The pelvic floor is one of those topics we seem only to discuss in hushed voices or when divided into groups of the same gender. It feels a bit like health class in middle school. Remember when you learned all the anatomically correct words, but no one believed you were mature enough to do this with BOYS in the room?!?
OK, maybe we weren’t. But I would like to make a different suggestion for learning about the pelvic floor. It just might be more effective if we didn’t wait until having babies to learn this stuff. After all, the pelvic floor is a group of muscles. Yes, muscles. And although they reside in an intimate location, they still do all the super cool things that other muscles do. Let’s take a look.
The pelvic floor is where exactly?
The pelvic floor muscles run horizontally around all the special bits between your legs. They have attachments at the front of the pelvis, where the two pubic bones meet, at the very tip of the tailbone, and in several places in between.
To make things simple, let’s talk about the pelvic floor in two layers. There is a deep layer, that is further toward the inside of the body. It provides an upward lift to help keep the internal organs where they belong and to provide them support.
Then, closer to the outside world, there is a more superficial layer, that plays a greater role in providing the squeeze that is important for preventing the escape of pee, poop, and gas when the time is not right. Both layers help in the regulation of pressure within the abdomen, but we will cover that in greater detail in a minute.
What does the pelvic floor do?
What most people think of
Because of its location, it is only natural that the pelvic floor plays a role in fecal and urinary continence (stopping the pee, poop, or gas). In the more superficial layer, we each have sphincters that contribute to the closure of the urethra and the anus. These circular muscles wrap around the openings and play a role in keeping waste in and in letting it go. There are components of voluntary and involuntary control at both sphincters.
Sexual function is another common association with the pelvic floor. Obviously, there are a lot of factors that can come into play here, but the muscles of the pelvic floor have an important role in surrounding and supporting the vagina. They need to be able to contract and relax for healthy sexual activity.
And lastly, the reason most of us learn about the pelvic floor in the first place is in preparation for, or after, childbirth. During pregnancy, the pelvic floor typically softens and stretches under the weight of the growing fetus. Hormones also play a role in this. When it comes time for delivery, at least in a vaginal birth, the pelvic floor muscles can stretch up to 16 cm (or about 6.25 inches!) as the child passes through the birth canal.
The less often discussed roles of the pelvic floor
I mentioned previously that both the deep and superficial layers of the pelvic floor help to regulate pressure within the abdomen. To do this, they must coordinate with the diaphragm. When the diaphragm moves upward, the pelvic floor should as well. Likewise, the diaphragm and pelvic floor should also lower together. Like any other muscles, the pelvic floor can adapt its response to meet the demands it encounters.
This coupling of the diaphragm and the pelvic floor creates a pressure gradient that provides stiffness and stability to the spine, hip, and pelvis. When this stability is in place prior to movement of the rest of the body, it allows the movement to occur over a stable base. This means less compensation and more effective movement patterns while simultaneously decreasing injury risk.
This same coordination with the diaphragm also indicates the pelvic floor’s role in respiration. On inhale, it should relax and move downward with the diaphragm, and on exhale, it should contract and move upward. This synchrony allows the pelvic floor to both contract and relax during a normal breath cycle, and its efficiency at doing this impacts the effectiveness of breathing.
Posture is another important function for the pelvic floor. Because of its attachments to the pelvis and tailbone, contractions of the pelvic floor can affect the position of these bones and thus, the position of the spine stacked on top of them. Lastly, the muscles in the front of the pelvic floor play a role in belly shape and strength. When contracted together, the deepest abdominals and the muscles in the front of the pelvic floor enhance the function of each other. These abs, the transverse abdominals, are important for core strength and function, and they are also the ones that narrow the waist.
One more note on normal function
Before we move on to what it looks like when the pelvic floor does NOT function correctly, I want to take a moment to make an important point. The pelvic floor muscles are a group of muscles, meaning that the term applies to several different muscles located in the same area.
Just as you have several muscles in your arm or leg, you also have several muscles in your pelvic floor. Likewise, each of these muscles has a slightly different role, and although they work together, they are not always doing the same thing.
To put this a different way, there is a left and a right side and a front and a back of the pelvic floor. Sometimes, these muscles contract and relax together, and other times, they function more independently. The appropriate activity of each muscle is necessary for normal function, and it is entirely possible to have issues in some parts of the pelvic floor and not others. For normal function, we need all the components to contribute.
Indications that the pelvic floor is not working well
Now that you know what normal pelvic function looks like, it follows that dysfunction can occur within any of these roles. A common example is unintended leaking of pee, poop, or gas (urinary or fecal incontinence). Even the fear of leaking can be an indication of an issue. Incontinence (or the fear of it) often occurs with a sneeze, cough, laugh, or some form of exercise. But leaking is not the only indication of dysfunction. Other examples can be constipation, difficulty with starting or stopping pee, or peeing a second time after standing up.
Pelvic floor issues may also show up in your sex life. This is a topic where treatment may need to extend beyond the pelvic floor, but problems that are most likely to be muscular in nature are things like pain with penetration or a lack of sensation compared to previous experience (especially if this previous experience is before kids).
Lastly, pain in the pelvic region is often indicative of issues with the pelvic floor muscles. It is not always the answer, but it is a good place to start with any pain in this area.
The pelvic floor dysfunction you may not recognize
It is much easier to see that the above symptoms are indications of pelvic floor dysfunction because these are jobs we more likely associate with the pelvic floor. But now, let’s take a look at some of the issues we often neglect to attribute to the pelvic floor.
These might look like issues with posture, hip or spine stability, or pain in places distant to the pelvic floor (ex. back, hip, knee, shoulder, neck, jaw). Further, strategies for breathing that only include the chest or only include the belly can indicate pelvic floor issues because both of these lessen the coordination of the pelvic floor with the diaphragm.
Because the front of the pelvic floor and the deepest abdominals enhance the function of each other, pelvic floor issues can also contribute to bellies that still look pregnant months or years after delivery. And lastly, but possibly most importantly for postpartum women, are problems with pressure regulation. As previously mentioned, this is a crucial role for the pelvic floor, and when pressure is not well regulated it results in some of the big postpartum issues. These are things like diastasis recti, prolapse, and even the incontinence we previously discussed.
The two most common pelvic floor issues
Generally, women either use their pelvic floor too much or too little. If they use it too little, it gets weak. If they use it too much, it can get tight, tired, or painful. Sometimes, it can be difficult to tell which of these scenarios is the case.
A common solution offered to women is Kegels, which refers to a contraction of the pelvic floor. If the issue is weakness, this can be helpful, but the answer is rarely this simple. In a similar vein, the solution for shoulder problems is generally more complex than just contracting the shoulder muscles. Like other parts of the body, the pelvic floor is part of a system that works together to produce normal function. Only when all the components contribute and coordinate with each other do we see success. So, even if Kegels are the answer, they rarely work in isolation.
On the other hand, more common than weakness is the overuse of these muscles. Women often do this to make up for lack of strength or alignment issues elsewhere in the body. In this scenario, the woman needs a strategy to reduce the load on her pelvic floor and reduce her symptoms. Strengthening pelvic floor muscles, themselves, can actually be the WRONG answer in this case.
As you can see, the pelvic floor does not need to be a mysterious, hidden part of the body. Instead, it is a group of muscles that should be considered within the whole person. In fact, it can be a part of the solution, even in issues that do not seem like pelvic floor issues. The more we talk about it the more normal it becomes.