What is a Pelvic Floor?
The pelvic floor is a hammock-like group of 14 thin muscles intertwined with nerves and surrounded by connective tissue that supports the abdominal organs while playing a key role in urinary, bowel, and sexual function as well as postural support. When you consider the many ordinary (and extraordinary) tasks the pelvic floor plays - a role in urination and bowel movements, orgasm, childbirth, continence, even walking - it is difficult to understand why it is such an under-recognized part of human anatomy! Here is a great video showing the muscles in more detail: https://www.youtube.com/watch?v=P3BBAMWm2Eo
Most people do not realize they have a pelvic floor until something goes wrong. When these muscles become dysfunctional, the associated symptoms are embarrassing and scary. Two sub-categories of pelvic floor dysfunction (PFD) exist: muscles that have become too weak or over-lengthened, called low-tone pelvic floor dysfunction, and muscles that have become too tight and painful, known as high-tone pelvic floor disorders or pelvic pain.
Low-Tone Pelvic Floor Dysfunction
Generally speaking, low-tone PFD occurs because of normal age-related changes because our muscles, everywhere, weaken over time. Symptoms of low-tone PFD are stress urinary incontinence (leaking urine when you laugh or sneeze), urge urinary incontinence (you put the key in your front door and leak urine before you can reach the bathroom), fecal incontinence, pelvic organ prolapse (the uterus, bladder, or rectum herniates into the vaginal canal or even outside of it) and diminished orgasm. The symptoms of low-tone PFD are more common in women than men because pregnancy, labor and delivery can also cause weakening of the pelvic floor muscles. These symptoms are most common in women who have just given birth and perimenopausal and menopausal women, though other circumstances can and do occur to cause problems in women outside of these two categories. 90% of women by the age of 50 experience urinary incontinence. Additionally, men can also suffer from low-tone pelvic floor disorders. The symptoms include urinary urgency, frequency, and incontinence and/or erectile dysfunction. 85% of men experience erectile dysfunction and/or urinary incontinence following prostatectomy procedures. It is important to note that while these symptoms are very common, they are NOT normal! The good news for both men and women with low-tone pelvic floor disorders is that specialized pelvic floor physical therapy is the first-line treatment and an effective way to treat these problems. It makes sense that physical therapy is necessary because these symptoms are musculoskeletal in origin, even though they appear to be associated with dysfunction in the GI, urinary, or reproductive systems.
High-Tone Pelvic Floor Dysfunction
When pelvic floor muscles become too tight they can cause pain and dysfunction that is extremely distressing and can be disabling. Some of the many symptoms of high-tone pelvic floor disorders include:
Urinary urgency, frequency, burning in the absence of infection
Diminished or absent orgasm
Women: vulvovaginal pain with intercourse
Men: post-ejaculatory pain and erectile dysfunction
Clitoral, vaginal, penile, scrotal, perineal, and/or anal itching/pain/burning
Unwanted persistent genital arousal during contextually inappropriate times
Pelvic Pain Diagnoses include:
Painful Bladder Syndrome/Interstitial Cystitis
Nonbacterial Chronic Prostatitis/Chronic Pelvic Pain Syndrome
Irritable Bowel Syndrome
Because the pelvic floor muscles support the pelvic organs, tightness in these muscle cause symptom referral to the neighboring structures and can mimic other diseases such as yeast infections, urinary tract infections, venereal diseases, or prostatitis, to name just a few.
Here’s the deal: if you are suffering with these symptoms, you should ALWAYS see your physician and get a culture vs. using over-the-counter medications because you may not actually have an infection. If you are being treated for repetitive infections and not getting better your pelvic floor muscles are likely part of the problem and pelvic floor physical therapy can help.
20% of all women and 8-10% of men will have pelvic pain at some point in their lives. In the last two decades the medical community became aware of high-tone pelvic floor disorder as a source of pelvic pain. Prior to this, people were diagnosed with psychiatric disorders or TREATED with medications that they did not need. Therefore, most physicians do not know how to do a pelvic floor examination and likely do not know that pelvic floor physical therapy exists. If you suspect you have a pelvic floor problem we suggest that you speak with your doctor and also pursue pelvic floor physical therapy.
What is Pelvic Floor Physical Therapy?
Pelvic floor physical therapists undergo specialized post-graduate training to learn to evaluate and treat these disorders. During the first appointment, the physical therapist will take a detailed history. The evaluation portion is next. The physical therapist will leave the room to allow the patient to undress from the waist down and cover themselves with the provided drape. The physical therapy examination consists of manual therapy and movement techniques to assess muscle tone, nerve irritability, tissue and joint issues, motor control, and biomechanics. External and internal structures are evaluated. The internal examination consists of the PT inserting a gloved, lubricated finger transvaginally or transanally to evaluate the pelvic floor muscles and nerves.
After the evaluation is complete, the PT will discuss the findings with the patient, develop an assessment (how the patient developed their symptoms, which structures are causing which symptoms, etc.) and a treatment plan. Most people with pelvic floor dysfunction will go to physical therapy 1-2 times per week for about 12 visits. Of course, the length of treatment will vary based on the severity and chronicity of a person’s case. The treatments are usually an hour in length and consist of a combination of manual therapy techniques, home exercises, and referrals to other providers depending on the underlying causes and persevering problems. While the symptoms are embarrassing and distressing, treatment plans that include physical therapy are effective for eradicating the symptoms and restoring pelvic health.
About the Pelvic Health and Rehabilitation Center
Stephanie Prendergast and Elizabeth Akincilar-Rummer founded the Pelvic Health and Rehabilitation Center in 2006 in San Francisco. Nine years later, they have clinics in SF, Berkeley, Los Gatos, Los Angeles, and Boston. The physical therapists at PHRC are considered national experts in the management of pelvic floor disorders. Stephanie and Liz teach continuing education courses to medical professionals, lecture globally, and are authoring a book titled Pelvic Pain Explained. Stephanie is the Past-President of the International Pelvic Pain Society and current program chair for the 2nd World Congress on Abdominal and Pelvic Pain.
Past-President, International Pelvic Pain Society
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