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The Elusive Pelvic Floor: A Framework for Understanding What’s “Normal” for Men & Women

Ok, I’m finally going to talk about something I’m super passionate about: the pelvic floor. People often ask me how I got into pelvic health, and I’m not entirely sure how I got here. But, thinking back to when I started in PT school, I knew that I didn’t want to work in a stereotypical outpatient PT clinic; I wanted to work with an underserved population in some capacity. My early exposure to pelvic PT showed me that patients suffering from these symptoms are underserved because they aren’t getting the treatment they need. Why is this? First of all, things often go mis-diagnosed when it comes to the urinary, bowel and sexual systems. Health care providers may not have a good enough understanding of the pelvic floor to recognize when a patient’s symptoms are indicative of pelvic floor dysfunction in order to provide referral to a PT.  Worse yet, these symptoms can often get dismissed by physicians! Another barrier to care is the embarrassing and personal nature of these symptoms, as people may be reluctant to even bring them up with their doctor. Read on to learn about the myriad of symptoms associated with pelvic floor dysfunction.

What exactly is the pelvic floor?  The pelvic floor is skeletal muscle, meaning that it is under voluntary control, just like our biceps or hamstrings.  It is primarily (70%) slow twitch muscle, which is involved in endurance, but it does have fast twitch fibers as well. It is comprised of three different layers that all have specific functions, but all three layers work together as a coordinated unit.

And what exactly does it do? Glad you asked! It does a lot:

  • It supports our pelvic organs (bladder, bowel and uterus in women) and keeps them buoyant within our pelvis. I often describe our abdominal cavity as a tube of toothpaste with the opening directed toward the floor (it’s affected by gravity). Think about what happens when you squeeze that tube of toothpaste – it comes out! The pelvic floor essentially acts like the cap on that tube, keeping our organs inside. Because guess what? Your organs can prolapse out of your vaginal or rectal openings if your pelvic floor doesn’t function correctly.  
  • The pelvic floor also houses our urethral and anal sphincters. The function of our sphincters is complex, but basically, they need to contract to maintain continence and then relax to urinate and pass bowel movements. If there is any dysfunction here, people can have a hard time fully emptying their bladder or bowels, and can also become incontinence of urine or feces (or both).
  • The pelvic floor also serves to stabilize the pelvis. The pelvis isn’t a solid bony structure, but is actually comprised of four bones, which are held together by ligaments and muscle (including the pelvic floor). First of all, I want to emphasize that the pelvis is really the fulcrum of our body. What I mean by this is that it really is our hinge point between our upper and lower body. The muscles from our abdomen and low back insert onto the pelvis, and the muscles of the hip girdle originate here. So, it stands to reason that the pelvic floor can be impacted by dysfunction in our abdomen, low back or hip.
  • It’s no surprise that pelvic floor is also involved in sexual function; it helps to control blood flow necessary for arousal and orgasm.
  • Finally, the pelvic floor muscle also helps to drain our lymphatic tissue from our lower body.
In this model, you can see how the pelvic floor muscles work to support the pelvic organs.

Now, let’s talk about what can go wrong and what that looks like in terms of symptoms.  Just like muscle tissue anywhere else in your body, the pelvic floor can become weak, it can become spastic or develop trigger points, and it can become dis-coordinated. These things issues can develop over time with poor posture or weakness through your core or hips as a compensation, they can also develop in response to dysfunctional habits (e.g. repeated straining with using the bathroom or with suppressing the urge to use the bathroom for several hours repeatedly).  Of course, trauma can also contribute to pelvic floor dysfunction (think tearing during childbirth or a major injury to the pelvic girdle like a pelvic fracture). When tissues connected to the pelvis are injured, there can be an effect on the pelvic floor. Some common examples of this are hip injuries (especially labral tears) or abdominal surgery. Think about it: if your hip muscle or abdominal muscle is compromised, your pelvic floor has to pick up the slack to keep you stable.  

Here are a list of things that are often indicative of pelvic floor dysfunction. Remember, “common” and “normal” are NOT synonymous. A lot of these symptoms are common, but they are NOT normal and may be indicative of pelvic floor dysfunction:

  • Urinary frequency – Peeing more than every 2 hours is NOT normal. Of course, your fluid intake can affect this, but in the absence of excessive fluid or caffeine intake, you should easily be able to go at least 2 hours between using the bathroom to pee.
  • Urinary urgency – The urge to pee should not come on all of the sudden and you should be able to suppress the urge to pee in order to get to the bathroom without leaking.
  • Urinary incontinence – Leakage of ANY kind is not normal. Let me repeat: urinary leakage is NOT normal. Ever. I never want to hear someone say, “I pee when I laugh, but I had a baby, so that’s normal” or “I went so hard on that workout that I peed.” NOT. OK. Urinary incontinence is a sign of a muscle failing to do its job and it can be corrected.
  • Pain with urinating (“dysuria”) – I see a lot of women who tell me, “I have had several UTI’s that don’t respond to antibiotics.” If your urine sample doesn’t come back positive for bacteria, you should not be put on antibiotics, because your symptoms may be the result of something else, like pelvic floor spasm. Similarly, most young, healthy men that get diagnosed with acute prostatitis are prescribed antibiotics, even though it’s typically not bacterial in nature.
  • Night-time urge to pee (“nocturia”) – Having to pee more than once in the middle of the night is also not normal, especially if it happens regularly.
  • Fecal incontinence – This one is pretty straight-forward; most everyone recognizes that this is not normal and needs to be addressed.
  • Pain with bowel movements or bleeding with bowel movements – If your pelvic floor is too tight, it may not be able to relax and may result in pain or tearing with bowel movements.
  • Pain with sexual arousal, intercourse or orgasm – Any of these symptoms are signs of pelvic floor spasm and should be addressed. I often see women who cannot tolerate any type of vaginal penetration (whether that be for intercourse, pelvic exams or tampon use) and are are told, “it’s in your head.” Please, ladies, do NOT accept this if you’re dealing with these issues! Know that there is help for this. Along similar lines, I often see both men and women who experience pain associated with arousal and orgasm, which is also not normal and can be a sign of pelvic floor dysfunction.
  • Genital pressure or pain – In the absence of active infection or acute injury, this is never normal. It shouldn’t hurt to sit or to lift something heavy, and if it does you likely are experiencing pelvic floor dysfunction. Prolonged sitting or cycling can cause nerve entrapment, which leads to pain. Our pelvic organs can also prolapse, or fall downward, after childbirth or with repeated heavy lifting, which can create the sensation of pelvic pressure.

If you are experiencing any of the symptoms above, I implore you to seek a consult with a pelvic floor physical therapist; especially if you’ve undergone an abdominal surgery, sustained a hip or back injury, delivered a baby, had a change in hormone status (e.g. menopause), or failed to respond to traditional treatment of a bladder, prostate or yeast infection. Let me also say that simply doing kegels is not normally the answer. A skilled pelvic PT should take a whole-body approach to help you figure out how other body areas are affecting your pelvic floor in order to really get to the root of the problem. The amazing thing about pelvic PT is that people often respond to treatment pretty quickly.

I’m sure you can see why I’m passionate about pelvic health – because it is so often overlooked and can be so instrumental to improving quality of life. I have worked with too many people who have been dealing with these symptoms for years before finding pelvic PT. Remember, pelvic floor dysfunction can occur in anyone – any gender and at any age. I hope that this post brings awareness to the field of pelvic health and initiates a more open discussion about pelvic floor dysfunction so that people can find timely, effective treatment and relief of these troublesome symptoms.

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