Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following sports injury

Danielle R. Steilen-Matias, MMS, PA-C

In this article, we will discuss new research and what doctors are recommending moving forward in the treatment of Pelvic Floor Dysfunction in women.
We will also explore how regenerative medicine treatments may provide a missing answer to the problems of bowel movement dysfunction, urinary incontinence, unexplained back and pelvic pain and other symptoms attributed to Pelvic Floor Dysfunction in cases where conventional treatment has failed.

Please see our companion article: Pelvic Floor Disorders, Pelvic Girdle Pain, and Symphysis Pubis Dysfunction following childbirth

We see many patients in our clinic who have been diagnosed with pelvic floor dysfunction or chronic myofascial pelvic pain. Before we discuss the differential in diagnosis, let’s look at some of the challenges we have seen affecting these patients and likely you the reader.

A woman will sit on our examination table, sometimes fighting back emotion and pain as the act of sitting can be causing her discomfort. When we ask her when did this pain start, she may respond:

“It started while I was pregnant”
“It started right after childbirth”
“One day I coughed really hard.”
“One day I sneezed really hard.”

Sometimes there will be a story of the long journey the patient took before they came into our office. Their stories may sound like this:

I was in the middle of my divorce. It had been enormously stressful on me and produced episodes of panic, anxiety, and a lot of depression. I recognize that I was in mentally and physically draining situation that was wearing me down. I started to notice that I was “leaking,” and started to wear pads. As this continued and I started to have pain sensations I thought that I had a urinary tract infection or a yeast infection. I had not of this but I did get antibiotics and antifungal medications, “just in case.” As my symptoms continued I moved onto the ultrasound examination. My gynecologist could not find a likely or probable cause for my problem. I always have the feeling that I need to urinate.

I think I have to urinate all the time.

This is a common problem in situations of Pelvic Floor Dysfunction

Spasms of the muscles of the pelvic floor commonly result in urological issues such as:
- poor urine stream
- urinary frequency and urgency
- urge incontinence.

I can’t poop

When these symptoms occur with a sensation of pain in the bladder area, Vulvodynia (chronic pain in the vulva), genital pain, infection or disease will be suspect but not found. When a patient reports that chronic constipation and discomfort with bowel movement has joined the list of symptoms, another set of diagnostic tests are brought into play. Musculoskeletal diagnostic including MRI may be recommended when there are complaints of

Chronic lower back pain
Rectal pain
Coccydynia (tailbone pain)

What is described are symptoms common in pelvic floor dysfunction, they are also common in other situations. It is however likely that if you are reading this article you are well researched in your symptoms, have visited many doctors and are still looking for some answers. This article presents one possible solution. Tendon and ligament weakness and damage that causes your pelvic floor to be unstable and unsupportive.

Above we relayed a story of one scenario. Other causes of Pelvic Floor Dysfunction may include:

An older patient will tell us she does not know when it started but it has been getting worse, age-related problems may be a cause.
Sometimes we will see a patient who is obese, obesity can be a factor.
Sometimes we will see a patient who is an endometrial or cervical cancer survivor. Radiation treatment can be a factor.
Sometimes we will see a patient after pelvic area surgery or hysterectomy. The surgery may have caused problems.

The surgery option

In May 2017, 13 radiologists from 8 institutions representing five different nations wrote in the medical journal European Radiology, (1) that there is a need to develop recommendations that can be used as guidance for a standardized approach regarding the diagnosis and grading of pelvic floor dysfunction. The standardized approach being surgery. Here is the reasoning behind this study:

“Imaging of the female pelvic floor is of rising interest due to an aging population, harboring an increasing incidence of pelvic floor disorders and the rising need for comprehensive diagnosis and treatment.”

Confusing diagnosis can lead to confusing and improper treatment

We are going to cover the symptoms above and continue describing some of the challenges our patients face in treating their Pelvic Floor Dysfunction, but before we do, let’s discuss the problems of confusion.

It is estimated that nearly 25% of women suffer from pelvic floor dysfunction. (1) That means 1 in 4 women are currently dealing with this condition right now. The most common causes are childbirth, trauma, obesity, history of previous pelvic surgery, and nerve damage. While this condition is most common in women, men can also suffer from pelvic floor dysfunction that may be from trauma or exercise-induced.

