What is the Pelvic Floor?

You may have heard the term “pelvic floor” before or maybe you’ve been to physical therapy for a back, knee, or shoulder injury, but what is pelvic floor physical therapy and why would you need it? Pelvic floor physical therapy, or pelvic physical therapy as some call it, is a specialized type of physical therapy that is focused on the muscles of the pelvis. 

First, we will explore what the pelvic floor is before we talk about pelvic floor physical therapy. The pelvic floor is a “hammock” of muscles between your pelvic bones. The muscles stretch all the way from the pubic bone in the front to the sacrum and coccyx (tailbone) in the back, and attach to the ischium on the sides. 

The pelvic floor muscles have several main jobs: support, sphincter, and sexual functions. We will start with support. These muscles hold the urinary, reproductive, and digestive organs, including the bladder, the uterus and vagina in females, the prostate in males, the urethra, and the rectum. The muscles support these organs, and have a special relationship with the respiratory diaphragm and other core muscles. They provide pelvic stability and promote proper functions of the pelvic organs as well as promote proper posture and breathing. Muscles with sphincteric function are involuntary muscles, meaning we have no conscious control over them. These sphincter muscles help maintain urinary and fecal continence. And lastly, these muscles have sexual functions. They are important for initiating and sustaining erections. When pelvic muscles fail to work well, pain and symptoms can occur which interfere with normal functioning. 

Anatomy of the pelvic floor

There are two layers of muscle in the pelvic floor, a superficial layer and the deep layer. The superficial layer is mostly responsible for sexual function, but also plays a role in support as well. The superficial muscles are the bulbocavernosus in females (bulbospongiosus in males), ischiocavernosus, and the superficial transverse perineal muscles. The bulbocavernosus/ bulbospongiosus are important muscles for erection in both females and males. The superficial transverse perineal muscle is important for stability and strength of the pelvic floor. These superficial muscles are all innervated by the perineal branch of the pudendal nerve, from S2-S4. Hopefully a little nerve talk is familiar to you here at Dakota Chiropractic! Chiropractic can have an impact on the pelvic floor through these nerve roots! 

The deep layer of pelvic floor muscles consists of the levator ani group (pubococcygeus, puborectalis, and iliococcygeus) and the coccygeus muscle. These muscles offer the main support of the pelvic floor. The puborectalis is mainly responsible for bowel continence. This is important because when it is tight or in a shortened position, it can make bowel movements more difficult because it puts a bend in the rectum. This is good when we are going about our daily activities because it keeps us from pooping our pants. However, the puborectalis is the reason squatty potties are so important - it relaxes when the knees are higher than the hips, thus making the resistance for a bowel movement lower. This means it is less likely that you will have to strain. Add a little lean forward and an exhale and you might be surprised how easy it is!

What to expect at a pelvic floor physical therapy evaluation

So now that you know what the pelvic floor is, what can you expect during pelvic floor physical therapy? During an initial evaluation, we go through many of the basics as with any physical therapy evaluation. This includes taking a thorough history, talking through bowel and bladder habits, and asking questions about any pain or symptoms you may be having. Pelvic floor physical therapy entails a lot more than just the pelvic floor itself. We believe it is important to look at the whole person and not just where the symptoms are. So the physical exam includes many parts: a postural assessment, an in-depth breathing assessment, a mobility and movement screen, range of motion testing, several strength assessments, balance testing when appropriate, and feeling for any tight or painful spots in the low back, hips, and glutes. We pay special attention to the lumbar spine, hips, and posture because they are closely tied to the pelvic floor. Then, when warranted and if the patient is comfortable, we do an internal exam. 

You may be asking, “What is an internal pelvic floor exam?” We use a glove and some lubricant to make sure the experience is as painless and smooth as possible. We insert a finger into the vaginal or rectal opening and assess for tissue quality, pain, tenderness, muscle tension, and then perform several tests for strength, endurance, quick contractions, and check for prolapse. 

Internal assessments are particularly helpful when the patient has symptoms of leaking, pelvic organ prolapse, or pain with intercourse because we can more easily determine where the problems may be coming from. Internal pelvic physical therapy is also helpful when the tissues of the pelvic floor or other muscles deep in the pelvis are tense and painful because we can do manual therapy (hands on) to help calm the tissues down. 

The pelvic floor and the core

The pelvic floor functions in concert with the respiratory diaphragm. When you take a deep breath, your diaphragm descends (goes down) and your pelvic floor should too. Then when you exhale, your diaphragm should come back up and your pelvic floor should come back up as well. The pelvic floor and the diaphragm are both extremely important for core stability. The core and abdominal muscles cannot function optimally if either the diaphragm or the pelvic floor is not working properly. 

The abdominal muscles and the spinal stabilizers make up what we generally think of as the core muscles. This includes the 4 main abdominal muscles, the rectus abdominis (6 pack), internal and external obliques, and the transversus abdominis. The transversus abdominis wraps around your middle section, attaching to the spine by a strong band of connective tissue and attaching in the front at the linea alba (line down the middle of your stomach above and below your belly button). This muscle is also really important for optimal core function. 

