The pelvic floor muscles are a group of muscles that collectively form a floor enclosing the bottom of the lower pelvis. They are arranged in two layers, superficial and deep and play primary roles in our pelvic support, sphincter control and sexual functioning by:
- Supporting the pelvic organs and their contents against gravity, and withstanding any increase in pressure in the abdominopelvic cavity during activities such as coughing, laughing, sneezing, lifting and physical exertion. This support is increased during childbirth and when there is an increase in weight and volume of the internal organs.
- Serving as a passage way from the interior (bladder and rectum) to the exterior of the body. They contribute to maintaining continence due to the elasticity of the musculature.
- Contributing to sexual function in men and women by providing tone to the vaginal walls, maintenance of clitoral and penile erection and reflexive contraction of the pelvic diaphragm during orgasm. Poor sexual response has been associated with weakened muscle strength and lack of muscle awareness.
Superficial muscles – These muscles form a structure from front to back between the pubis and the coccyx and laterally between the two ischial tuberosities (sit bones). the muscles form a figure 8 that crosses at a central point in the perineum.
- Bulbospongiosus muscle- Runs from the clitoris to the central tendon of the perineum.
- Ischiocavernosus muscle- Runs from the pubis to the central tendon of the perineum.
- Superficial transverse perineal muscle- Is stretched between the two ischia (sit bones). it converges in the center at the central tendon.
- External sphincter of the anus- Surrounds the anus
- External sphincter of the urethra- surrounds the lowest part of the urethra
Male reproductive organs: Penis- Composed of columns of erectile tissue. when this tissue fills with blood, the penis becomes erect.
- Corpus cavernosum- This column of erectile tissue is one of two that lie side by side along the penis.
- corpus spongiosum- This spongy, erectile tissue surrounds the urethra and widens to form the glans of the penis (along the penile head).
Female reproductive organs: Clitoris- Like the penis, this organ contains spongy, erectile tissue and nerve endings.
- External genitals- the vagina and urethral openings are surrounded by skin folds called labia.
- labia majora- Are the outer lips. labia minora are the inner lips. the two sides of the labia minora double up to form the hood of the clitoris.
Deep pelvic floor muscles defined: These muscles are deeper and above the preceding layer. they are closer to the internal organs. these muscles form a hammock holding the pelvic organs such as the bladder, uterus, vagina and rectum within their space. they respond passively and actively to variations in abdominal pressure.
- Levator ani muscle- Consists of two main parts and is responsible for supporting the internal organs.
- Medial- Puborectalis muscle – begins at the pubis and slings around the rectum
- Pubococcygeus muscle- Surrounds the rectum
- Lateral- Iiococcygeus/ coccygeus muscle- Is the posterior portion of the levator ani. it stretches between the ischial spine, sacrum and ends at the coccyx.
The following muscles border the pelvic floor muscles. Their contractions can be mistaken for that of the pelvicfloor muscles:
- Deep hip muscles- Rotate the hip inward and outward- these muscles are attached to the pelvis and extend outward to the top of the femur.
- Piriformis muscle- Attached to the lower internal surface of the sacrum and runs forward and outward, leaving the pelvis and ending at the top of the femur.
- Obtorator internus muscle- Attached within the pelvic cavity.
- Hip adductor muscles- Found on the inside of the thighs and draws the thighs together.
- Gluteal muscles- Includes the gluteus maximus.
- Abdominal muscles- Situated between the ribs and the pelvis.
The pelvic floor muscles and their associated biochemical, nervous, and mechanical processes usually go on without requiring your conscious effort or attention. These muscles are usually dynamic, working and resting throughout the day. They are meant to have the ability to tighten and relax at will. This relaxation allows for proper oxygenation, nutrition, management of waste and rejuvenation of tissue.