The problem of accurate diagnosis

In November 2018, researchers at Washington University in St. Louis published their findings in the American Journal of Obstetrics and Gynecology (z) on the suggestion that pelvic floor dysfunction treatment can benefit patients with urinary tract symptoms. The discussion centers on Myofascial (muscle) pain and the review of dozens of medical studies. The problem, they note, is that determining if pelvic floor dysfunction is the problem urinary tract symptoms is challenging to physical therapists.

Here is what they wrote:

“Myofascial pain is characterized by the presence of trigger points, tenderness to palpation, and local or referred pain, and commonly involves the pelvic floor muscles in men and women. Pelvic floor myofascial pain in the absence of local or referred pain (other pain sources such as low back pain or hip pain for example) has also been observed in patients with lower urinary tract symptoms, and we have found that many patients report an improvement in these symptoms after receiving myofascial-targeted pelvic floor physical therapy.
“Physical examination methods to evaluate pelvic musculature for presence of myofascial pain varied significantly and were often undefined. Given the known role of pelvic floor myofascial pain in chronic pelvic pain and link between pelvic floor myofascial pain and lower urinary tract symptoms, physicians should be trained to evaluate for pelvic floor myofascial pain as part of their physical examination in patients presenting with these symptoms. Therefore, the development and standardization of a reliable and reproducible examination is needed.”

The pelvis consists of three paired bones: the ilium, ischium, and pubis that interconnect and meet in the midline at the pubic symphysis anteriorly and the sacrum posteriorly. The midline joint anteriorly is called the pubic symphysis joint and posteriorly the sacroiliac joint. These are the stabilizing joints of the pelvis and are held together by ligaments and the pubic symphysis, which is a disc.

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.

It is important to mention that the hips can also contribute to pelvic floor dysfunction, as the hip joint is partly made up by the pelvis. Any laxity of the pubis, sacroiliac joint, or surrounding ligaments can increase strain on the hip, leading to a hip injury. The reverse is true as well – hip injuries can increase forces on the pelvic floor, leading to pelvic pain.

When an individual experiences pelvic floor muscle spasms, the pain is excruciating, and any activity that puts pressure on the pelvis, the involved organs, and the pelvic floor ligaments can easily make the symptoms worse.

Most patients with chronic pelvic floor dysfunction feel their quality of life has been greatly affected and find it hard to live with chronic pelvic symptoms. Often times, women with pelvic floor dysfunction post-baby find themselves struggling with the idea of having more children, being intimate with their partners, working, or continuing with their active lifestyle due to their chronic pelvic pain and associated symptoms.

Pelvic Floor Dysfunction is a real sports injury

Pelvic floor dysfunction as related to sports injuries can happen in both men and women, though most pelvic floor disorders do affect women. Most pelvic floor sports injuries come from high impact exercises. Though, hip sports injuries could also contribute to the development of pelvic floor dysfunction.

Recently, researchers writing in the Scandinavian Journal of Medicine & Science in Sports pushed to acknowledge that the pelvic floor must be considered as an entity. This is what researchers had to say:

The pelvic floor provides support to the pelvic bones and all pelvic organs. Therefore, it is likely that female athletes involved in high-impact and in strong-effort activities are at risk for the occurrence of pelvic floor dysfunction.

In their study, the doctors investigated the occurrence of urinary incontinence and other Pelvic Floor Dysfunction [anal incontinence, symptoms of constipation, dyspareunia (difficult or painful intercourse), vaginal laxity, and pelvic organ prolapse] in 67 amateur athletes compared with a group 96 of nonathletes. The conclusions?

Athletes are at higher risk to develop pelvic floor dysfunction either practicing high-impact or strong-effort activities.
The pelvic floor must be considered as an entity and addressed as well.
Women involved in long-term high-impact and strengthening sports should be advised of the impact of such activities on pelvic floor function and offered preventive Pelvic Floor Dysfunction strategies as well.(2)

Pelvic Floor Dysfunction and Low Back Pain

Injury to the sacroiliac ligaments and with pubic symphysis injury can cause pelvic instability and lead to pelvic floor dysfunction

In September 2019, research lead by Canadian researchers at McMaster University and published in the journal Physical Therapy (September 2019) examined the connection between pelvic floor muscle dysfunction and low back / pelvic pain.(y)

Here is what the researchers said:

“There is evidence to suggest that a large proportion of individuals seeking care for lumbopelvic pain also have pelvic floor muscle dysfunction. Because the majority of physical therapists do not have the requisite training to adequately assess pelvic floor musculature, determining predictors of pelvic floor muscle dysfunction could be clinically useful.”

