The document provides an extensive overview of pelvic floor anatomy, its functions, and common dysfunctions that affect women, including risk factors, assessment methods, and treatment options. It highlights the importance of pelvic floor muscles in supporting internal organs, maintaining continence, and influencing sexual function, as well as the challenges many women face in seeking help for pelvic floor dysfunction (PFD). Treatment recommendations include lifestyle modifications, dietary adjustments, and specific therapeutic techniques to manage both hypertonicity and hypotonicity of pelvic floor muscles.

1. Dr. Navinderpal Singh
Professor,
Jammu College of Physiotherapy

3. Pelvic Floor Anatomy

4. Pelvic Floor
 The pelvic floor muscles stretch
like a muscular trampoline from
the tailbone (coccyx) to the pubic
bone (front to back) and from one
sitting bone to the other sitting
bone (side to side). These muscles
are normally firm and thick.
 Just like a trampoline, the pelvic
floor is able to move down and up.
The bladder, uterus (for women)
and bowel lie on the pelvic floor
muscle layer.

5. Pelvic Floor has Five layers
 Layer One -Urogenital Triangle
 Layer Two- Urogenital Diaphragm
 Layer Three- Pelvic Diaphragm
 Perineal Body

6. Layer One
 It consists of :
 Bulbocavernosus (bulbospongiosus in men)
 Ischiocavernosus
 Superficial transverse perineal
 External anal sphincter

7. Layer Two
 It consists of:
 Urethral sphincter (sphincter urethrae)
 Compressor urethrae
 Sphincter urethral vaginalis
 Deep transverse perineal
 Perineal membrane

8. Layer Three Pelvic Diaphragm
 The pelvic diaphragm is a wide but thin
muscular layer of tissue that forms the
inferior border of the abdominopelvic
cavity. Composed of a broad, funnel-shaped
sling of fascia and muscle, it extends from
the symphysis pubis to the coccyx and from
one lateral sidewall to the other. It Consists
of
 Levator ani
 Coccygeus
 Piriformis
 Obturator internus
 Arcus tendinous of levator ani
 Arcus tendinous fasciae pelvis

9. Pelvic Diaphragm

11. Perineal Body
 Fibromuscular structure located between the
vagina/testicles and the anus, attaching to the sides of
the ischiopubis rami by the deep transverse perineal
muscle. It is know as the central tendon of the pelvis
because many pelvic floor structures intersect with the
perineum at this structure.

12. Other Muscles are
 Psoas
 Rectus Abdominus
 Transverse Abdominus

13. Functions of Pelvic Floor

14. Functions of Pelvic Floor
 Support internal organs vaginal and
rectal walls(Faubionet.al. 2012)
 Sphincter control of urethra, vagina
and rectum to maintain continence
(Sapsford et.al.,2009)
 Sexual function for orgasm and blood
flow (Junginger et.al.,2010)
 Sump –Pump action for venous and
Lymphatic return (Mitchell and
Esler,2009)
 Optimize stability of pelvic joints and
spine(Lee and Lee ,2004)

15. Stability function of Pelvic Floor

16. Pelvic Floor Problems
 Problems with bladder and/or bowel caused by
weakened pelvic muscles or tears in the connective
tissue.
 One or more symptoms:
 Feeling pelvic pressure or bulge in the vagina.
 Urine leakage (urinary incontinence).
 Overactive bladder (gotta go).
 Difficulty emptying the bladder.
 Problems having a bowel movement.
 Gas or stool leakage (fecal incontinence).

17. Risk Factors for PFD
 Age and life stage:
 1 in 3 women—risk increases with age.
 Pregnancy and childbirth.
 1 in 4 younger women (20 to 39 years).
 Lifestyle and behaviors:
 Obesity and limited physical activity.
 Smoking.
 Chronic Coughing
 Constipation
 Health conditions:
 Stroke.
 Problems urinating and having a bowel
movement.
 Pelvic injury, pelvic surgery
1 in 4 younger women
1 in 3 women with increase age

18. Types of PFD
 Common Pelvic Floor
Dysfunctions entangling
the Women are:
 Bladder control
problems
 Bowel control problems
 Pelvic organ prolapse

19. Pelvic Floor Dysfunction
 PFD is Multifaceted and is characterized by:
 Weakness
 Poor Endurance
 Excessive tension
 Shortened Length
 Over activity
 In case of both excessive tightness or weakness pelvic floor
cannot engage itself in maintaining the determined functions
and result in problems of incontinence, prolapse and pain.

