Non-relaxing Pelvic Floor: Where muscles of the pelvic floor remain in a tight or contracted state causing a range of symptoms including constipation, bloating, bladder pain, interstitial cystitis, painful intercourse and musculoskeletal pain.
How can physiotherapy help this condition?
Physiotherapy and a Non-Relaxing Pelvic Floor:
A non-relaxing pelvic floor presents where muscles of the pelvic floor remain tight or in a contracted state. Symptoms vary widely; from sexual dysfunction, to inability to pass stool or urine, to musculoskeletal pain e.g. hip pain. This wide variety of symptoms, which are not necessarily attributed to the pelvic floor, make a non-relaxing pelvic floor difficult to diagnose.
The pelvic floor consists of muscles, connective tissue and bone and they have a role in providing support to the pelvic organs, and the pelvic girdle. In order for the pelvic floor to be functioning optimally, it must be able to contract and relax.
Symptoms of a Non-Relaxing Pelvic Floor:
- Bladder and Bowel Symptoms: To evacuate stool and urine, it is required that the pelvic floor has the ability to relax. Some patients strain or push out faeces or urine rather than relaxing – which is known as dyssynergia. Some symptoms include:
- constipation or straining, an incomplete sense of emptying or bloating, irritable bowel syndrome (IBS).
- recurrent urinary tract infections (or interstitial cystitis), urinary retention (holding urine in), frequency, hesitancy, bladder pain or urge incontinence (increased urgency to go to the toilet).
- Dyspareunia or pain with intercourse:
- Pain with insertion may present as a burning pain if the superficial muscles are too tight or unable to relax.
- Deep or penetrative pain may present as an ache, if the deeper muscles are too tight or unable to relax.
- Increased tension of the pelvic floor muscles may present with a number of musculoskeletal conditions such as:
- Low back pain, hip pain, thigh pain, sacroiliac pain.
How Does This Happen?
There are a number of potential mechanisms for a non-relaxing pelvic floor. The exact mechanism is highly individual and often the symptoms may also be the cause, leaving the question – what came first…was it the chicken or the egg?
- Dysfunctional voiding or defecation. This may have started in childhood or adapted through adulthood and the pelvic floor has become tight as a result of voluntary holding of urine or stool.
- Intercourse may trigger involuntary muscle contraction of the pelvic floor, which is reinforced if intercourse is continued despite pain.
- Injury to the pelvic floor following childbirth or surgery has been reported to have a causative effect on a non-relaxing pelvic floor.
- Various syndromes, for example IBS and interstitial cystitis, may be associated with a non-relaxing pelvic floor through the theory of sensitisation and ‘cross-talk’. In these instances, thresholds are lowered resulting in pain that may be transferred from organs to muscles and vice versa.
- As the pelvic floor muscles interact with hips, pelvis and spine dysfunction to any part of this interconnected chain may account for a non-relaxing pelvic floor.
Assessment of a Non-Relaxing Pelvic Floor:
A thorough subjective and objective examination is used to assess the pelvic floor. This is often an internal examination as well as a physical examination of the whole body.
Image A below shows the pelvic floor muscles looking from below, up. Figure B shows how internal palpation of the pelvic floor muscles is used to assess the ability to contract, relax and to evaluate pain.
Figure taken from: Recognition and Management of Non-relaxing Pelvic Floor Dysfunction. Faubion et al. Mayo Clin Proc. 2012 Feb; 87(2): 187-193.
Treatment of a Non-Relaxing Pelvic Floor:
Once diagnosis has determined that the patient may have too tight a pelvic floor, there are various treatment options. Determining the cause is often key, however this is quite difficult as there are often a number of causes for a non-relaxing pelvic floor.
- If the patient reports bladder or bowel dysfunction, the first line of treatment may be educating the patient on correct postures when voiding.
- Providing education about the pelvic floor muscles and the function. Many women are unaware that the pelvic floor muscles have many more functions than the common knowledge that is to just hold urine in!
- Manual therapy of the pelvic floor muscles.
- Using manual biofeedback to ensure the patient is aware of how to relax the pelvic floor
- Trigger point massage and myofascial release of the musculature to lengthen the pelvic floor.
- Rehabilitation exercises which may involve breathing and relaxation exercises.
- Treating the patient’s whole body to determine if there are other parts of the body that are causing the pelvic floor to remain in a contracted state. For example, releasing parts of the hip or thorax may allow the pelvic floor to relax in which case, releasing just the pelvic floor muscles would not achieve an optimal result. Postural and movement re-education is essential.
A non-relaxing pelvic floor can present with any number of symptoms and it is all too often that women are unaware that these symptoms may actually be as a result of muscles of the pelvic floor being in a contracted state and with an inability to relax.
It is essential to identify women with symptoms of a non-relaxing pelvic floor and provide a physical examination to assess and treat this pelvic floor dysfunction.