A Crash Course on the Pelvic Floor

Most of us do not really give too much thought about what goes on down there. Our bodies do their thing, and we don’t question it… That is until there is a problem… Then we think about it a lot.

Often times we think that we are the only ones experiencing a problem. It is not an area that we generally talk about to our coworkers and peers, and most of us are embarrassed to talk about issues involving the pelvic floor, even to our doctors, or we just assume it is a normal part of life. I often have patients come in saying “It’s just because I’m getting old,” “This is what happens after you have children,” “My mom, sister, aunt have incontinence, so I’m going to have it too,” “Sex has never been comfortable”… Issues with the pelvic floor are definitely common; however they are NOT NORMAL.

What I want to discuss is what is the pelvic floor, how it works, common problems associated with the pelvic floor, and how physical therapy can help.

The pelvis is composed of bones, muscles, ligaments and tendons, just like any other part of our
body. The pelvic floor is comprised of layers of muscles that support the bottom of the pelvis. They
function to hold in all of our pelvic and abdominal organs, they maintain bowel and bladder function,
sexual function, and they provide postural support.

There are two layers of muscles. The most superficial muscles make up what is called the urogenital triangle (bulbospongiosus, ischiocavernosus and superficial transverse perineal). They aide in sexual functions such as maintenance of an erection, and prevent urine from traveling through the urethra during ejaculation. Deep to these muscles are the Levator Ani muscle group (pubococcygeus, iliococcygeus and pucorectalis) a.k.a. the Kegel muscles. It is these muscles that work with the core for postural support, maintain bowel and bladder function, and sexual function. Levator ani functions like a little elevator in our bodies. When they contract, the muscles lift up, and when they relax they lower back down.

Normally, they will be partially contracted during the day, and contract slightly more when we have a full bladder or colon in order to prevent leakage from occurring, until we have made the decision that it is an appropriate time to toilet. It is at this time, that the muscles will relax to allow us to empty. Sounds pretty simple, right? We can run into problems however if these muscles are too tense, or too weak, which can lead to issues such as urinary or fecal incontinence, constipation, pelvic organ prolapse, urinary frequency, hesitancy (shy bladder), pain with urination/defecation, or pain with intercourse to name a few. Also, after vaginal delivery or some surgeries, including prostatectomy, TURP, hysterectomy, bladder sling surgery, C-section, we can run into problems with the pelvic floor, whether it is bowel, bladder or symptoms of sexual dysfunction.

The pelvic floor also functions as a postural stabilizer. It works with the deep abdominal muscles
(transversus abdominis), the respiratory diaphragm, and the deep spinal muscles (multifidus) to
maintain trunk support. Without the pelvic floor muscles working with the other core muscles, we can
run into issues including low back pain and hernias, and without the other core muscles working with
the pelvic floor, we can run into bowel and bladder issues, pelvic organ prolapse, and pelvic pain.
Everything definitely is connected.

So, how can physical therapy help?

Well physical therapists are the experts in the musculoskeletal system, and as I mentioned above, we are dealing with the musculoskeletal system when working with the pelvic floor.

A licensed Physical Therapist who has been specially trained in treating pelvic floor dysfunctions (usually through the American Physical Therapy Association’s Sections on Women’s Health, or Hermann and Wallace) will do an evaluation, first gathering subjective information on your symptoms. They will often ask questions regarding your obstetrical history (for women), surgical history, bowel and bladder habits, and sexual function. Depending on your symptoms, they may issue you a bowel and or bladder diary to complete in order to assess bladder habits as well as dietary effects on bowel and bladder function.

They will also likely perform an external and internal digital pelvic floor muscle examination. This will be similar to an Obstetrical examination for women, however without using stirrups or a speculum, or a prostate examination for men. The Physical Therapist will likely assess your muscle tone (are the muscles too tense?), strength, coordination, and also looking for areas of pain or tenderness. Afterwards, the PT will discuss a treatment plan, working on restoring normal pelvic floor muscle function, addressing pain, and incorporating exercises for the pelvic floor with the other core muscles in order to restore proper core stabilization and coordination of these muscles with the pelvic floor.

Pelvic floor issues are very common, but as I mentioned above, they are not normal. Too often I
hear people say that they didn’t know that they could get help, or that physical therapy was never
offered as an option to them.

Pelvic floor rehabilitation is growing in physical therapy, and doctors are becoming increasingly aware of physical therapy as an option. I hope that more people will be able to get the help that they need as a result.

If you or a loved one is looking for a physical therapist that specializes in pelvic floor rehabilitation in North County, it is offered here at Pipeline Physical Therapy.

If you are looking for a PT out of the area, or out of state, I recommend asking your physical therapist or physician for a recommendation, or visiting the PT Locator on the APTA’s Section on Women’s Health (however this only lists PTs who are members of the APTA’s section on women’s health, so may be a little limited).