Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following childbirth
Ross Hauser, MD | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following childbirth
In this article we will discuss little known but effective treatments for Pelvic Floor Disorders (Pelvic Floor Dysfunction), Pelvic Girdle Pain, and Symphysis Pubis Dysfunction. These treatments may help women who have been struggling with symptoms for, in some instances, many years without significant relief.
The treatment, known as H3 Prolotherapy addresses and treats, non-surgically:
- Pelvic and spinal ligament damage.
- Tendon attachment damage to the pelvic and vaginal area muscles.
In our clinics, we have had success treating pelvic, groin, and vaginal pain in women following childbirth. Our Comprehensive H3 Prolotherapy approach typically requires three to six treatments and are given approximately one month apart. This type of treatment does not require medications and allows the woman to remain active, and encourages motion and exercise, between treatments.
H3 Prolotherapy to the pelvis involves a dextrose injection treatment to any of the numerous ligaments and tendon attachments that may be weak and causing the pelvic instability. This treatment initiates a mild inflammatory response in the treated pelvic area. Once the ligaments are strengthened, the pelvis becomes stabilized. Referral pain will stop, contracted muscles will relax, and the chronic pelvic pain will abate.
Before we begin a further look at H3 Prolotherapy, let’s talk about the treatments you may have been recommended to and why they have not helped you.
To say the pain is coming from a single diagnosis of Pelvic Floor Disorders, or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.
We just described what H3 Prolotherapy is and how it works, below we will cover some of the research. Before we do, we will cover some of the treatments that may be more familiar to you. The ones that you have been prescribed and recommended to. If you are researching and reading this article, it may be safe to say: “the treatments that did not work for you.”
The challenges and pain women have soon after or for years after vaginal delivery are usually not problems that sit in isolation.
At least not in our many years of experience in seeing women with postnatal or postpartum musculoskeletal disorders. To say the pain is coming from a single diagnosis of Pelvic Floor Disorders,or Pelvic Girdle Pain, or Symphysis Pubis Dysfunction, or vulvodynia or sciatica, is to not understand that this is a pelvic, groin, vaginal, low back problem of multi-dimensions and treating one problem may not be the most effective strategy.
All the doctor did was tell her something she already knew
What is my diagnosis?
A patient came into our office for her first visit. She had been searching for some time to find the cause of her vaginal/pelvic problems. She related a story where after seeing many doctors and many specialists she finally found a health care practitioner who was willing to give her a diagnosis: vulvodynia.
This patient revealed at first joy at receiving the diagnosis because this meant that a plan of attacking her problem could be made based on the fact that she had vulvodynia.
When she heard exactly what vulvodynia was, the patient felt despair. Not because of the diagnosis but because the diagnosis was dismissive of her, vulvodynia, she learned, simply means that she was complaining of “Vulva” meaning vaginal and “dynia” means pain. She was complaining of vulvodynia or “vaginal pain.” All the doctor did was tell her something she already knew. She had vaginal pain.
A case story relayed by one of our patients in the Journal of Prolotherapy also describes a “revelation” that an answer to her groin pain was found that made sense. The treatment recommended however, did not. Here is her story:
“Upon examination by the orthopedist, a pelvic reconstruction specialist, he suggested I complete a new pelvic ultrasound and weight-bearing X-rays of my pelvis, standing on one leg in a flamingo-like pose. The X-rays showed a mild separation of my pubic symphysis and a definite shift of the weight-bearing side when standing on one leg. Just as expected, the MRI also returned signs of “early-mild osteitis pubis,” or inflammation of the suspect joint (inflammation in the groin). We had finally found the root source of my pain: pelvic instability due to an injured pelvic joint. This, my orthopedist told me, could have been a result of the hormonal changes a woman goes through during pregnancy as her body prepares for delivery and the joints open to make room for the baby. But more likely, it was aggravated by a 9+ lb baby coming down the birth canal and the long labor that I had to endure. Slowly, my back, hip, and groin pain began to make more sense. After receiving the results, the obvious question became, how do we fix this? The orthopedist suggested I consider fusion of the symphysis pubis. My husband and I left his office, happy to find an answer, but unsure that surgery was the answer for me.”
