Not just Kegels: Four Different Roles of Pelvic Floor Function

I want to talk about the pelvic floor muscles – a sheet of muscles that lies at the base of the pelvis, running between all the pelvic bones. The pelvis is a hollow ring of three connected bones and the pelvic floor muscles (PFM) lie like a sling across the bottom of the pelvis.  Nestled above the PFM are the pelvic organs, including uterus, ovaries, bladder and bowel. The pelvis interacts with many body systems – respiratory, musculoskeletal, reproductive, urinary, gastrointestinal, neurological, and lymphatic.  The PFM impacts and is impacted by all of them. 

These muscles provide many different actions and have many different roles.  And like all of us, the muscles need to function properly for things to work optimally:  they need to be strong enough to do their job, they need to be flexible enough to allow movement, and they need to be well enough connected to your brain that you know what is going on down there. But what is it is that the pelvic floor actually does?  Let’s find out!

Support: A primary role of the pelvic floor is to hold the internal organs in place.  That sling of muscles that spans the opening of the pelvic cavity functions like a hammock holding up the rectum, uterus, and bladder. Gravity is continually pulling things downward and without good muscle and connective tissue support, our organs may begin to drop or fall out. This is called pelvic organ prolapse.  This falling down, or dropping, can be hereditary, can be related to general aging and decreased activity, or can be from strenuous experiences like pregnancy, childbirth, excessive pressure (coughing or lifting), or constipation. Poor muscle support can lead to difficulty emptying bowels or bladder, a sense that things are “falling” out, feeling a bulge in the vagina, and urinary or fecal leakage. These can ultimately lead to the need for pelvic surgery.  Good pelvic floor function can keep the organs in place and manage the downward pressure to prevent descent of the pelvic organs with strenuous or upright activities. In PT, we work on PFM strengthening exercises (the infamous kegel!) and hip strengthening. We also do a good deal of work on breathing mechanics, rib movement and abdominal strengthening. We work on coordination of breath, core, and PFM. When addressing support issues, we also discuss options like vaginal weights, pessaries for support, or splinting for improved bowel emptying.

The PFM support the pelvic organs like a hammock

Sphincteric: A second key role of the pelvic floor is sphincteric.  A sphincter is a circular muscle that closes an opening when it contracts– like your lips! The urethral sphincter (controlling the bladder exit) and the anal sphincter (controlling the bowel exit) are imbedded in the pelvic floor muscles and have the crucial job of keeping the exit passageways from the bowel and bladder closed to provide continence and control. Like a chip clip – it holds things closed when you want them closed, and opens when you want things to come out! Dysfunction in this area could present as weakness (lack of control or incontinence) or tightness (limited emptying or constipation). Pelvic PT helps people to identify the muscles, determine what needs to be improved, and begin the appropriate exercises to help.  Many bowel and bladder issues can also be improved with simple diet and behavior changes.

The PFM work to close the bladder and bowel exits to prevent leakage much like a chip clip

Stability:  Another fabulous role of the PFM is stabilization. Stability in the trunk is key to being able to safely and accurately move our arms and legs; Stability protects our spine and allows us to lift heavy things without injury. We need a solid foundation to reach out from: Our deep core stabilizers are the key to good balance. Think of the PFM as an octopus in the center of a hula hoop – pulling in from all directions to keep things stable.  Kind of like an elastic hair tie – it wraps around to hold things together so you can get important things done! Your PFM work in coordination with your diaphragm and your abdominals to create your “core” (a cannister of sorts) to manage pressure and generate support to the spine. This gathering together of all the muscles holds everything in the optimal position.  If this pressure cannister is not managed well, you can develop hernias, prolapse, or back pain. During pregnancy, the hormones surging throughout the body create laxity or lose of stability in all the joints which can lead to pain, especially low back pain. We can reinstate stability by improving the strength of not only the PFM, but the abdominals and breathing muscles as well. We can also find pain relief by adding artificial support with belts or bands. Learning optimal posture and movement patterns can help alleviate pain and improve tolerance to daily activities and exercise.

We need deep core stability to be able to do challenging activities

Sexuality: The final function of the PFM that we will talk about today is by far the most fun – sexuality.  Because of its attachments to the clitoris and the way the PFM wrap around the vagina, the pelvic floor has a significant role to play in sexual function.  Poorly functioning PFM can lead to problems in this area: muscles can be too tight, too weak, or too poorly connected to our brains to know what is happening down there! A very tight or tense pelvic floor can make vaginal penetration difficult.  This can limit not only intercourse, but use of tampons or a medical exam. If the mind believes that it will be painful to insert anything, the body will subconsciously and reflexively tighten up at any attempt at entry, making the muscles tighter and beginning a cycle of pain and tightness. This may have always been present, or may have developed after a stressful event.  All the lube in the world may not help. And a bottle of wine won’t likely help either!  PT can help by directly working with the muscles, through massage and stretching, or vaginal dilators, to gently lengthen and relax the muscles in a non-threatening, controlled way.  Relief may also be found with massage to pelvic scars from prior surgeries or childbirth injuries. We can use biofeedback (think video games for your vagina!) to allow your eyes to see a visual representation of what the PFM are doing. We may think we are relaxed but are really tense and don’t even know it – we have just been tight for so long.  And it is not really intentional – it’s just a tight muscle.  Our goal is to practice relaxing in a controlled environment so you can use this skill during intimate moments.  We also discuss positioning, foreplay and lubrication issues.  

The PFM play a role in sexuality as well!

On the other hand, PT can also help if there is poor sexual response – limited pleasure, decreased orgasm or sensation.  Often this is a result of stretching and laxity related to childbirth or general weakness, and a strengthening program can do wonders to get things working again!

The PFM are like an intricate web - affecting many different functions in the body.

An Intricate Web: The pelvic floor is a highly complex, inter-connected group of muscles that is part of many of our bodily functions.  When there is a dysfunction in one area, it often impacts other areas.  A tight muscle can limit intercourse and cause constipation, weak muscles can allow for back pain and leakage.  Bladder issues can limit willingness to participate in intercourse or play with kids and grandkids. Prolapse can keep women from exercising leading to increased weakness and limited function. By addressing these issues, we can get women back to a confident, enjoyable life! Reach out to a pelvic physical therapist for help reaching your unique goals!