What Pelvic Floor Dysfunction is, How it Happens, and How to Heal it

How Your Shoulders, Feet, and Nervous System Connect to Pelvic Floor Function

Though historians say that all roads lead to Rome, physical therapists say all roads lead to the pelvis. That is because the pelvis is connected to both the trunk and the legs, between the internal organs and the outside world. The pelvis is involved in:

1. Support: It provides a sturdy base for the spine, supports the weight of the upper body, and connects the upper body to the lower body.

2. Connection: Many major muscle groups including the quadriceps, hamstrings, gluteal muscles, abdominal muscles, psoas (which connects the upper bones of the low back, the lumbar spine, to the pelvis), quadratus lumborum (which connects the pelvis to the ribs), as well as other muscles that flex and extend the spine.

3. Organs: The pelvic floor supports the bladder, intestines, and internal reproductive organs (prostate for men and uterus, ovaries, and vagina for women)

4. Movement: Alignment and mobility of the pelvis has a significant impact on how well we can walk, run, and move more generally.

5. Childbirth: The pelvis is literally a portal from the otherworld to this world by bringing new life into the world.

Because of all of these connections, problems in the hands, feet, or emotions can have a big impact on the pelvis and likewise, problems in the pelvis can cause problems relatively far away. For example, I have been participating in a training program targeted on healing the pelvic floor and have noticed substantial improvement in chronic shoulder and calf injuries.

The pelvic floor is part of the canister that makes up your core, along with the diaphragm, abdominal, and back muscles. When the core is healthy, it can respond to the many varied and dynamic movements we need to engage in throughout the day. If you’ve ever dealt with stress incontinence, low back pain, or pelvic pain, you know that spontaneous movement without planning and strategy can be difficult. However, when the system functions well, it can respond to variable forces from many different directions. You can pick up a bag of dog food from the floor or lower baggage from the overhead compartment of an airplane. You can sneeze, bend and twist, or jump on a trampoline.

When the muscles of the pelvic floor are dysfunctional people may experience:

• Difficulty starting urination

• Bulging of the bladder or into the vagina, the uterus outside the vagina (uterine prolapse), the upper portion of the vagina outside the vagina (vaginal prolapse), the intestines into the vagina, or the rectum into the vagina

• Involuntary leakage of urine (incontinence)

• Pain during or after sexual intercourse

• Constipation

• Involuntary leakage of stool (fecal incontinence)

• Pelvic pain

• Pain where the pubic bones meet (pubic symphysis)

• Pain where your tailbone meets your pelvis (sacroiliac joint)

• Low back pain

Pelvic floor dysfunction affects 50% of childbearing women, and 1 in 5 women have surgery to address stress urinary incontinence (the type of incontinence caused by increased abdominal pressure like sneezing, coughing, jumping, and heavy lifting). Pelvic floor dysfunction is common and getting moreso. In 2010, there were 28 million American women with pelvic floor dysfunction. Researchers project that there will be 43-58 million women with pelvic floor dysfunction in 2050 and a 55% increase in both urinary and fecal incontinence over that time. Though pelvic floor dysfunction is more common in women who have had children, other factors like a sedentary lifestyle and stress mean that people who have never had children (including men) can experience pelvic floor problems. When women mention symptoms of pelvic floor dysfunction to a medical provider, they are often instructed to do kegels. Kegels are voluntary contractions of the pelvic floor muscles. However, pelvic floor weakness is not the only cause of pelvic floor dysfunction. Too much tension in the pelvic floor muscles or difficulty coordinating pelvic floor movements can also cause painful or troublesome symptoms. Kegels can worsen tension in already too tight pelvic floors.

Pelvic Floor Tension

Four main issues contribute to pelvic floor tension (though there are other less common ones).

1. High-intensity exercises like heavy lifting or box jumps: If you start lifting heavy without learning how to manage the increase in pressure inside your abdomen, sometimes the pelvic floor stops knowing when and how to relax.

2. Bathroom habits: Holding your pee frequently or for long durations can lead to overuse and tightness in pelvic muscles. Sitting on the toilet for a long time reading or scrolling can also overuse and tighten those muscles.

