Pelvic Floor 301: Pelvic Floor Dysfunction
Now that we've discussed what the pelvic floor is and what the pelvic floor does, we need to talk about what can happen when the pelvic floor doesn't work properly. The pelvic floor muscles--just like any other muscles--can be overly tight (known as a 'hypertonic' pelvic floor or pelvic floor muscle spasm), lack strength or endurance or experience changes in sensation.
Overly tight or strained pelvic floor muscles can irritate the nerves that run through the pelvic floor, causing pain anywhere along the length of the nerve. Sometimes it's the other way around, where a nerve injury at the back or tailbone may cause numbness or tingling and may even cause the muscles that the nerves innervate to become weak, tight, and painful.
Constantly strained muscles can develop trigger points--in the same way a tight neck muscle can cause a headache. A trigger point or knot in the pelvic floor muscles may be experienced as pain deep in the pelvis, in the low back, hip, or groin, or even on the inner thighs or abdomen. Patients are often amazed when pressing on a trigger point within the pelvic floor reproduces the pain they have been experiencing at a completely different site.
Any type of pelvic pain has the potential to involve the pelvic floor. Any pain or inflammation at the digestive organs or reproductive organs (IBS, cysts, UTI, etc) can irritate the pelvic floor, exacerbating the pain. Regardless of the initial cause, the pelvic floor needs to be assessed and addressed with any kind of chronic pelvic pain.
A common symptom of pelvic floor dysfunction is urinary urgency and frequency. It's considered normal to urinate 4-6 times each day; any more (regardless of how much water you drink) may be a sign of dysfunction.
Often tight pelvic floor muscles irritate the bladder nerve. The brain interprets this as a need to go, triggering the body to urinate. Patients sometimes feel the need to urinate as many as 20 times a day.
Communication between the bladder, pelvic floor, and brain is crucial. When things are working normally, the bladder recognizes that it's filling and asks the brain for permission to go. The pelvic floor is holding back urine, telling the brain it's not yet time to go and you can hold it a little longer. The brain takes both of these messages and processes them, letting you plan a trip to the bathroom when it's convenient.
But urinary urgency and pelvic floor dysfunction can throw off this communication. The bladder begins to dominate the conversation, so the brain is constantly feeling the urge to go. Part of treating urinary urgency and frequency is retraining the body and restoring normal communication between the brain, bladder, and pelvic floor.
Stress incontinence occurs in response to a specific physical challenge to the pelvic floor. Common stressors include heavy lifting, coughing, sneezing, laughing, or running. All of these activities make it more difficult to hold back urine. Incontinence occurs when the pelvic floor muscles aren't up to the challenge.
Urge incontinence refers to the uncontrollable urge to void. The urge grows too strong and the pelvic floor muscles aren't able to control the bladder or bowels any longer. This urge can actually be triggered by dysfunction within the pelvic floor. When pelvic nerves are irritated, the brain can interpret that nerve irritation as the urgent need to void.
Importantly, incontinence isn't as simple as the pelvic floor being too weak and needing strengthening. In some patients that's true, but in others the pelvic floor is actually too tight and unable to function properly. Just like a cramp in your calf makes it impossible to walk, a spasming pelvic floor makes it difficult to hold back urine or feces.
The answer isn't just Kegel exercises; these can be counter-productive if the pelvic floor is too tight. Even if the pelvic floor is weak, Kegels should still be only a small part of an overall strengthening program.
Pelvic Organ Prolapse
When the pelvic floor is unable to properly support the pelvic organs, prolapse can occur. The pelvic organs begin slipping down, and can bulge into the vagina (in women) or rectum (both genders). Depending on which organ is involved, this may be called a cystocele (bladder), uterine prolapse, or rectocele.
Childbirth is a major risk factor for prolapse; studies have shown up to 30% of women experience some form of prolapse after delivery. There may not be any significant pain or other symptoms with a prolapse, and many go unrecognized or undiagnosed for years.
Pelvic organ prolapse can again be due to pelvic floor muscles that are too weak, too tight, or (most likely) a combination of both. Restoring normal muscle function and tone can help resolve symptoms of prolapse and even reduce any stage of prolapse.
Orthopedic Pain - Low Back, Hip, Groin, or Tailbone Pain
The pelvic floor has a stabilizing function for the core, and dysfunction with the pelvic floor often manifests as orthopedic pain in the pelvic region. One study showed that 95% of women with chronic low back pain also had pelvic floor dysfunction. The pelvic floor is directly implicated in hip and groin pain as well. All pelvic floor muscles connect (directly or indirectly) to the tailbone, so tailbone pain (coccydynia) is also a symptom of pelvic floor dysfunction.
Any traumatic injury of the hip, groin or back such as a fall or car accident may also injure the pelvic floor or cause your pelvic floor to overcompensate for the injured region. Surgery or scars at the chest, abdomen, back, or legs can also impact the pelvic floor by causing trauma, compensation, or excessive tension.
Often the pelvic floor is overlooked in the treatment of chronic orthopedic pain, when it may be the primary cause or a major contributing factor. Many patients grow frustrated when traditional physical therapy or surgical options don't 'stick' or result in long-term improvement. For many of these cases, pelvic floor dysfunction needs to be addressed for true healing to take place.
Painful Intercourse and Sexual Dysfunction
As the pelvic floor is responsible for sexual function, it should be no surprise that issues within the pelvic floor can result in either pain or dysfunction during sex. In fact, sexual function is among the most complex responsibilities of the pelvic floor, requiring the pelvic muscles to both relax and contract in quick succession.
Nearly half of women report they've experienced painful intercourse. While there are several potential causes, pelvic floor dysfunction is one of the most common - and overlooked! - reasons for pain. Tight pelvic floor muscles don't relax completely to allow penetration and intercourse impacts muscles that already have painful trigger points. The pelvic floor muscles responsible for arousal and orgasm clench during sexual activity and can flare up pain or other symptoms, sometimes even for days afterwards. Many women with other pelvic floor symptoms also experience painful intercourse, without realizing the underlying connection.
Medical terms used for painful intercourse with women include dyspareunia, vulvodynia, vestibulodynia, and more, but the pelvic floor is often the underlying cause.
Men also experience both pelvic pain and dysfunction. This often manifests as pain after ejaculation or with erection, both of which require the pelvic floor muscles to activate. Up to 70% of men also experience erectile dysfunction during their life. To create an erection, blood has to be able to flow into the penis; often, tight pelvic floor muscles prevent the initial blood flow. Then, to sustain the erection the pelvic floor muscles clench tight. Again, if the pelvic floor muscles are unable to perform these functions, erectile dysfunction is the result. Pelvic symptoms often flare for men after intercourse or ejaculation.
Pelvic Floor Physical Therapy
The good news is that each each of these symptoms can be resolved with pelvic floor physical therapy. Pelvic PT works to alleviate trigger points in the pelvic floor, restore normal function, and address the underlying cause of the dysfunction.
Dr. Nicole Cozean is the founder of PelvicSanity physical therapy, Orange County's premier pelvic floor physical therapy clinic. One of only 270 PTs to be board-certified in the pelvic floor, and the first PT to serve on the ICA Board of Directors, Nicole is the author of the acclaimed and best-selling book The Interstitial Cystitis Solution (2016). She is an adjunct professor at her alma mater, Chapman University. The PelvicSanity blog focuses on presenting practical, positive information to help patients beyond the walls of Nicole's clinic.