Is A Tight Pelvic Floor A Strong Pelvic Floor?
- Pelvic floor muscle overactivity has a multifactorial aetiology and pathophysiology.
- It can contribute to many pelvic floor disorders such as sexual pain, pelvic pain and bladder / bowel dysfunction.
- An individualised treatment approach targeting the cause of the muscle overactivity is recommended.
What Is An Overactive Pelvic Floor?
- Hypertonicity: “A general increase in muscle tone that can be associated with either elevated contractile activity and/ or passive stiffness in the muscle”1.
- Pelvic floor muscle spasm: “The presence of contracted, painful muscles on palpation and elevated resting pressures by vaginal manometry. This persistent contraction of striated muscle cannot be released voluntarily. If the contraction is painful, this is usually described as a cramp”1.
What Causes An Overactive Pelvic Floor?
- Neurologic conditions
- Problems with motor control
- Protective physiological reflexes
- Visceral or autonomic connections
- Emotions or fear / anticipation of pain
For example, the pelvic floor muscles have been found to involuntarily, and often unconsciously, contract in response to potential physical or emotional pain. One study found pelvic floor activity to be enhanced whilst watching films about sexual violence, and also during anxiety provoking films without sexual content2.
Symptoms Of An Overactive Pelvic Floor
- Pelvic pain: vulval, penile, testicular, perineal, rectal, or suprapubic pain. We often see this muscle presentation in endometriosis, painful bladder syndrome and chronic pelvic pain.
- Dyspareunia: in particular entry dyspareunia or inability to achieve penetration. There is strong evidence that most women with vulvodynia present with increased resting and contractile tone in their pelvic floor muscles.
- Voiding dysfunction / bladder symptoms: reduced stream, incomplete emptying, urethral irritation.
- Obstructed defecation: urge to empty but unable, incomplete bowel emptying, straining.
How To Diagnose An Overactive Pelvic Floor?
How To Treat An Overactive Pelvic Floor?
- Education: explaining the concept of an overactive pelvic floor and how it is contributing to the clinical presentation. A detailed understanding makes a huge difference in a patient’s ability to normalise their pelvic floor muscle function, as often they have had the perception that their muscles are ‘weak’ or that it is good to hold their muscles tight. We see this presentation frequently in gymnasts, dancers and those doing lots of “core” exercises.
- Pelvic floor muscle ‘downtraining’: teaching the patient how to consciously contract and then RELAX their pelvic floor muscles, using education and varying forms of biofeedback such as tactile via internal examination, real-time 2D transperineal ultrasound, EMG, or a mirror.
- Internal pelvic floor muscle release: in the presence of muscle spasm, gentle internal vaginal or rectal stretching and muscle release will help the muscles to contract and relax normally.
- Vaginal trainers: to retrain the learned behaviour of pre-emptive muscle spasm prior to penetration.
- Referral to psychology / sexual counselling: to address fear and anxiety surrounding pain.