20. 26% Women
Wait over 5
Years to Seek
Help
41% Seek Help
Within 1 Year
33% Wait 1
to 5 Years
Why There is Delay in Diagnosing This problem?

21. Clinical presentation in PFD
 Many Women with Pelvic Floor Dysfunction presents
with
 Posterior Pelvic Tilt
 Decreased Lumbar Lordosis
 78% of Women Seeking Treatment for LBP report
Urinary Incontinence.
 Insufficient activation of postural musculature.

22. Low Back Ache
 LBP is number one cause for global disability and also
the number one reason for visiting a primary health
care provider( Beaudet et.al.,2013)
 Highest prevalence of LBP is among women aged 40-
80 years(Hoy et.al. ,2012)
 The Link between LBP and Pelvic floor dysfunction
particularly in women is evident in various literature
( Arab et.al.,2010,Van Wingerden,2013)

23. LBP In Women with PFD-
Rethinking the Bio in
Biopsychosocial

25. Conditions That may Contribute to PFD in Women
 Gynecological: Endometriosis,Adenomyosis,Chronic
Pelvic Inflammatory Disease, Benign Tumors etc.
 Gastrointestinal: Constipation ,Irritable Bowel
Syndrome, Chronic appendicitis
 Urological: Bladder pain syndrome(Cystitis),Urethral
Pain Syndrome
 Neuromuscular: Trauma, Surgery,Vaginal Muscle
spasm, Neuralgia due to nerve entrapment, Sacroilliac
Joint dysfunction, Pyriformis syndrome etc.
 Psychological: Depression,Anxiety,History of Sexual
abuse.

26. Factors responsible for LBP in PFD
 Ineffective management of Pelvic floor in contribution
to management of intra abdominal pressure to support
the transfer of loads during functional movement.

27. Factors responsible for LBP in PFD
 Pelvic Floor Muscle
 Studies have reported that Pelvic floor muscles
tenderness( Higher Resting tone and decreased
relaxation) and weakness are both associated with
Urinary incontinence and are correlated with Lumbo
pelvic pain.( Dufour et.al. 2018)

28. Factors responsible for LBP in PFD
 Central Pain Mechanism
 Central pain mechanism has been found to be a
significant component in Lumbo pelvic pain and is
influenced by variables such as:
 Psychological status-Emotional and Behavioral states,
Mood, Stress etc
 Endocrine system Hormones released by Hypothalamic
pituitary adrenal axis and Sex Hormones.
 Autonomic Nervous system

29. Assessment of PFD
 History should include questions about women’s
 Pain
 Menstrual cycle
 Bowel and Bladder Function
 Sexual function
 Level of Functioning( How pain affects womens life
and ADLs)
 Co morbidities
 Medicines( Some of them might be contributing to
constipation)

31. Co morbidities-Central Pain Mechanism
 Chronic Fatigue syndrome
 Irritable bowel syndrome
 Primary Dysmenorrhea
 Migraine
 Headache
 Chronic pelvic pain and Endometriosis
 Vaginismus
 Mayofascial Pain syndrome
 Interstitial Cystitis.

32. Assessment of PFD

33. Assessment of PFD
 Physical Examination
 It involves external and internal aiming to detect Tenderness,
Strength and Tone
 Pelvic Floor Muscle Tenderness: Pain elicited during firm
digital vaginal palpation of pelvic floor muscles.
 Pelvic floor strength :Positive test for weakness of pelvic floor
muscles if women patient is unable to lift , squeeze and
maintain pelvic floor contraction for at least for 5 sec in digital
vaginal examination. Muscle strength is graded from 0 to 5.

34. Assessment of PFD

35. Assessment of PFD
 Check for Obturator Internus
Tension
 Forced Faber Test: Patient
reports pain when the leg is
flexed, abducted and externally
rotated while in supine. Pain
provoked in SIJ when examiner
applies overpressure to knee
and opposite ASIS.

