Saturday, January 18, 2014

Pelvic Floor Spasm

You hear a lot about strengthening the pelvic floor muscles, but for many of us this does harm. The pelvic floor muscles may be weak due to them being too tight!

"...the very large oversight is that tight or hypertonic pelvic floor muscle will register as “weak” because it is unable to generate force due to the fact that this muscle is already in its tightest (and shortest) position."

(There is a lot that goes on in the pelvis.)

So why does this happen?

"When the brain perceives an irritation in the pelvis it sends a signal down to the pelvic floor muscle to "protect" your pelvis. This signal puts your pelvic floor muscle in an involuntary contraction.
The irritation may start with a bladder infection, vaginitis, endometriosis, recent surgery, irritable bowel, or interstitial cystitis (breakdown of the bladder lining). Sometimes, the brain sends an exaggerated response. Other times the brain continues to send a dysfunctional signal to the pelvic floor to stay in contraction, even after the original problem has cleared up, healed or been controlled. This dysfunctional continuous signal is believed to happen because the brain perceives the discomfort of the contraction as an irritation and it becomes a vicious cycle of involuntary nerve and muscle response. (In actual fact, it is not so much a signal to contract, but lack of a signal NOT to contract).
Over time the pelvic floor muscle becomes tender from being in a chronic tetanic contracted state, a condition we call pelvic floor spasm."

"Many women with endometriosis have tight painful pelvic muscles. Sometimes pain from spasm in these muscles is worse than the pain from their endometriosis. It can be confusing, too, because painful muscles don’t show at a laparoscopy or on an ultrasound scan. They are a good example of a pain you can’t see. When the muscles around the opening of the vagina are tight, sex becomes painful. It may also be painful using a tampon, or having a cervical smear test. When the muscles on the side of the pelvis become tight, there may be sudden sharp pains on one side. The pain can come at any time, can make it difficult to walk, may also be felt down the leg on that side and is often better with a heat-bag or hot bath...."

This can lead to problems with chronic pain, spasms, trouble with peeing or defecating, and so on.

"Nonrelaxing pelvic floor dysfunction is not widely recognized. Unlike in pelvic floor disorders caused by relaxed muscles (eg, pelvic organ prolapse or urinary incontinence, both of which often are identified readily), women affected by nonrelaxing pelvic floor dysfunction may present with a broad range of nonspecific symptoms. These may include pain and problems with defecation, urination, and sexual function, which require relaxation and coordination of pelvic floor muscles and urinary and anal sphincters. These symptoms may adversely affect quality of life. Several terms such as pelvic floor tension myalgia, piriformis syndrome, and levator ani syndrome3 have been used to describe this entity, but the term nonrelaxing pelvic floor dysfunction may be preferable because it will help the clinician identify a recognizable pattern of symptoms....Women with these disorders tend to have the dysfunctions diagnosed and managed by specialists who usually focus on symptoms pertaining to their expertise (eg, urologists for bladder problems, gastroenterologists for defecatory problems, physiatrists for low back or pelvic pain)....Pelvic floor rehabilitation with neuromuscular education is the cornerstone of therapy for women with nonrelaxing pelvic floor dysfunction. Therapy is ideally provided by a physical therapist with training in pelvic floor dysfunction. The specific therapy used is guided by symptoms and usually includes strategies to optimize lumbopelvic and spinal function and to improve bowel, bladder, and sexual function. Manual techniques may include trigger point massage, myofascial release, strain-counterstrain, and joint mobilization, among others.31, 37 In addition, exercises to strengthen and stabilize the core muscles usually are included with pelvic floor physical therapy. A resource to help clinicians identify physical therapists who specialize in pelvic floor dysfunction may be found at the American Physical Therapy Association's Web site ("
"A patient with high-tone pelvic-floor muscle dysfunction experiences sudden and involuntary contractions of the levator ani muscles, or pelvic-floor muscles, which hold the bladder, uterus, vagina and rectum in place like a hammock. These spasms also can occur in the obturator internus muscles, which control the rotation of the leg and are closely related to the levator ani muscles....Patients who have interstitial cystitis, endometriosis, vulvodynia or fibromyalgia also appear more susceptible...."
(Did anyone else at first glance think it looked like the gloved hand was punching the pelvic floor??)
Here is a good article on pelvic floor spasm and its treatment:

Pelvic Floor Spasm: The missing link in chronic pelvic pain


"Acute or chronic pelvic pain is often due to musculoskeletal disorders, which may go unrecognized during a traditional pelvic examination. Proper evaluation facilitates the diagnosis of spasm or trigger points, and physical therapy often achieves a major improvement in quality of life for these women....