Study summary: Based on participants self-report symptoms, three clinical findings characterized pelvic floor muscle dysfunction:

weakness of the pelvic floor
lack of coordination of the pelvic floor
and pelvic floor muscle tenderness on palpation

Women who have lumbopelvic pain, uncontrollable urinary urgency, and central sensitization were, on average, 2 times more likely to test positive for pelvic floor muscle tenderness on palpation. Further studies are needed to validate and extend these findings.

Pelvic Floor Dysfunction and Obesity

As with many problems of chronic pain, obesity plays a major role. In a recent study appearing in the medical journal Best Practice & Research. Clinical Obstetrics & Gynaecology, doctors acknowledged that obesity is associated with a high prevalence of pelvic floor disorders.

Patients with obesity have wide-ranging symptoms from urinary, bowel and sexual dysfunction problems as well as uterovaginal collapse.
Urinary incontinence, fecal incontinence and sexual dysfunction are more prevalent in patients with obesity.

Weight loss plays a major role in the improvement of these symptoms in such patients. The treatment of symptoms leads to an improvement in their quality of life. (3)

Treatment of Pelvic Floor Dysfunction

Treatment will vary depending on the cause of the condition. Many times, the underlying cause is not determined. Physical therapy is frequently recommended. In the Journal of Sex Medicine doctors have shown that physical therapy can assist with symptoms including urinary incontinence and sexual function.(5)

BUT WHAT HAPPENS WHEN ALL OF THESE TREATMENTS FAIL?

These treatments may offer some temporary relief to the sufferers of pelvic floor dysfunction, but when the underlying problem is an unstable pelvis, they do not mend the actual source of the problem, and therefore do not bring permanent relief. Sufferers continue to live with PFD trying to “control” the symptoms, but the symptoms still decrease their enjoyment of life.

Prolotherapy for Pelvic Floor Dysfunction

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. Regaining stability in the pelvis can help to get rid of chronic pelvic pain and help patients “get their lives back”. If you are suffering from chronic pelvic floor dysfunction, wouldn’t you like to get back to your normal self?

1. Memon H, Handa V. Vaginal childbirth and pelvic floor disorders. Womens Health (Lond Eng) 2013; May 9(3). [PubMed]

2.Almeida MB, Barra AA, Saltiel F, Silva-Filho AL, Fonseca AM, Figueiredo EM. Urinary incontinence and other pelvic floor dysfunctions in female athletes in Brazil: A cross-sectional study. Scand J Med Sci Sports. 2015 Sep 15. [Google Scholar]

3. Ramalingam K, Monga A. Obesity and pelvic floor dysfunction. Best Pract Res Clin Obstet Gynaecol. 2015 Feb 19. pii: S1521-6934(15)00021-8. doi: 10.1016/j.bpobgyn.2015.02.002. [Google Scholar]

4. El Sayed RF, Alt CD, Maccioni F, Meissnitzer M, Masselli G, Manganaro L, Vinci V, Weishaupt D, ESUR and ESGAR Pelvic Floor Working Group. Magnetic resonance imaging of pelvic floor dysfunction-joint recommendations of the ESUR and ESGAR Pelvic Floor Working Group. European radiology. 2017 May 1;27(5):2067-85. [Google Scholar]

5. Sacomori C, Cardoso FL. Predictors of Improvement in Sexual Function of Women with Urinary Incontinence After Treatment with Pelvic Floor Exercises: A Secondary Analysis. J Sex Med. 2015 Jan 13. [Google Scholar]

y Keizer A, Vandyken B, Vandyken C, Yardley D, Macedo L, Kuspinar A, Fagahani N, Forget MJ, Dufour S. Predictors of Pelvic Floor Muscle Dysfunction Among Women With Lumbopelvic Pain. Physical therapy. 2019 Sep 2. [Google Scholar]

z. Meister MR, Shivakumar N, Sutcliffe S, Spitznagle T, Lowder JL. Physical examination techniques for the assessment of pelvic floor myofascial pain: a systematic review. American journal of obstetrics and gynecology. 2018 Nov 1;219(5):497-e1. [Google Scholar]

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