The problems of Pelvic Girdle Pain and Symphysis Pubis: Women are grateful just to be heard much less treated
Recent research confirms what we hear from patients following childbirth who suffer from Pelvic Girdle Pain (PGP) or Symphysis Pubis Dysfunction. That these women suffer from pain that is largely ignored or dismissed by doctors. From some women, when we ask what did they do when health care providers ignored their problems, they responded, “I just lived with it. I sucked it up because I have children I need to take care of.”
Clearly you did not need research to be told that your symptoms are being ignored. The appreciation is that the research at least acknowledges what we have seen in over 26 years years of clinic experience. You maybe able to take this research to your provider to help them understand your problem.
Read the learning points:
Published in the journal Physical therapy,(1) investigators at the School of Nursing and Midwifery, Trinity College Dublin, Ireland asked 23 women, who after their first childbirth had continuing pain in their pelvic region for at least 3 months following the birth about their pain, symptoms, and treatment:
They found that among the women:
- The women put up with the pain, but had to balance activities to allow for the pain and were grateful for support from family and friends;
- The women did not “feel back to normal”, but described feelings of physical limitations, frustration and a negative impact on their mood;
- The women were distressed that they were not told these symptoms may occur and the symptoms were an unexpected consequence;
- The women wanted a treatment, but the future impact of their symptoms was met with great uncertainty, so much that the women expressed worry about having another baby.
When we ask what are the symptoms that are causing distress, the woman in our office may have a long list that could include:
- Pelvic pain or pressure that is chronic and generally severe.
- Chronic constipation and discomfort with bowel movement
- Chronic lower back pain
- Genital pain
- Rectal pain
- Vulvodynia (chronic pain in the vulva)
- Coccydynia (tailbone pain)
- Hip impairment
- Pain with sitting
- Painful intercourse
- Sleep disturbances
- Spasms of the muscles of the pelvic floor commonly result in urological issues such as:
- poor urine stream
- urinary frequency and urgency
- urge incontinence.
The condition is real, how about a treatment that works?
The confusing plight of many women with Pelvic Floor Disorders or Pelvic Floor Dysfunction can easily be seen in routine recommendations they receive from their health care providers. While these recommendations can help with symptoms, they do not address the cause of the condition which we find to be in many patients, damaged connective tissue that makes muscles weak and their pelvis unstable. Again we mention that challenges related to the pelvic floor are problems of the pelvic and spinal ligaments and the connective tissue tendon attachments to the pelvic and vaginal muscles:
These are the recommendations of treatment that many of our patients received in previous trips to other medical offices and the possibilities as to why these treatments did not work.
- Pelvic floor muscle training – Kegel exercises may not work
- For many women these exercises will strengthen their pelvic floor muscles. For many women these exercises will not. Why do these exercises fail? For exercise to be effective there must be resistance. The muscles will get strong when they push against or try to pull away from a counterforce (the bone). Muscles generate this resistance through the tendons and the enthesis, the tendon attachment to the bone. If these vital connective tissue are damaged and weak, the muscle cannot strengthen, the pelvic floor remains weak. The exercise and physical therapy will fail.
- Weight loss addresses symptoms, not cause.
- A woman struggling with weight after child birth will be told that their weight is increasing pressure on their bladder and this combined with weakness in their pelvic muscles puts them at great risk for urinary incontinence and Pelvic organ prolapse. While losing weight can be beneficial, weight loss does not put the pelvic organs back into place. Repaired muscle attachments and ligaments can. While weight loss is beneficial it will not provide long-term benefit as a “cure,” for Pelvic Floor Disorders or Pelvic Floor Dysfunction
- Dietary change to prevent constipation
- Stool softening diets, laxatives, and other recommendations are treating the problem of strain on the muscles caused by inability to have an effortless bowel movement. While this can help some women, constipation prevention diets does not address the problem of damaged connective tissue.
Other traditional treatments for pelvic floor dysfunction include:
- External and internal soft tissue mobilization (massage or manipulation)
- myofascial and trigger point release (injections into the muscle to relieve spasms),
- Visceral manipulation (abdominal pelvic)
- transcutaneous electrical nerve stimulation (TENS),
- heat and cold therapy,
- postural education,
- nerve blocks,
- and epidurals.