Sometimes this coordination of the diaphragm and the pelvic floor gets interrupted. This can happen for a variety of reasons, but a few notable ones are when a woman has diastasis recti after having a baby and her core is unstable, when someone’s pelvic floor is tense and they have trouble relaxing, and when a person breathes with a shallow breathing pattern. These are all things that can be addressed with pelvic floor physical therapy! And sometimes, the pelvic floor isn’t even the focus of therapy, even if it is seeming to cause symptoms. 

Pregnancy can change a lot about how your core functions and can have lasting effects if they are not treated. In order to make space for the baby, your connective tissue at the linea alba stretches out, your pelvic organs get compressed, and the ribs flare outward and upward. Your core and pelvic floor get weaker under the weight of the growing baby and uterus. This often leads to a shallow breathing pattern, decreased activation of the deep abdominal muscles, and pelvic floor weakness. This is why at Moms in Motion PT, we believe every pregnant and postpartum woman should get a pelvic floor physical therapy evaluation! Yes, you can get pelvic PT during pregnancy! 

But pregnancy and childbirth aren’t the only cause of pelvic floor dysfunction. Dysfunction can also occur due to falling on your tailbone, groin injuries, excess jumping or pounding such as in gymnastics, anxiety, poor sleep, and more. You might not even remember the first “injury” that caused your pelvic floor dysfunction. It could have been a fall from years ago that didn’t bother you much at the time, but it may not have healed properly. If you have another trauma or a stressful event, sometimes these issues start to show up in the form of pelvic floor symptoms. 

Conditions we treat with pelvic floor physical therapy

We treat each person as a whole, meaning we look at your entire body for clues as to why your symptoms are occuring. This means we may treat your neck or your ankles if we believe they are contributing to your symptoms. We usually start by looking at where your symptoms are, but we have to play detective sometimes to get to the bottom of why they persist. Common conditions we treat: 

• Pregnancy-related low back pain, sacroiliac (SI) joint pain, sciatica, neck and shoulder pain, round ligament pain, joint pain, wrist pain (carpal tunnel syndrome), tailbone pain, leg cramps, incontinence (leaking)

• Safe exercise during pregnancy

• Preparing your core and pelvic floor for labor and delivery

• Postpartum-related low back pain, upper back and neck pain, wrist pain, stress incontinence and urge incontinence (leaking), diastasis recti, pelvic floor dysfunction

• Childbirth recovery

• Return to run and return to exercise postpartum

• Menopause symptoms such as constipation, stress incontinence, and painful intercourse

• Pelvic floor dysfunction and pain

• Low back pain, SI joint pain, sciatica, hip pain, core weakness, upper back and neck pain

If you think you may have pelvic floor dysfunction or you are experiencing any of the symptoms listed above, please don’t hesitate to reach out. We would love to help! 

Treatment for the pelvic floor

After your evaluation, the physical therapist will come up with a treatment plan if you are a good candidate for pelvic floor PT. Your treatment plan may include: 

• Education: educating the patient on pelvic anatomy and their condition, how their habits may contribute to symptoms

• Breathing exercises: timing of breathing, breathing techniques

• Pelvic floor exercises: contracting and relaxing the pelvic floor muscles relative to other muscles

• Relaxation exercises for tense pelvic floor muscles

• Stretching or strengthening exercises of the hips and legs

• Stability exercises for the core and pelvic floor muscles

• Coordination exercises: coordinating

• Manual therapy: hands on massage and stretching to improve mobility, posture, and circulation

• Education in self-management of symptoms

Each patient receives an individualized treatment plan, which often includes manual therapy of the pelvic floor and surrounding tissues as well as specific exercises for your specific needs. Manual therapy is usually a mix of internal and external treatments. If a patient is ever uncomfortable with internal treatment, our therapists are sensitive to the needs of every individual and won’t start internal treatment if the patient is not ready. External manual therapy techniques include trigger point release, deep tissue massage, myofascial release, nerve gliding, skin rolling, and joint mobilization. Internal techniques involve passing a finger through the rectum or vagina to do trigger point therapy by applying pressure on a specific point on the muscle.

The goal of pelvic floor physical therapy is to restore strength and function to the whole body. Pelvic floor physical therapy is usually quite effective at easing pain and associated symptoms. Patients often feel embarrassed and defeated when they come to us, but they often see good success and experience improved quality of life and restored function following treatment. Much of our patients’ success depends on their condition, their commitment to therapy sessions, and their willingness to follow through on their exercises at home. 

What is therapy like at Moms in Motion PT?

At Moms in Motion PT, we see patients for 60 minutes in the comfort of their own homes. We bring our treatment table and any supplies we may need to your house. We want to make the experience as convenient and comfortable as possible for you. We generally see patients once a week at first, and then space out treatment sessions as symptoms improve. 

If you or a loved one is suffering from pelvic pain or associated symptoms, please know that pelvic pain is not normal and that getting pelvic floor physical therapy can make a big difference, especially when treatment starts early.

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