These muscles are not meant to be chronically tensed. Chronic tension will tend to shorten the muscles so that the posture of a shortened muscle begins to feel normal. Research has shown that people with chronic pelvic pain syndrome (cpps) tend to have elevated pelvic floor muscle tension even when resting. This constant pelvic floor muscle tension results in an environment that is inhospitable to the nerves, blood vessels, and structures within it.
Common pain patterns associated with internal pelvic floor muscles:
- Puborectalis- One of the most important muscles for male pelvic pain. It can refer pain to the following areas : tip of the penis, shaft of the penis, bladder and urethral. it can cause urinary frequency and urgency and refer pressure/fullness in the prostate.
- Anterior levator ani, middle portion- Refers pain and pressure to the base of the penis, prostate, bladder and pelvis and recreates frequency and urgency.
- Anterior levator ani, inferior portion (puborectalis) -Refers pain and pressure to the perineum, the base of the penis and the prostate in men. in women, it can refer lateral vaginal wall, perineal, anal sphincter or referral pattern toward the anterior levators, bladder and urethra.
- Middle levator ani- (iliococcygeus) it can refer lateral wall, perineal, anal sphincter, prostate fullness pain/discomfort referral pattern toward the anterior levators and prostate.
- Coccygeus/ ischiococcygeus- Trigger points in this muscle typically refers pain and pressure associated with the sense of having a golf-ball-in-the-rectum, pain to the coccyx and gluteus maximus. pre or post bowel movement pain is often associated with the sense of having a full bowel (due to trigger point referral from these muscles).
- Bulbospongiosis and ischiocavernosis- Pain referred to the vagina and perineum.
- Sphincter ani- Can refer pain in the anal sphincter itself as well as radiating to the front and back from the sphincter.
- Superficial transverse perineal muscles- Refers pain to the vagina and palpation site.
- Piriformis muscle (internally accessed)- Trigger points here can refer to the sacroiliac joint, the hip girdle and hamstrings.
- Obturator internus muscle- Can refer dull ache on the side palpated, golf-ball-in-the-rectum sensation, coccyx, hamstrings, posterior thigh, urethra, vagina, vulva(important in vulvodynia).
- Perineal body- It can refer pain and sensation to the rectum, vagina, and site of palpation.
- Palpating the coccyx- This is a bony palpation. in treating pelvic pain, if the coccyx is immobile, it can be a factor that perpetuates trigger points that cause pelvic pain.
Treatment associated with pelvic floor muscle dysfunction:
1. Understanding the postural and movement component associated with pelvic floor muscle imbalances. Evaluation of the pelvic floor complex must include alignment and mobility of the surrounding joints to rule out misalignment. Special emphasis should be placed on the: lumbosacral, sacroiliac, sacrococcygeal and pubic symphysis joints and their muscular attachments.
2. Direct internal assessment of pelvic floor muscles. assessment includes joint and muscle mobility, pain palpation and assessment of strength.
3. Direct internal manual treatment of pelvic floor muscles. Myofascial release is a treatment of choice and has been found to be a tremendous help within the various conditions affecting the male and female pelvic floor. The organs are sacs that are meant to move, expand and empty. This is true for the bladder, uterus, vagina, rectum and colon. Should they not be able to move because of fibrotic attachments, endometrial adhesions, tissue changes or scarring from surgery, symptoms of pain, pressure, constipation, urinary frequency plus many others, could develop.
Should the organs not be stabilized in their proper position because of weakened or torn muscles and ligaments, problems such as prolapse, perineal pressure, pain and constipation may present. Myofascial release techniques along with strengthening programs for the internal muscles as well as the supporting musculature can have a profound effect on normalizing muscle tone and restoring normal function of the pelvic floor muscles as well as the male and female reproductive organs.
All of the therapists at hands on physical therapy have extensive training in treatment of pelvic floor dysfunction. Talk to your physician if you feel that you are a candidate for pelvic floor assessment and treatment. If you are currently receiving treatment at hands on physical therapy and have pelvic floor symptoms that have not been addressed, please be sure to mention it to your therapist.
Jody Hendryx, PT