If all these do not work, then a call is suggested to make an appointment with a psychotherapist.
Years later, same pain and new pains, recommendations for surgeries.
When physical therapy and exercise fails, your doctor then will typically sit down with you and start to discuss the surgical options. Many of you reading this article are already familiar with “slings,” and “mesh,” that will hold your bladder and rectum in place and the recommendation to hysterectomy to remove your uterus. But does it have to get this far? We will explore this question also below.
In 2017, doctors from the Department of Clinical Sciences, Obstetrics and Gynecology at Umea University in Sweden wrote in the journal BMC musculoskeletal disorders (2) that “Pelvic girdle pain is not always a self-limiting condition.” In other words, if you have Pelvic girdle pain for many years, the problem branches out to impact your health. Here is what the researchers wrote:
“Women with more pronounced persistent (Pelvic girdle pain) report poorer health status compared to women with less pronounced symptoms. The knowledge concerning the long-term consequences of Pelvic girdle pain is limited, thus more knowledge in this area is needed. “
Many of you became aware of Pelvic girdle pain during the second, sometimes third trimester of your pregnancy. You may have reported a terrible, stabbing pain in your pelvis that startled you. When you went to the doctor you were assured that this pain would eventually go away. For many women it does. If you are reading this article, it is likely that this pain never went away for you.
In the research we are discussing, the Swedish doctors examined 295 women 12 years after childbirth.
- 40.3% (119 of the 295 women) reported pain to a various degree
- These pains included:
- Overall poor self-rated health,
- pain from sciatica, (defined as pain in the leg or both legs in connection with low back or pelvic pain
- Pain in the neck and/or thoracic spinal pain
- The need to go on sick leave within the past 12 months,
- The women who reported persistent pain sought prescription and/or non-prescription drugs
- These pains included:
- 11% had been granted disability due to Persistent Pelvic Girdle Pain.
The pelvic floor is composed of muscles and fascia that form a sling from the pubic bone to the tailbone and functions to support the pelvic organs (bladder, intestines, and uterus) during contraction and relaxation. These pelvic floor muscles attach to the pubis (anterior) and coccyx (posterior) and work to stabilize the pelvis. If functioning properly, they can help prevent urinary and fecal incontinence.
The sacrotuberous, sacrococcygeal and sacroiliac ligaments are vital to providing stability in the “back portion” of the pelvic rim upon which the muscles attach. The pubic symphysis provides stability in the “front portion” of the pelvic rim, onto which muscles also attach. If these supporting ligaments of the pelvis become injured or stretched out, joint instability can result. This means that the pelvic bones become unstable because its primary stabilizers (ligaments) are too weak or lax to properly hold them in place. The same can happen if the pubic symphysis becomes stretched out or sprained.
Subsequently, if the pelvic floor muscles are trying to contract and the pelvis is unstable, muscle spasms will occur. This can also happen if the pelvic floor musculature is trying to stabilize the pelvis – these muscles can spasm trying to provide stability but can be very painful and contribute to pelvic floor dysfunction.
A brief discussion on urinary incontinence – the sling and exercises are not as effective as you may think
Questions of whether pelvic floor disorders cause urinary incontinence or urinary incontinence causes pelvic floor disorders and how best to treat is the subject of intense research.(3) Troubling is that the “sling” type surgeries for urinary incontinence are the cause of groin pain in many women post-operation. This has been documented in a series of recent studies. (4) Also troubling is the vaginal mesh procedures as a cause of significant and chronic groin pain in women. A study published in the journal Scientific Reviews in September 2017 opens with this sentence: “Complications of surgical mesh procedures have led to legal cases against manufacturers worldwide and to national inquiries about their safety.”(5)
Our article focuses on weakened pelvic ligaments and weakened tendon attachments to the muscles as A if not THE main cause of pelvic area problems in vaginal delivery mothers. If these structures are weak, lax, or loose they cannot be expected to provide the support a mother needs to strengthen her pelvic and vaginal muscles. In other words, as mentioned in this article, if you do not have soft tissue resistance, you cannot have successful exercise programs. Let’s explore a March 2019 study to help make sense of this.
