What is the pelvic floor?
The “pelvic floor” refers to a group of muscles that attach to the front, back, and sides of the pelvic bone and sacrum (the large fused bone at the bottom of your spine, just above the tailbone). Like a sling or hammock, these muscles support the organs in the pelvis, including the bladder, uterus or prostate, and rectum. They also wrap around your urethra, rectum, and vagina (in women).
Coordinated contracting and relaxing of these muscles controls bowel and bladder functions—the pelvic floor must relax to allow for urination, bowel movements, and, in women, sexual intercourse.
What is pelvic floor dysfunction?
Pelvic floor dysfunction (PFD) is characterized by inappropriate muscle activity in the complex of muscles that make up the pelvic floor. It refers to a wide range of issues that occur when the muscles of the pelvic floor are weak, tight, or there is an impairment of the sacroiliac joint, lower back, coccyx, or hip joints. Tissues surrounding the pelvic organs may have increased or decreased sensitivity or irritation resulting in pelvic pain. Many times, the underlying cause of pelvic pain is difficult to determine.
What are the symptoms of PFD?
- Constipation, straining, pain with bowel movements
- Urinary urgency, frequency, hesitancy, stopping and starting of urine stream, painful urination, or incomplete emptying
- Urinary incontinence, fecal incontinence, pelvic organ prolapse
- Unexplained pain in the low back, pelvic region, genital area, or rectum
- Pain during or after intercourse, orgasm, or sexual stimulation
- Uncoordinated muscle contractions causing the pelvic floor muscles to spasm
How is PFD diagnosed?
Physicians or physical therapists (PTs) who are specially trained in treating PFD diagnose the condition during a physical examination. Using external and internal “hands-on” or manual techniques to evaluate the function of the pelvic floor muscles, they can assess your ability to contract and relax these muscles.
Bones and muscles of your lower back, hips, and sacroiliac joint can stress your pelvic floor muscles. Your doctor or PT will first check externally and internally for problems such as muscle spasms, muscle knots, and weakness or sacroiliac misalignment (where your sacrum and upper hipbones meet).
If an internal examination is too uncomfortable for you, your doctor or physical therapist may use externally placed electrodes, placed on the perineum (area between the vagina and rectum in women/testicles and rectum in men) and/or sacrum (a triangular bone at the base of your spine) to measure whether you are able to effectively contract and relax your pelvic floor muscles.
How is PFD treated?
The goal of treatment for PFD is to relax these muscles and avoid stressing them. Treatment usually combines self-care, medicines, physical therapy, and home exercise.
- Self-Care—Avoid pushing or straining when urinating or defecating, and ask your healthcare provider about how to treat constipation. Relaxing the muscles in the pelvic floor area overall is important. Using methods such as warm baths or heat packs are also helpful.
- Medicines—Low doses of muscle relaxants such as diazepam (Valium), 2 mg three times a day, may be helpful. Maintaining good posture to keep pressure off your bladder and pelvic organs and using stretching or other techniques such as yoga to avoid tightening and spasms in the other pelvic muscles, also help PFD therapy to succeed.
- Physical therapy—A physical therapist specially trained in pelvic floor rehabilitation may take the following steps to help you obtain relief from your PFD:
- External and internal evaluation of your pelvis
- External and internal manual therapy
- Application of various devices to help relax your pelvic floor
- Training in home exercises, posture, pain management, bowel/bladder techniques, self-relaxation, and general fitness activities.
External and internal manual therapy
The therapist may do manual therapy or massage both externally and internally to stabilize your pelvis before using other kinds of treatment. Manual therapy takes time and patience, and may require one to three sessions per week, depending on the technique used and your response to treatment. You may feel worse initially. However, many patients see improvement after six to eight weeks.
For internal massage, your PT may insert a finger into the vagina or rectum and massage the muscles and connective tissue directly. A frequently used technique is “Thieles massage,” in which your therapist finds a trigger point by feeling a twitch in the muscle underneath, exercising it using a circular motion, and then putting pressure on it to help relax it, repeating the process until the muscle starts to release. Internal massage can also help release nerves. Sometimes, anesthetics can be injected into these trigger points. PTs may do this in a few states, but in most states, a doctor or nurse must administer injections.
If there is too much discomfort with internal therapy techniques, your PT may start with external techniques to help you begin to relax these muscles, including:
- Skin rolling
- Deep tissue massage, often called “myofascial release”
- Trigger-point therapy to release tight spots or “knots”
- Nerve release
- Joint mobilization
Application of various devices and therapies to help relax your pelvic floor
- Biofeedback uses electrodes placed on your body (on the perineum and/or the area around the anus) or probes inserted in the vagina or rectum to sense the degree of tenseness in your pelvic floor muscles. Results displayed on a computer or other devices provide cues to help you learn to relax those muscles. Usually, patients feel relief after six to eight weeks of therapy.
- Home exercise and therapy is also a mainstay of PFD rehabilitation. Because the goal of PFD therapy is to learn to control and, especially, relax the pelvic floor, therapists will teach you techniques for use at home to build on the therapies they do in their offices. This usually begins with general relaxation, stretching the leg and back muscles, maintaining good posture, and visualization—part of learning to sense your pelvic floor muscles and to relax them.
Some information adapted from the Interstitial Cystitis Association website: http://www.ichelp.org
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