The pelvic floor consists of striated muscles, ligaments, and connective tissues that support the pelvic organs against gravity and intraabdominal pressure. The pelvic diaphragm is composed of the coccygeus muscle posteriorly and the levator ani anterolaterally. Although they are not fully distinct, the components of the levator ani consist of the iliococcygeus, the pubococcygeus, and the puborectalis muscle group. The pelvic floor must allow relaxation of this support at the urogenital hiatus during voiding and parturition while maintaining the anatomic position of pelvic structures. The complex mechanics of its bimodal function and frequent insults to the integrity of the pelvic diaphragm from gravity, daily activities, and vaginal birth contribute to the pelvic musculature’s vulnerability to damage and injury. Lying within the pelvic cavity are the piriformis, and obturator muscles, which are not elements of the pelvic diaphragm but may contribute to pelvic pain when injured.5

Pelvic floor hypertonus may be the primary cause of pelvic pain in some patients; in others it may simply be a response to the underlying pelvic disorder.6 Several mechanisms of injury may lead to spasm of the pelvic floor. These include, but are not limited to, traumatic vaginal delivery, pelvic surgery, positional insults such as prolonged driving or occupations that require prolonged sitting, gait disturbances, traumatic injury to the back or pelvis, and sexual abuse. Malalignment of the pelvis, especially in the sacroiliac joint, due to trauma, poor posture, pelvic floor deconditioning, muscular asymmetry, or excessive athletics also may contribute to muscular dysfunction of the pelvis.

Injury leading to myofascial pain begins with an acute phase, characterized by inflammatory and immune responses. The injury may perpetuate itself with spasm promoting further inflammation, neurotransmitter release, and central nervous system sensitization. As the injury evolves, the second stage is the musculodystrophic stage, during which fibrosis develops and the process favors a chronic syndrome.

Pelvic floor dysfunction can also arise in response to other common chronic pain syndromes, such as endometriosis, irritable bowel disease, vulvodynia, and interstitial cystitis. A prospective evaluation of patients with chronic pelvic pain of various etiologies found abnormal musculoskeletal findings in 37%, versus 5% of controls.7 For this reason, the pelvic floor should be included in any evaluation regardless of the suspected source of pelvic pain....

The treatment of symptomatic pelvic floor hypertonus begins with rehabilitation of the neuromuscular unit or neuromuscular reeducation using biofeedback, muscle relaxation techniques, and soft-tissue manipulation. During the therapist’s manipulation of the affected pelvic floor musculature, the patient is asked to contract and relax. Verbal and tactile cues are used to help the patient recognize when she has appropriately controlled the pelvic floor. External or intravaginal electrodes may be used to monitor the electrical activity of the pelvis and provide visual or auditory biofeedback as the patient attempts to contract or relax. A key objective of neuromuscular reeducation is to improve the patient’s proprioceptive awareness of the pelvic floor. Once a woman is able to recognize contracted versus relaxed pelvic musculature, she is better able to control the pelvic floor.

Physical therapy modalities for chronic pelvic pain also include massage, ultrasound, and myofascial release. Therapists may perform intravaginal soft tissue work as well as manual stretching, although these techniques are most beneficial in the presence of trigger points, banding, or contractures. Massage tools allow self-treatment at home on a more frequent basis. A crystal wand is one of the most commonly used devices for independent therapy of the pelvic floor. In some cases, therapeutic exercise may address musculoskeletal imbalances, and neuromuscular stimulation is used to relieve persistent spasm.

No single modality for pelvic floor therapy has proved to be superior, perhaps because most physical therapists take a multifaceted approach to this complex disorder. Although most treatment options can be applied to almost any patient, our experience suggests that generalized hypertonus usually responds best to generalized therapy (such as strengthening, stretching, biofeedback, ultrasound), whereas trigger points and other focal anomalies more often require manual therapy (such as myofascial release, crystal wand manipulation, trigger point injection). Substantial overlap exists, and a multimodal approach is therefore typical. Some therapy options, such as intravaginal manual therapy, may not be acceptable to all patients.

Physical therapy is relatively successful for patients with chronic pelvic pain related to pelvic floor dysfunction, especially considering the typical outcome and persistence of symptoms for this patient population as a whole. Only a few prospective randomized trials have been conducted, but FitzGerald et al demonstrated a 57% response rate to myofascial physical therapy for urologic pelvic pain syndrome among patients presenting with pelvic floor tenderness.10 The same multicenter collaborative group later confirmed these results with a 59% response rate in women treated with myofascial physical therapy for interstitial cystitis and painful bladder syndrome.11 In a study by Glazer et al, patients with vulvar vestibulitis and pelvic hypertonus also demonstrated a 50% response rate to physical therapy and biofeedback.12

Finding a physical therapist with the skill and interest to address pelvic floor dysfunction may pose a challenge in some geographic areas. Therapists familiar with women’s health issues and chronic pelvic pain are listed at the American Physical Therapy Association Web site ( under the “Find a PT” link.  The Herman & Wallace Pelvic Rehabilitation Institute ( specializes in pelvic floor rehabilitation training for physical therapists and maintains a database of practitioners.