Doctors from medical universities in Italy wrote of their findings on the effectiveness of pelvic exercise in preventing or helping urinary incontinence in the medical journal Archives of gynecology and obstetrics.(6) Here is a summary:
“During the second and the third trimesters of pregnancy and in the first 3 months following childbirth, about one-third of women experience urinary incontinence. During pregnancy and after delivery, the strength of the pelvic floor muscles may decrease following hormonal and anatomical changes, facilitating musculoskeletal alterations that could lead to urinary incontinence. Pelvic floor muscle training consists in the repetition of one or more sets of voluntary contractions of the pelvic muscles.
By building muscles volume, Pelvic floor muscle training elevates the pelvic floor and the pelvic organs, closes the levator hiatus (the openings between the levator ani muscle group where the urethra, vagina, and rectum pass. These openings can become enlarged which allows for the condition of Pelvic Floor Prolapse), reduces pubovisceral length (tightens the stretched out connective tissue) and elevates the resting position of the bladder.”
Let’s stop here because this is what many women and their doctors believe Pelvic floor muscle training does. Indeed, it may for many women, but not for all women. If you are reading this article it is likely that Pelvic floor muscle training did not work for you.
The doctors in Italy recognized that perhaps Pelvic floor muscle training is not as effective and successful as patients and doctors think, at least in regard to urinary incontinence. So they examined the studies that dealt with: “pelvic floor muscle training”,”urinary incontinence”, “urinary stress incontinence”, in “postpartum” and “childbirth.”
Here is what they found:
“Overall, the quality of the studies was low. (To support the use of Pelvic floor muscle training) At the present time, there is insufficient evidence to state that Pelvic floor muscle training is effective in preventing and treating urinary incontinence during pregnancy and in the postpartum. However, based on the evidence provided by studies with large sample size, well-defined training protocols, high adherence rates and close follow-up, a Pelvic floor muscle training program following general strength-training principles can be recommended both during pregnancy and in the postnatal period.”
In other words, there is no evidence that Pelvic floor muscle training works for everyone, but keep doing it because it may work for you.
Our entire contention is, if that you strengthen the pelvic ligaments and tendon attachments through regenerative medicine techniques such as H3 Prolotherapy injections, then you will most decidedly increase the odds that Pelvic floor muscle training will work for you because you are providing the ligament and tendon strength necessary to provide the resistance needed to make pelvic muscles strong.
Exercise and Physical Therapy may be hurting your back, neck, shoulders and arms. Is exercise really making you worse?
Let’s take this one step further. Is it possible the physical therapy and exercise programs you are on are making you worse? There will be many women reading this article who will respond with a resounding YES. Why? because exercise made them worse.
Let’s bring in the opinion of a specialist. Britt Stuge is from the Division of Orthopaedic Surgery, Oslo University Hospital, Oslo, Norway. In the March/April 2019 edition of the Brazilian journal of physical therapy, he published this: Evidence of stabilizing exercises for low back- and pelvic girdle pain – a critical review.
- Women with low back pain and pelvic girdle pain report a significantly lower health-related quality of life than that reported by healthy women.
- A major factor affecting the women’s quality of life is lack of physical ability and a greater loss of physical condition seems to be not a cause but rather a consequence of low back pain and pelvic girdle pain in pregnancy.
- Whereas most women recover after delivery, a number of women continue living with disabling pelvic girdle pain for months and years. Discouragement, isolation and loneliness may be part of women’s lives with pain and limited physical activity.
To briefly review here and none of this should come as a surprise to women suffering from these challenges but at least you have research that acknowledges your dilemma:
- Low back and Pelvic girdle pain cause more health issues than isolated to the pelvic region.
- These health issues are not the causes of your health problems but rather are symptoms and consequences of low back pain and pelvic girdle pain during pregnancy
- Discouragement, isolation and loneliness are also symptoms.
The ligament and tendon “damage” of vaginal delivery on your ligaments and supportive soft-tissue.
The connection between Pelvic Floor Dysfunction and vaginal childbirth is seemingly beyond debate. The majority of new studies centers on reducing the risk of Pelvic Floor Dysfunction after vaginal delivery. This followed a wave of studies that examined the long-term effects of a single vaginal and cesarean delivery.