3. Stress and anxiety: Just like your jaw or shoulders tighten up when you’re under stress, your pelvic floor and gluteal muscles do too. We often have less sensory perception to notice it than we do in other muscle groups.

4. Injury due to childbirth: The pelvic floor often tightens in response to muscle tears or other traumas to protect you from further injury.

People with pelvic floor tension often experience two main issues–pain or problems with peeing and pooping. When the muscles in the front of the pelvic floor get too tight, it can be difficult to empty the bladder all the way, which increases the likelihood of developing UTIs. These tight pelvic floor muscles can also lead to muscle spasms. Those spasms prevent the urethra from opening enough to let urine out. When you push against the spasm, it can sometimes cause a feeling of burning when you pee, even though you don’t have an infection. When pelvic floor muscles are tight, they can also compress the bladder or other nearby structures which gives the urge to pee frequently. Additionally, incontinence either due to pressure (coughing, sneezing, laughing, lifting, jumping) or a strong urge to pee both suggest that the pelvic floor isn’t working as it should. Lastly, when the muscles at the back of the pelvic floor are too tight, they can cause problems with pooping, usually constipation or straining.

Several types of pain are associated with pelvic floor tightness. Just like muscular tightness around the urethra and anus affects our ability to pee and poop, tightness around the vagina can lead to painful sex. Tight pelvic floor muscles also frequently contribute to painful period cramps, pelvic pain, low back pain, hip pain, and tailbone pain. Tight pelvic floor muscles can also contribute to trigger points in the thighs, hips, back, and abdomen.

Picture from Rehabilitation of the Short Pelvic Floor via Nutrititious Movement

When we are under stress, our sympathetic nervous system activates. That causes increased tension in all of our muscles, including the pelvic floor. The pelvic floor muscles become tight and overactive, which leads to incontinence, pain with sex, and pelvic pain. In other words, the pelvic floor needs not only the strength to contract and the endurance to maintain that contraction, but also the length to be able to relax and release tension.

Pelvic Floor Weakness

Pregnancy, particularly accompanied by a long or difficult delivery is the most common, but certainly not the only, cause of pelvic floor weakness. The additional weight and pressure on the pelvic floor during pregnancy can stretch those muscles. Pelvic surgeries, getting older, and poor posture can contribute as well. It is often difficult to distinguish whether symptoms of pelvic floor dysfunction are due to weakness or excessive tension because they often involve pain and incontinence in both. Pelvic organ prolapse is more likely in people with weak pelvic floor muscles. Stress incontinence (peeing due to increased pressure like lifting, coughing, sneezing, jumping) is more likely due to pelvic floor weakness than tension. Urge incontinence, peeing because an urge comes suddenly is more likely due to pelvic floor tension, but both can happen from either.

Psoas Tightness

Many people have very tight psoas muscles. The most common cause is excessive sitting. Our bodies evolved to be mobile more than we are. Hunter-gatherers aren’t constantly moving though, they actually work less hours per day than we do. They also rest in different ways. The key is that almost every chair we sit in encourages us to sit with the pelvis tucked (sitting mostly on our tailbone). That requires less muscular effort than sitting so the weight is distributed over the triangle that includes the pubic bone and the sitting bones. Here is the difference in sitting positions:

Certainly, it is less effort to sit in the first way. That’s why we do it. However, you can also see how my shoulders slump forward when I do that. Over time, that creates a lot of unnecessary neck and shoulder tension too.

Here are some examples of chair-free resting positions from Nutritious Movement:

Additionally, many of us perform exercises that result in repetitive hip flexion like running, cycling, and weightlifting. The psoas is also known to store emotional tension.

A tight psoas muscle pulls on the spine and pelvis. It will pull the pelvis too far forward leading to pelvic floor weakness. A weak psoas muscle can’t stabilize the pelvis and will lead to worse posture that increases pressure on the pelvic floor.

