Levator Ani Syndrome, Vaginismus, Hypertonic Pelvic Floor
Hypotonic Pelvic Floor Muscles
Hypertonic Pelvic Floor Muscles
Incoordination of the pelvic floor and abdominal muscles
The pelvic floor refers to all the muscles, nerves, tissues, and ligaments that connect to bones on all sides of the pelvis. Pelvic floor muscles (PFM) are thin layers of muscle that form a basket (or bowl) to support the pelvic organs (urinary, digestive and reproductive), control bladder and bowel functions, and are critical to sexual function.
Pelvic floor muscle dysfunction (PFMD) refers to muscles that have an abnormal muscle tone or are not performing their jobs correctly. PFMD can be classified as either hypertonic or hypotonic.
Hypertonic pelvic floor dysfunction refers to a condition where the muscles in the pelvic floor have tightened at rest and/or shortened. There is usually pain and the muscles may spasm. The tightening decreases blood flow which affects the oxygen supply to the muscles and ultimately results in the release of bradykinin, cytokines and lactic acid which causes a feedback loop for inflammation and increased sensitivity to pain (hyperalgesia) . The buildup of lactic acid irritates the nerves passing through the muscles causing pain and symptoms of inflammation which feed the pain cycle (1). This tension in the pelvic muscles is an involuntary contraction of the muscles for extended periods of time resulting in limited mobility. Decreases in blood flow, shortened muscles, and limited mobility; can lead to the development of painful trigger points (or knots) in the muscles. As a result of this decreased range of motion, hypertonic muscles have poor motor power and functionally present as weakness.
Hypotonic pelvic floor dysfunction refers to a condition where the pelvic floor muscles are lengthened at rest, demonstrate poor motor power and/or are inadequate to respond to voluntary contraction) and/or are too weak. Hypotonic muscles may not be (adequate to support pelvic organs or prevent incontinence. During a pelvic exam the muscles may feel thin, loose, and weak. Weakness is (determined by voluntary motor power and contractile endurance up to 10 seconds) accessed by trying to voluntarily contract the muscles and/or holding a contraction for 10 seconds. Often, patients with hypotonic pelvic floor muscles will have trouble contracting the muscles fully or at all and they may have decreased endurance or an inability to hold a contraction.
Incoordination (aka discoordination) of the pelvic floor and/or abdominal muscles refers to a condition when muscles (are no longer synergistically operating) respond opposite as intended, or an inability to use pelvic floor and abdominal muscles correctly. For example when trying to urinate the pelvic floor muscles contract and stop the flow of urine rather than relax.
Signs & Symptoms
The signs and symptoms of muscle dysfunction can mimic the same symptoms of many sexual pain conditions and even promote urogynecologic infection. PFMs interact with the pudendal nerve and its branches throughout the pelvis. The pain can radiate meaning that it can be felt in other parts of the body (such as hips, back, and even the feet) masking the true origin of the pain in the pelvis. This condition can be present in all genders.
Symptoms of hypertonic pelvic floor muscles include:
- Urinary retention and/or frequency
- Painful urination or defecation
- Vulvar burning and/or vaginal burning
- Dyspareunia (pain with sex)
- Vulvodynia (Vulva pain)
- Vestibulodynia: It should be noted that vestibulodynia can be caused by PFMD or congenial or hormonally mediated vestibulodynia can cause PFMD. When PFMD causes vestibulodynia the pain is limited to or most intense at the posterior vestibule (6 o’clock).
- Clitorodynia (Clitoral pain)
- Lower back pain
- Hip and thigh pain
Symptoms of hypotonic pelvic floor muscles include:
- Urinary incontinence
- Bowel incontinence
- Orgasm dysfunction
- Vaginal laxity
- Pelvic organ prolapse
- Sexual dysfunction
There are four generally recognized root causes of pelvic floor disorders: inflammation, infection, trauma and musculoskeletal conditions. PFMD can be either primary or secondary to other sexual pain conditions (1). Patients can get caught in a pain loop making it difficult to distinguish the original cause. In patients with hypertonic pelvic floor muscles contributing causes may include: chronic straining, poor postures in the sitting, standing, or toileting positions, dysfunctional gait patterns, previous sexual or physical abuse, harmful repetitive movements, childbirth injuries, infection, trauma , cancer-related treatments, abdominal or pelvic surgery, autoimmune disorders and inflammatory conditions (2).
Pelvic Floor Disorders can affect men and women, young and old alike. The highest prevalence in the U.S. is observed in women. Research indicates that 25% of women experience one or more pelvic floor disorders in their lifetime and 15-20% specifically with pelvic pain (3, 4).
