Dysfunction Overview

The pelvic floor muscles (levator ani) are attached at the front to the pubic bone and behind to the lateral walls of the pelvis and the coccyx. They form a sling as they support the pelvic organs from back to front. They are responsible for bladder and bowel control, organ support and sexual function.

There are a number of reasons that the pelvic floor can become dysfunctional, the pelvis is the centre through which we move, we sit on it, we need it for bladder and bowel control, it houses our organs, it carries a pregnancy, a baby will pass through it and it is a strong emotional centre in our bodies meaning that we can hold it excessively without even knowing. Is it any wonder it is susceptible to injury ? Here are some of the more specific causes of damage.

1. Causes

• A direct blow to the coccyx - The coccyx is the tail bone attached to the base of the spine, a direct blow can happen as a result of a car accident, a fall or childbirth. A holding pattern can set itself up secondary to pain.

• Chronic constipation - Constipation over a long period of time will damage the Pelvic Floor weakening it and straining the organs. An imbalance can set itself up further feeding in to the pattern of constipation where the muscle dysfunction becomes the main problem.

• Childbirth - Childbirth can be traumatic on the pelvic floor, leading to muscle and fascial tears and organ descent. The variations in presentation are immense and it should not be assumed that a muscle is weak because of a tear or loss of attachment, it is common that weakness post childbirth occurs with negative tension and muscle imbalance.

• Pelvic girdle pain in pregnancy - Pelvic girdle pain in pregnancy is the potentially debilitating pain that some women suffer when the pelvis loses stability and alignment. The pelvic floor will often respond by becoming overactive in its effort to restore stability and pelvic floor muscle dysfunction will follow.

• Poor postural holding patterns - The pelvis is an important movement centre in our bodies, it is common that the lumbar spine pelvis and hips are not aligned correctly and that the pelvic floor sets up a negative holding pattern.

• Post surgery - The pelvic floor can become tense and out of balanced due to scar tissue following surgery.

• No known cause - There are many pelvic floor disorders that can appear with no known cause, some may be hereditary as there is some evidence that connective tissue types are passed on through generations and symptoms from these are described in the next section.

1. Symptoms

The symptoms of pelvic floor dysfunction are often debilitating and can affect quality of life:

• Bladder dysfunction - Under this heading are symptoms of stress urinary incontinence, urinary urgency, urge incontinence, frequency, painful urethra and bladder and on the other end of the scale inability to initiate flow. All can co exist with pelvic floor muscle dysfunction.

• Bowel dysfunction - Symptoms may include fecal incontinence, fecal urgency, defecation dysfunctions and rectal pain(either spasmodic or constant).

• Pelvic organ descent - Pelvic organ descent can refer to prolapse of the urethra, bladder, uterus or rectum through the vagina or through the back passage. Any combination is possible. Symptoms are distressing, balance can be restored making symptoms more tolerable where the prolapse is not too advanced.

• Chronic pelvic pain - Chronic pelvic pain conditions such as “vulvodynia” in women and “chronic prostatitis” in men are distressing and common, they require management by a multidisciplinary team. The physiotherapy management is to release over activity and trigger points in the pelvic floor and surrounding muscles and to teach breathing control. Endometriosis is another condition that comes under this heading.

• Coccydynia - Coccydynia is chronically painful coccyx , it is usually preceded by damage to the coccyx but can set itself up secondary to chronic tension in the pelvic floor in the absence of damage. It often coexists with a pelvic movement dysfunction.

• Overactive pelvic floor disorders - Overactive pelvic floor disorders are vaginismus and anismus and other defecation disorders. These are conditions where the pelvic floor muscles are held chronically tight and voluntary release is hard if not impossible. Treatment is largely aimed at passively releasing the muscles involved and gaining voluntary release and control. The multidisciplinary team approach is important again.