure generated within the intra-abdominal cavity during a cough, sneeze or impactful activities such as running/jumping, or when the strength of bladder contractions overwhelms and exceeds the pelvic floor muscles power and ability to maintain closure around the urethra. The extent of incontinence may vary from slight drops of urine leakage ranging to full bladder emptying.
3 Fecal incontinence: When there is weakness within the pelvic floor muscles, the muscles that wrap around the anus may not have enough power and endurance to maintain a tight closure around the anal opening. This may lead to sensations of strong urgency with the urge to have a bowel movement that is difficult to defer and may result in loss of stool at inappropriate times.
What are the most common symptoms of a hypertonic/overactive pelvic floor?
1 Pelvic pain
If the pelvic floor muscles are in a constant state of contraction over a long period of time, this compromises the natural circulation of blood flow that allows for constant nutrient and oxygen exchange within the tissues of the pelvis. As a result, the pelvic muscles can become painful and sore and the nerves that supply these muscles can become very irritated. The pain may radiate to different areas of the pelvis including the low back, abdomen, and hips.
2 Urinary retention
During bladder emptying, the pelvic floor muscles must fully relax. This signals the bladder to contract strongly and provides an open outlet for urine to pass through the urethra. Hypertonic pelvic floor muscles lack the ability to fully relax their tone, thereby inhibiting bladder contractions and providing less space for the urine to pass through. This may lead to sensations of incomplete bladder emptying, weakened urinary stream, hesitation to start the flow, and urine retention.
The pelvic floor muscles that wrap around the anus and rectum must fully relax in order to allow for stool to pass through the anal opening. Tense pelvic floor muscles inhibit stool from passing through the anal opening and may lead to infrequent and painful bowel movements.
4 Dyspareunia or painful intercourse
A shortened and contracted pelvic floor lacks the flexibility and elasticity needed to allow for comfortable and painfree penetration. Pain may present superficially at the opening of the vagina or anus, may be felt deeper with deep penetration or may occur immediately post sexual activity. For men, they may experience pain with erection, ejaculation, or following ejaculation and both men and women may even experience pain in and around the genital area with arousal.
Did you know?
Both females and males can present with symptoms of pelvic floor dysfunction
What are the risk factors for developing pelvic floor dysfunction?
Some of the risk factors for developing pelvic floor dysfunction include pregnancy/childbirth, hormonal changes associated with menopause, obesity, poor dietary habits leading to persistent constipation or bladder irritation, smoking, straining and poor lifting techniques with repetitive strenuous activity, pelvic surgeries or health conditions (such as Parkinson’s, stroke, Multiple sclerosis) that affect the nerves that supply the tissues and muscles within the pelvis.
What can Pelvic Physiotherapy do to help?
A physiotherapist with specialized training in pelvic floor dysfunction will be able to identify problems with pelvic floor muscle tension, strength, and coordination.
The goal of pelvic physiotherapy is to first identify if the pelvic floor muscles are hypertonic/overactive or hypotonic/underactive. If the pelvic floor muscles are identified as “non relaxing” or too tense, treatment focuses on normalizing the pelvic floor muscle tone first before initiating any form of a pelvic floor muscle strengthening program. Once a normal pelvic floor resting tone is reached, the pelvic strength is reassessed and a strengthening program is then prescribed if appropriate.
Pelvic physiotherapists work with patients to optimize the mobility, flexibility, strength, and coordination of the pelvic floor muscles as well as identify and address any lifestyle factors or habits that may be significantly contributing to the development of the patient’s pelvic floor dysfunction.
To learn more about pelvic health physiotherapy treatment modalities and options go to: Treatment Options
If you have any signs of pelvic floor dysfunction, it is essential to see a pelvic floor physiotherapist. Not all conditions are resolved or will benefit from “Kegels” or pelvic muscle contractions. Often times, contracting a hypertonic pelvic floor will make the symptoms worse. To be on the safe side, it is best to first be properly assessed by a trained physiotherapist who is able to tailor treatment specifically to your needs and guide you on the correct exercise program for your path to recovery.