During childbirth, the pelvic and spinal ligaments are stretched, sometimes stretched too far. The tendon and enthesis attachments that hold the muscle to the bone are also stretched out, sometimes too far. Ligaments and tendon attachments that hold your pelvic region together. After childbirth, for some women, they did not snap back into place, your pelvis and everything within it became very unstable. The physical therapy you are trying, the exercises you are doing are not offering the results you seek because the resistance these muscle require to get strong, needs to come from the tendon attachment that holds the muscle to the bone. Many studies suggest the use of forceps and other childbirth procedures may cause significant damage to the mother resulting in long-term problems.
In fact, the American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins-Obstetrics, released Practice Bulletin No. 165 addresses this concern. The summary is found here: Prevention and Management of Obstetric Lacerations at Vaginal Delivery
Here is one learning point:
- “Severe perineal lacerations (vaginal tears), extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth.”
But is it only lacerations and more easily recognizable injuries during childbirth that are causing the problem? What if the cause of the problem is seemingly invisible?
The invisible undiagnosed damage – the pelvic ligaments
Research is recognizing that ligament laxity or weakness is a major problem for post childbirth women. Then why aren’t you getting treatment for this. Here is some research
In 2016, the same Swedish research team we cited above published these findings: It explains the traditional treatment route. Nothing is said about ligaments. It should be pointed out that this research is published in the journal Chiropractic and manual therapies (7) as an answer from a manipulation stand point is being sought.
In this study, 176 women were asked whether or not they had Pregnancy-related low back pain and/or pelvic girdle pain postpartum.
- 34 (19.3 %) reported ‘no’ pain,
- 115 (65.3 %) ‘recurrent’ pain,
- 27 (15.3 %) ‘continuous’ pain.
- The vast majority (92.4 %) of women reported that they had neither been on sick leave nor sought any healthcare services (64.1 %) during the 6 months – 12 months postpartum. (Agreeing with the above research that the women were tolerating the pain and discomfort. They were “sucking it up.”
- Women with ‘continuous’ pain during the 6 months – 12 months postpartum reported a higher extent of sick leave and healthcare seeking behaviour compared to women with ‘recurrent’ pain.
- Most women with persistent Pregnancy-related low back pain and pelvic girdle pain had been on sick leave on a full-time basis.
- The most commonly sought healthcare was physiotherapy (exercise, massage, sometimes manipulation), followed by consultation with a medical doctor, acupuncture and chiropractic.
None of these treatments are designed to strengthen spinal, pelvic, vaginal, groin area ligaments
Why is no one treating your ligaments?
If pelvic floor pain lingers and no known source is found, injured, loose or weak ligaments and instability of the pelvis should be considered. The numerous ligaments that surround and stabilize the pelvis undergo relaxation due to the hormone relaxin that is secreted during pregnancy. This hormone does just what it says – it relaxes the ligaments in the pelvis to allow the baby to pass through the birth canal. In some cases, the relaxed ligaments may not return to their normal properties and the woman is left with pelvic ligament laxity and instability, which can include the hip(s) in some cases. This can be especially true for women who already have joint hypermobility.
Numerous ligaments surround the pelvis and help to keep it stabilized. When these ligaments become weak, they are unable to maintain pelvic stability and can cause pain. Injury to the pubic symphysis, pubic ligaments or any of the ligaments that stabilize the lower back (especially sacroiliac joint) would cause the pelvic floor muscles to contract continually against an unstable base.
In pelvic floor dysfunction, the musculature is in spasm and muscles that are constantly contracting or in spasm will generate pain. Muscles spasm because they are trying to provide stability in an unstable region.
Pelvic floor pain and Symphysis Pubis Dysfunction – instability because of weakened damaged ligaments
The pubic symphysis is frequently an overlooked joint located in the front of the pelvis. It is a joint that is strongly bonded and is rarely injured in isolation. The pubic symphysis is actually a fibrocartilagenous disc supported on the top by the superior pubic ligaments. It helps unite the left and right pubic bones.
In the female, the pubis is located above the vulva. In cooperation with the sacroiliac joints, the symphysis pubis forms a stable pelvic girdle. The anatomy of the pelvic girdle is quite complex. The pelvis is a ring, and any anatomical change or force of pressure to one area will expand throughout the ring.