Pharmacologic management options for pelvic floor dysfunction begin with nonsteroidal anti-inflammatory drugs, cyclobenzaprine, amitriptyline, or baclofen. Narcotics are tempting for patients in extreme discomfort but are a poor long-term solution. Gabapentin and pregabalin have shown promise in patients with pelvic floor myalgia.8,13 Injection of persistent trigger points with lidocaine, with or without cortisone, is also a successful approach to the myofascial component of pelvic pain.8 More recently, purified botulinum toxin (Botox) has been used to treat pelvic floor muscle spasm, with proven success.8,13 Sacral nerve, pudendal nerve, and posterior tibial nerve stimulation are all developing modalities with therapeutic promise.8...

 Attention to the pelvic floor musculature during pelvic examinations is an effective and inexpensive diagnostic strategy that can be life-changing for patients with pelvic pain, yet requires minimal time and effort. These patients may have to undergo the usual chronic pelvic pain algorithm without the option of physical therapy if hypertonus goes unrecognized.Physical therapy with or without pharmacologic management offers many patients significant relief or even resolution. Educating patients and using physical therapy to make them active partners in their own care give women with chronic pelvic pain a sense of empowerment and benefit them physically and psychologically."

"In most cases of pelvic floor disorder, not only is the pelvic floor’s timing off due to chronic tension patterns, tension in the abdomen is also great....Tension in the abdomen has nothing to do with strength (Tattoo this in your mind: Tension does not equal strength). Chronic “sucking your stomach in” habits are found more often in those who feel they have something to hide, right? If you’ve got military posture, been slightly tucking your pelvis to give the appearance of a flatter stomach and butt, lifting your chest (at-ten-tion!), or have simply done one too many core exercise session, the tension in the diaphragm and psoas is higher than it should be.
Lie on your back, placing your hands on your lower abdomen. Cough and see if the lower abdomen bulges. Ideally, a cough should produce an upward motion, not a downward one.
If you find that you measure “positive” for all three assessments, time to relax the belly and release all those tense muscles!...Trigger points, points of extreme tenderness or weird “lumpiness” in the specific parts of the body are common in those with hypertonicity of the pelvic floor. Here’s a picture of some typical areas with excessive sensitivity to pressure and/or lumpiness:
Picture from Rehabilitation of the Short Pelvic Floor
What makes these areas lumpy and sensitive? No one knows how it gets this way, but muscles that are tight and non-innervated tend to pull on connective tissues (called fascia) in a way that gets the fascia all wadded up, so you’ve got this tight, cold (cuz there’s not much blood there), dehydrated, non-uniform muscle/fascia tissue bundled in chunks around your body. When you push on a big wad instead of smooth, supple layers, the pressure on the sensory organs becomes higher, which means you feel it more...
Restoring length to the pelvic floor is a combination of not only what you need to do, but also what you need to do less often.
Here’s my (read: your) to-do list:

Helpful stretches for patients with pelvic pain

Buttock Stretch 1 Place your right ankle in front of your left knee. Grasp your left thigh with both hands and gently pull it towards you. The stretch is felt in the shaded area on the diagram (buttock and back of thigh). Hold for at least 30 seconds. Repeat on the other side.

Buttock Stretch 2 Draw your left knee towards your right shoulder. Hold for at least 30 seconds. Repeat on the other side.

Rotation Stretch Keep both shoulders on the floor and roll one leg and hip to the opposite side. This stretches your low back area.

Happy baby pose
Hip flexor stretch
hamstring stretch
Video of some of these stretches:
(Link for several other stretches:
"Activities and Exercises to Avoid with Pelvic Floor Muscle Tension
  • Pelvic floor exercises or kegel exercises
  • Intense core abdominal exercises
  • Painful intercourse/ painful vaginal penetration
  • Prolonged sitting
  • Heavy lifting or heavy activity
  • High impact exercise e.g. running
  • Stress
How to Promote Pelvic Floor Relaxation- ‘Down Training’ Methods

Treatment for pelvic floor muscle spasm is multifaceted. The following Down Training steps (Shelly 2002) can encourage the pelvic floor relaxation when performed regularly.
  • Relax–lie down with a pillow under the knees for 20-30 minutes daily to relax the pelvic floor muscles. Sometimes a warm pack placed over the pubic area or lower abdomen can assist pelvic floor relaxation.
  • Employ diaphragmatic breathing – this means breathing into your diaphragm. Slow diaphragmatic breathing (like yoga breathing) is very important for relaxing the pelvic floor muscles.
  • Visualise your pelvic floor muscles relaxing and a warmth in the pelvic floor region
  • Gentle perineal bulging – this is very gentle bulging of the pelvic floor and should be taught by a pelvic floor physiotherapist. Bearing down too strongly can actually increase spasm so this must be done gently.
  • Choose a relaxed environment is important e.g. soft music, surrounding warmth.
  • Total body relaxation – relax the muscles of the whole body, this may involve progressive relaxation of the different muscles from the face and neck through to the feet.
  • Employ body scanning for any areas of increased muscle tension and aim for complete physical relaxation."