Shoulders, Feet, and the Pelvic Floor

Anatomically, the pelvis and the shoulder are intimately connected. The abdominal oblique muscles connect the low back and pelvis to the opposite shoulder. The gluteus maximus muscle extends into the fascia of the low and mid-back which crosses over the latissimus dorsi (a large back muscle that is used for pulling things down or back). The tilt of the pelvis changes the curvature of the spine, which changes posture. The head of the humerus bone is positioned inappropriately when there is low back and pelvis dysfunction. Walking effectively depends on integration of the shoulder and pelvis. Not only that, but the pelvic floor engages before we move our shoulder every single time. Physical therapist,

Julie Wiebe, PT, DPT

notes, “The pelvic floor, along with the other inner Core components (Diaphragm, Transverse Abdominis, and Multifidus), secure our physical center to create a sturdy anchor for the muscles that support and create shoulder motion before we start moving our arm, every time we move our arm, no matter which way we move our arm.” Tight shoulders often pull us into poor posture. That along with a forward head position changes our breathing mechanics, restricts rib range of motion, and increases the pressure in the abdomen.

Our feet impact pelvic health in several different directions. First, there are the biomechanical changes that depend on where and how your foot strikes the ground. Is it only your toes? Does your weight fall on your outer foot? Do your arch and knee collapse inward? Second, motor and sensory input from the foot and genitals are located next to each other in the brain. Third, Fascia connects from the foot to the spine and core muscles. Last, feet and pelves serve as shock absorbers for the body.

Flat feet/collapsed arches cause thigh and hip rotation, which can lead to excessive gripping and tightness in the pelvic floor. Rigid feet decrease the body’s ability to absorb impact, which increases pressure in the abdomen, especially during running. The nerves that supply the pelvic floor also supply the small muscles in the feet as well. Here are a couple of examples from OrthoPelvic PT:

For a person with flat feet/fallen arches:

1. While walking/running/existing, the knee falls in which pulls the adductors

2. This causes the hip to rotate in which pulls the rotators

3. Then tension from the knee/hip pulls on the pelvic floor muscles and put them in a tightened position

4. Tight pelvic floor muscles can cause the issues listed above.

For a person with high arches and a rigid/stiff foot

1. Stiffness in the foot means less force is absorbed when walking/running etc.

2. Because less force is absorbed by the foot, more force goes up to the pelvic floor

3. The pelvic floor and hip have to be stronger to counteract this increased force otherwise, this person may experience urine leakage or low back/hip/pelvic pain

Nervous System and the Pelvic Floor

For a long time, physicians and researchers thought tension in the pelvic floor was only related to physical or sexual abuse, which strikes me as a weird, illogical assumption. However, researchers connected electrodes to women’s pelvic floor muscles and trapezius muscles (the ones that are doing most of the work when it feels like your shoulders are up by your ears). They showed the women different types of movies. They found that pelvic floor tension is part of regular defense mechanisms/fight or flight responses.

According to Lauren Ohayon from Restore Your Core (can’t recommend her program highly enough by the way), feelings, presence, and sensation require a lot of energy from the body. Because of this our autonomic nervous system (what people talk about with fight or flight and rest and digest, though it’s a bit more complicated than that), uses sensation, memory, and past experience to guide what you will do. The system is designed for efficiency, so it is more likely to use tactics that are familiar over the ones that are the most functional. These adaptations influence breathing and postural patterns, emotional regulation, sensory awareness, and which parts of the body we connect to and which ones we avoid. When you have a quiet moment, lay down, try to sense your skin, muscles, bones, and organs individually. Notice which you can feel easily, which are difficult to perceive. Also note that the areas that are difficult to sense will only become easier when you are in an environment that feels safe.

The pelvic floor is one of the most sensitive and reactive parts of the body in its response to the nervous system. The pelvic floor is an anatomic part of you that correlates with the root chakra in yogic philosophy. A healthy root chakra is vital to our sense of safety and security. Echoing the traditional knowledge of the chakra system, the pelvic floor reflects a sense of safety more than muscle tone. When we don’t feel safe, it may manifest as pelvic gripping, numbing, and disconnection from sensation. Because of the numbing and disconnection, we often are unaware of the tension in our pelvic floors.

Creating a healthy pelvic floor requires stretching muscles, but it also requires slowing down, relaxation, and safety. The pelvis is a body structure that causes stimuli and responds to stimuli from head to toe. Though kegels have a role in caring for your pelvis, it's a small one. If you are curious about other ways to tend to your pelvic floor, you can find more specific exercises and movements below the paywall.