- Childbirth causes changes in the pelvic girdle, which can lead to excessive movement and instability.
- Severe shearing stress injuries, such as a fall may disrupt the pubic symphysis as well as fracture the pelvis.
The pubic symphysis joint can move about 2 millimeters, and with one degree of rotation. This small amount of movement is normal, but in some women the joint may become unstable, allowing for too much movement in the pelvis. Again, because of the anatomy of the pelvic ring, instability at the symphysis pubis often also affects the sacroiliac joints, and vice versa.
Symphysis pubis dysfunction has been described as a collection of signs and symptoms of discomfort and pain in the pelvic area, including pelvic pain radiating to the upper thighs and perineum.
Prolotherapy treatments addressing damaged ligaments
The fibrocartilagenous disc, that is the pubic symphysis joint, is composed of bundles of thick collagen fibers. These fibrous bundles resemble tendon cells. Since unresolved pain from symphysis pubis injury involves instability of this disc as well as ligament laxity in the pelvic girdle, a better approach is to strengthen the joints with Prolotherapy.
Clinical observations over the course of decades have shown Prolotherapy treatment to injured ligaments induces a mild “healing” inflammatory reaction, which stimulates the repair of injured or lax ligaments. Prolotherapy injections can strengthen the ligaments and pubic symphysis, increasing stability and relieving muscle spasm and other symptoms in pelvic floor dysfunction.
In those with pelvic floor dysfunction and associated pain in their back, pubis, pelvic floor, genitals, coccyx, and associated symptoms, Prolotherapy can help to strengthen injured or stretched out ligaments, allowing them to reinstate stability to the pelvis and allow tight muscles to relax.
The use of PRP injections for treating genital prolapse
Platelet Rich Plasma Therapy (PRP). Sometimes PRP is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots.
- PRP treatment takes your blood and concentrates its healing platelets into an injection or gel form.
- Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.
- The treatment can be used to strengthen connective tissue in the pelvic, groin, vaginal regions.
A June 2018 review of the medical literature published in the journal Clinical and experimental reproductive medicine (8), discussed the use of PRP Therapy for the treatment of genital prolapse. Here research is cited for the use of PRP for genital prolapse
The research team cited a 2017 study from Greek researchers (9):
Here are the learning points of that research:
- Platelet rich plasma (PRP) is extremely rich in growth factors and cytokines (proteins that help initiate healing), which regulate tissue reconstruction.
- It is suggested that PRP may be beneficial in helping women with Pelvic Organ Prolapse as the treatment may be effective in repairing uterine ligament defects.
Also cited was a 2016 study (10) on the effects of PRP treatment on Stress urinary incontinence. What was noted in this study was that “several surgical techniques have been proposed for the treatment of Stress urinary incontinence.” That these surgeries which include “the Burch colposuspension, retropubic mid-urethral slings (TVT), trans-obturator tapes (TOT), trans-obturator tapes inside out (TVT-O), bladder neck injections and the insertion of an artificial urethral sphincter,” sought to restore urethral support, which is naturally preserved by the pubourethral ligament.
Here these researchers speculated that treating the pubourethral ligament with PRP could repair pubourethral ligament damage.
Understanding the ligament damage – making sense of treatment
In a study of the three pubourethral ligaments in women, French surgeons wrote the following (11):
- The proximal pubourethral ligament was closely associated with the sphincter urogenitalis muscle. (Comment: If this ligament was damaged, the muscle that supported the urinary sphincter would be compromised.)
- The distal pubourethral ligament reinforce the role of the compressor urethra muscle. (Comment: If this ligament was damaged, the muscle that supported your ability to “hold it in,” or control urine stream is compromised.”
- The intermediate pubourethral ligaments along with the proximal and distal pubourethral ligaments “plays an effective role in passive and active suspension of the urethra.”
As are many of our articles, we update the information frequently. We hope we have been able to solve some questions you have had about Pelvic Floor Disorders (Pelvic Floor Dysfunction), Pelvic Girdle Pain, and Symphysis Pubis Dysfunction.
If you have questions about this article, Get help and information from our Caring Medical staff
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