Not only does pelvic pain and disorders have a direct impact on an individual’s quality of life, it carries a significant financial burden on the sufferer. Pelvic pain, alone, has a direct healthcare cost of approximately $2.8 billion annually (5). Part of this financial burden is directly related to obtaining a diagnosis. The National Vulvodynia Association reports that the majority of women consult at least 3 physicians before they receive a diagnosis of a pelvic pain condition (6). This is why public education is a key component for healing individuals suffering from pelvic pain.
Pelvic floor disorders/dysfunction can be assessed and evaluated by a trained medical provider (Primary Care Physician, Gynecologist, Sexual Medicine specialist, and/or Urologist) and/or a physical therapist trained in pelvic floor therapy.
When an individual is experiencing symptoms of pelvic floor dysfunction, they should seek out specialists who have experience in the treatment of these conditions, like a pelvic floor physical therapist. (A trained physical therapist with experience in treating pelvic floor dysfunction).
- At the initial pelvic floor physical therapy evaluation, the therapist will discuss, in depth, all of the sufferer’s complaints, medical history, past trauma, current medications and daily habits. Consent to perform an internal assessment and perform treatment is collected on the first visit.
- Next, the patient will be assessed globally for movement and/or muscle impairments as well as motor incoordination, weakness, myofascial restrictions, bony and ligamentous support, etc. Often, an internal muscle assessment will be performed either vaginally and/or rectally in order to properly assess the dysfunction at the source of pain.
- During an internal assessment, the patient would receive a sensory examination (to assess neurologic function of the pelvis), manual examination of the musculature (assessing strength, endurance and coordination as well as hyper/hypotonicity of the muscles) and soft tissue assessment of the surrounding tissues.
- Once the area of dysfunction is identified, the provider will formulate a treatment plan of care and review this plan with the patient. Timeline varies for each patient based on current symptoms, severity of symptoms, co-morbidities, etc.
Treatments vary for patients with pelvic floor disorders based on what dysfunction they are experiencing. If the patient demonstrates muscle weakness, they most likely will receive specialized exercises to help strengthen those muscles. If the patient has hypertonicity or muscle spasms/tension, their treatment may involve down-training/relaxation or muscle release techniques. Here are a few common treatment practices used in pelvic floor therapy:
- Manual Therapy - Manual therapy refers to treatment techniques used internally and/or externally to release and restore normal muscle function. These manual techniques vary based on the provider’s experience and/or expertise. Examples of manual therapy techniques include trigger point release, strain/counterstrain, myofascial release, manual lymphatic drainage, muscle energy technique, dry needling, visceral mobilization and craniosacral therapy.
- Therapeutic Exercises - These treatments are aimed to elongate or strengthen muscles of the pelvis and spine and often involve functional movement patterns. Examples of these exercises might be stretching, core stabilization, yoga or pilates, postural reeducation, balance training, pelvic floor strengthening, etc.
- Biofeedback is used in a variety of ways to restore pelvic function. Biofeedback is often used for used for muscle reeducation, muscle strengthening and/or down-training spastic/guarded muscles. The GOLD standard of biofeedback is manual biofeedback when performed internally by a trained provider.
The best treatment outcomes for pelvic floor disorders and pain conditions is when providers and patients are partnered with the same goal, intention and efforts behind healing. This means, the patient will often be expected to make changes at home and will be given specific instructions as homework. This home program will look different for each patient based on what dysfunction was discovered during the initial evaluation. However, with these efforts by the patient combined with the provider’s skill, patients often achieve lasting results. However, length of treatment varies for each individual patient and progress and results may not be linear.
- Stein, A. 2009 Heal Pelvic Pain McGraw-Hill Companies
- Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, and Sheryl A. Kingsberg. 2018. Textbook of Female Sexual Function and Dysfunction, Diagnosis and Treatment. John Wiley & Sons Ltd., Hoboken, NJ.
- Wu, Jennifer M et al. “Prevalence and trends of symptomatic pelvic floor disorders in U.S. women.” Obstetrics and gynecology vol. 123,1 (2014): 141-148. doi:10.1097/AOG.0000000000000057
- Zondervan, K, and D H Barlow. “Epidemiology of chronic pelvic pain.” Bailliere's best practice & research. Clinical obstetrics & gynaecology vol. 14,3 (2000): 403-14. doi:10.1053/beog.1999.0083
- McCoy, C.E. “The Economics of Treating Female Chronic Pelvic Pain.”Bovie Medical Corporation J-Plasma White Paper
- The National Vulvodynia Association. “Vulvodynia: Get the Facts.” The National Vulvodynia Association, www.nva.org/media-center. Accessed 14 Feb. 2022.