36. Tips to judge referral pattern of
tension in Obturator Internus
How does Tension in OI mimic ?
 Coccydynia
 Piriformis Syndrome
 Low back pain and Sciatic pain
 SI joint Pain
 Deep Gluteal pain
 Ischeal bursitis

37. Assessment of PFD
 Pelvic organ prolapse Identification:
 Visualization of the descent of the posterior or
anterior vaginal wall or uterine descent during
valsalva maneuver with patient in supine. It tell
us about weak connective tissues of pelvic organs.

38. Assessment of PFD
 Other methods are:
 To check ability to contract
 Ultrasound
 MRI
 EMG
 To check strength
 Manometry
 Dynamometry

39. Treatment
One has to be evolutionary
rather than revolutionary
and requires professional
expertise of physiotherapist.

40. Treatment
 Multifaceted treatment is recommended
for PFD
 Life style modifications
 Encourage natural pain modulating system
 The key pain modulating systems are
exercise and sleep
 Exercise reduces pain, increases level of
physical function, improves sleep, reduces
fatigue, improves mood, depression ,
anxiety and reduces weight .
 Sleep reduces the ability to cope up with
pain.

42. Treatment
 Dietary modification
 Diet rich in fruits and vegetables reduces free
radicals and stress on body and improves
immunity. These foods along with water have
been found to reduce constipation.
 Minimize intake of caffeine, carbonated
drinks, alcohol ,spicy food which contribute
to pelvic pain.
NO
YES

43. Treatment
 Avoid Smoking
 It has been found to increase
the co morbidity of
depression among patients
with PFD.
 Appropriate Medication
 NSAIDs, Antidepressants.
 Stress Management

44. One Size Fits All-A Wrong Notion

45. Tips for treatment of Pelvic floor
Muscles with Hyper tonicity
 1.Anti Gravity positions
 To off load pelvic floor muscles to reduce discomfort
avoid prolonged standing and sitting .
 2.Apply Heat. Mild heat for 15 to 20 mins to relax pelvic
floor and relive pain
 3.Pelvic floor relaxation
 Relax
 Diaphragmatic breathing
 Gentle perineal bulging
 Relaxed envoirnment- soft music

46. Tips for treatment of Pelvic floor
Muscles with Hyper tonicity
 4.Vaginal Dilator therapy –used in clinics and by women at
home to treat pelvic floor muscle tension.
 5.Stress reduction and cognitive behavioral therapy-
 Reduces stress and changes thinking and behavior related
to PFD.
 6.Manage Bowel-to reduce spasm .Correct bowel emptying
techniques, avoid straining, drink pleanty of water and add
fiber in diet.
 7.Correct sitting posture-minimize prolonged sitting ,sit
with good posture that is maintaining curve in lower back.

47. Tips for treatment of Pelvic floor
Muscles with Hyper tonicity
 8.Physiotherapy –Following techniques can be used to
relive PF tension:
 Desensitize painful area to touch using physical touch
and vaginal dilator
 Pelvic floor stretches and stretch to obturatur internus
 Massage Techniques
 Biofeedback
 Treating associated conditions like SI joint ,tail bone
or back problem.
 9. General exercises for overall strength and fittness.

48. Avoiding Exercises to avoid Pelvic
floor Tension
 Kegel Exercises
 Core abdominal Exercises
 Heavy Lifting or Heavy activity
 High impact exercises eg. running
 Prolonged sitting and standing
 Painful intercourse.

49. Tips for treatment of Pelvic floor Muscles
with Hypo tonicity(Weak Muscles)
 1.Avoid gaining body weight as it damages pelvic floor by
increase pressure on abdominal muscles.
 2.Do Kegel exercise
 3.Pelvic toners-helps in exercising right muscle ,provides
resistance, time can be increased and even resistance.
 4.Exercise classes –such as pilates incorporating pelvic
floor exercises, squats, bridges, lunges,vaginal cone
exercises. etc.
 5.EMG biofeed back
 6.IFT,Electrical stimulation.

50. Take Home Massage
 Screen PFD in all females presenting with Lumbo
pelvic and hip pain
 Develop skill to assess and treat both states of pelvic
floor dysfunction (weakness and tightness)weakness is
not the default mode.
 Weakness should be treated with internal treatment

51. THANK YOU