The Pelvic Floor: what it is, what it does and who treats it
We hear a lot about the pelvic floor and how important it is. But what is the pelvic floor really? What does the pelvic floor do for us? And what happens when things go wrong with the pelvic floor?
In this article you will learn:
What is the pelvic floor?
The pelvic floor is a group of muscles at the bottom of the pelvis. There are 3 different layers of muscle and they all work together for the same common goals. There is also attachment of hip stabilizing muscles in and around the pelvic floor which help with the functions of the pelvic floor.
The superficial layer of pelvic floor muscle is closest to the surface and includes the horizontal muscles of the superficial transverse perineal, the diagonal muscles of the ischiocavernosus and the figure 8 looking muscle of the bulbocavernosus/ bulbospongiosus. The external anal sphincter, which keeps our anus closed so we don’t leak stool, aligns with the first layer of muscle.
The middle layer of pelvic floor muscles contains a thick, fibrous connective tissue membrane and houses the compressor urethra and the deep transverse perineal which sits directly behind and inline with the superficial transverse perineal muscle. The external urethral sphincter, which keeps our urethra closed so we don’t leak urine, aligns with the second layer of muscle.
The deep layer of pelvic floor muscles contains the levator ani and the coccygeus. The levator ani is a group of muscle that can be split into the pubococcygeus (the part that run from the pubic bone in the front of the pelvis to the tailbone in the back of the pelvis) and the iliococcygeus (the part that run from the side of the pelvis and deep hip fascia to the tailbone and skin between your vagina or testicles and your anus called the perineal body). The coccygeus goes from the side of the pelvis to the tailbone and sacrum.
What does the pelvic floor do?
The function of the pelvic floor is multifactorial and includes support, sphincteric, sexual, stability, postural and lymphatic functions.
Support: the pelvic floor helps your ligaments and fascia hold in the pelvic organs which include your bladder, uterus/prostate, and rectum
Sphincter control: the pelvic floor is responsible for opening the holes of the urethra, vagina, and anus when things need to come out, like urine, feces or babies. It’s also responsible for closing those same holes to keep things in, like that diarrhea rumbling in your belly when the elevator just won’t get to your floor fast enough.
Sexual function: coordinated support of the pelvic floor allows for increased blood flow to improve erection of the sexual organs (clitoris or penis), orgasm, and ejaculation. **fun fact about orgasms: Did you know that the pelvic floor involuntarily contracts every 0.8 seconds during orgasm? To Learn more about sexual health, take a listen to Dr. Rena Malik.
Stability: the pelvic floor muscles work in coordination with the whole body, specifically the hips and trunk muscles to transfer momentum and force from one side of our body to the other to limit breakdown in a certain part of our body. If the pelvic floor is functioning in an overactive or underactive environment, this can change how the body moves and lead to dysfunction (more on that later).
Postural control and breathing: the pelvic floor works with the diaphragm during breathing. As we breathe in, the diaphragm drops downward from the chest toward the abdomen. In doing so, it gently presses the abdominal organs downward into the pelvic organs, which then gently push into the pelvic floor. Basically, as the diaphragm descends during inhaling, so does the pelvic floor. As you breathe out, the pelvic floor and diaphragm both move back upward to their respective starting positions.
Lymphatic flow management: Your lymphatic system is a highway of vessels and organs throughout your body that work together to move lymphatic fluid, support your metabolism and facilitate immune system function. Lymphatic flow is largely managed by muscle contraction in the area and the pelvis is a major powerhouse for lymphatic flow management in the body. When the pelvic floor muscles are well coordinated it allows for appropriate lymphatic flow through the pelvis and decreased pelvic congestion. When lymphatic drainage is not well managed it can lead to discomfort, swelling, infection and more.
What does it mean to have an overactive or underactive pelvic floor?
Many people think that when they are experiencing anything wrong with their pelvic floor that is because the pelvic floor is underactive.
An underactive pelvic floor is one that is not doing enough, like that classmate you got stuck with on the group project in high school who thought “bringing the markers” was an equal contribution to the hours of research you did. This is often, but not exclusively, seen in people who are immediately postpartum, those who are postmenopausal, people after a prostatectomy, kids who skipped or sped through motor milestones like crawling or those with generalized weakness throughout their body. Think about it like a quadriceps muscle after a knee surgery. It just sits there, not doing a whole lot.
