Pelvic Floor Dysfunction: Symptoms, Causes and Why Physical Therapy Works

Tight or weak: two different problems

Most public discussion of the pelvic floor is about weakness: leaking urine with coughing or exercise, and pelvic organ prolapse, typically after childbirth or with age. The treatment for weakness is strengthening, the familiar Kegel exercise.

Chronic pelvic pain is usually the opposite problem. The muscles are in a state of persistent contraction, tender to touch, and unable to lengthen when they should, for example to allow a bowel movement or penetration. Kegels make a tight pelvic floor worse. Telling the two apart requires an examination, which is why women with pain who have been told to "do their Kegels" often deteriorate.

Symptoms of a tight (hypertonic) pelvic floor

• A deep, aching or heavy pain in the pelvis, vagina, rectum or perineum, often worse at the end of the day or after sitting.
• Constipation with straining, a feeling of incomplete emptying, needing to change position or use a finger to pass stool, and pain with bowel movements.
• Urinary urgency and frequency, hesitancy, a slow or interrupted stream, and a feeling the bladder has not emptied, with negative urine cultures.
• Pain with penetration at the entrance, pain with deep penetration, and pain or spasm after orgasm.
• Pain inserting tampons or during pelvic examinations.
• Lower back, hip, groin or tailbone pain, because the pelvic floor attaches to all of them.

Why it develops

• Protective guarding: any persistent source of pelvic pain, such as endometriosis, bladder pain syndrome or a painful childbirth injury, causes the muscles to brace. Over months the bracing becomes the default and a pain source in its own right.
• Pelvic nerve irritation: an irritated pudendal or other pelvic nerve drives reflex muscle contraction, and the tight muscle in turn compresses the nerve.
• Habit and posture: chronic breath-holding, clenching, high-impact exercise without release, and prolonged sitting.
• Surgery, scarring and infection.
• Stress and trauma, which raise baseline muscle tone throughout the body and the pelvic floor in particular.

The endometriosis connection

Pelvic floor hypertonicity is present in a large share of women with endometriosis, and it explains a recurring clinical story: the endometriosis is removed by surgery (see excision vs ablation), the cyclical pain improves, but a daily aching pain, constipation and pain with sex remain. The muscles learned to guard over years and do not relax because a lesion was removed. For this reason, pelvic floor physical therapy is now considered part of comprehensive endometriosis care, before and after surgery, rather than an afterthought.

How it is diagnosed

There is no scan for pelvic floor dysfunction. A clinician or pelvic floor physical therapist assesses the external pelvic floor and then, with consent, performs a gentle single-finger internal examination, feeling each muscle group for tone, tenderness and trigger points and asking you to contract and relax. The ability to relax is as important as the ability to contract. Imaging may be arranged to look for coexisting conditions such as endometriosis or adenomyosis, since treating the muscles alone will not resolve pain that has a structural driver.

Treatment

• Pelvic floor physical therapy by a specialist: manual release of tight muscles and trigger points, teaching the muscles to lengthen, breathing and down-training, and biofeedback to show the muscle what relaxation feels like. This is the first-line and most effective treatment.
• Bowel and bladder retraining: positioning for bowel movements, timed voiding, and avoiding straining.
• Heat, stretching routines for the hips and pelvis, and reducing high-impact or clenching exercise during treatment.
• Muscle relaxants used vaginally or rectally, and trigger point injections for persistent focal spasm.
• Botulinum toxin injections into the pelvic floor for severe hypertonicity that has not responded to physical therapy.
• Treatment of the underlying driver: endometriosis, pelvic nerve pain or bladder pain syndrome.

Finding the right help

Ask for a referral to a physical therapist who specializes in the pelvic floor and treats pelvic pain, not only incontinence. Ask whether they perform internal assessment and treatment. If you have endometriosis, tell them, and tell your gynecologist you are seeing them, so the plan is coordinated. Improvement is usually gradual over weeks to months, and tracking pain, bowel and bladder symptoms through treatment shows what is working.