An overactive pelvic floor is one that is doing too much, like a helicopter parent with their teenager. This is often, but not exclusively, seen in high level athletes, those with chronic pain conditions, older teenage and younger adult populations, survivors of trauma, and those living with chronic stress. Think about it like having your hand clenched in a fist all day and then trying to shake hands with someone at the end of the day. It might feel painful, uncoordinated and weak. Is it actually weak? No. But is it really tight and tired? Absolutely!
The challenge lies in figuring out if a pelvic floor is overactive or underactive because both can appear to be weak. Both can feel painful. And both can have the same symptoms of urgency, leakage, and prolapse, but they have different treatments.
What is pelvic floor dysfunction?
Pelvic floor dysfunction is a general term for anything that is not working the right way in the muscles, nerves, organs, fascia, bones, or blood/lymphatic flow of the pelvis. This can affect the function of the bladder, bowels, uterus, or prostate. Pelvic dysfunction can cause pain that is acute or chronic and is impacted by surgery, pregnancy, trauma and chronic illnesses like endometriosis, PCOS (polycystic ovary syndrome), EDS (Ehlers Danlos syndrome) and cancer.
Major categories of pelvic dysfunction include:
Bladder - urinary incontinence, urinary urgency, Interstitial Cystitis (IC)/Painful Bladder Syndrome (PBS), difficulty emptying the bladder, chronic urinary tract infections (UTIs), bedwetting
Bowel - fecal incontinence, fecal smearing, flatulence, constipation, diarrhea, outlet dysfunction/difficulty emptying, bowel diseases like IBS and Crohn’s disease
Support - prolapse including cystocele, rectocele and uterine prolapse, Diastasis rectus abdominus (DRA), pregnancy and postpartum related complications, post prostatectomy complications
Pain - vaginismus, vulvodynia, pain with intercourse, adhesions from chronic illness or surgery, nerve conditions like pudendal neuralgia, pubic symphysis dysfunction
Who treats pelvic floor dysfunction?
There are a lot of practitioners out there who can help treat pelvic floor dysfunction. Most people think this is limited to the OB/GYN, urologist, or family doctor. In reality, there are a lot of people on the medical team. Your team may include physicians, pelvic physical therapist or pelvic occupational therapist, massage therapist, chiropractor, mental health professional, acupuncturist, personal trainers and more. If you’re pregnant or postpartum, your team may also include a midwife, doula, and lactation consultant.
Physicians are great to have on your team for a few reasons. First, they are highly knowledgeable in their specific area of expertise, but you do want to make sure you’re going to the right person. In the pelvic floor world, you may work with an OB/GYN, urologist, urogynecologist, gastroenterologist, colorectal surgeon, pain management specialist, or functional medicine physician. With complex cases, it is not uncommon for someone to work with more than one physician. Secondly, within the American medical and insurance based model, the physician acts as the gatekeeper for testing and treatment so it’s good to have a physician you trust on your team.
A great pelvic rehab practitioner is another important resource to have on your team. This can be a physical therapist or an occupation therapist who has done additional training in the diagnosis and treatment of pelvic floor dysfunction after graduating from graduate school. Pelvic rehab practitioners are uniquely qualified to assess and treat the internal muscles of the pelvis and have extensive knowledge and understanding of how those muscles affect and are affected by the entire body. It is not uncommon that when you work with a great pelvic floor practitioner that you initially start working with them for pelvic dysfunction and notice when you're done that the lingering ankle or neck pain you’d been having for years finally subsided.
Chiropractors are another practitioner you may want on your team as they can help with how the nervous system is functioning and how efficiently those nerve signals are traveling from the brain and spinal cord to the rest of the body.
Another part of the physical medicine team would be a massage therapist and acupuncturist. Both of these practitioners can be instrumental in calming the body and reducing overall tension in specific areas and throughout the entire body. They have completely different methods of intervention and can be quite complementary treatments.
How do I start my pelvic floor recovery journey?
The best plan is to meet with a qualified and skilled professional and work with them to develop a comprehensive team to help you reach your goals.
Keep in mind that there are good and bad practitioners in all fields and that a practitioner who is amazing for one patient may be a terrible fit for another and vice versa. Just because a certain practitioner wasn’t able to help you, don’t assume no one else in that field can.
As someone who specializes in chronic pain, it is not uncommon for me to be the third, fourth or even fifth pelvic physical therapist someone is working with. Don’t give up hope, just keep looking and you’ll find the right team for you!
If you think pelvic floor physical therapy is the place to start for you, reach out and we would be happy to kick off this journey with you!