Pelvic floor contracture (hypertonia)

• Anatomy
• Causes
• Symptoms
• Diagnosis
• Treatment

What is the pelvic floor?

The pelvic floor is a complex set of muscles located in the pelvic cavity, whose main function is to support the pelvic organs (vagina, uterus, bladder, anus, rectum).

The muscle most interesting for us is the pubococcygeus (PC), which surrounds the urethra, vagina, and anus, and is therefore responsible for proper urinary, sexual, and defecatory function.

Deep dive: Pelvic floor anatomy

How does pelvic floor contracture develop?

Usually, we are not aware of the existence of these muscles and therefore are unable to control them. As a result, the pelvic floor can develop a habit of being constantly contracted or excessively relaxed.

The habit of sucking in the stomach to appear slimmer also contracts the pelvic muscles.

Recurrent cystitis, interstitial cystitis, vaginitis, vulvodynia, hemorrhoids, and fissures cause involuntary muscle contraction as a reaction to pain.

Urgency or stress incontinence cause contracture in an attempt to hold in urine.

Surgical interventions (episiotomy, genital surgeries, genital radiotherapy, etc.) can cause injuries to the pelvic floor with subsequent fibrotic scarring that will cause this musculature to lose its normal contraction and relaxation functions.

If the pelvic muscles are constantly contracted, they will compress the blood circulation and nerve endings present in this area. The pain resulting from all these alterations will, in turn, increase the contracture, leading to a vicious cycle of pain-contracture-pain-contracture, which will result, depending on the involved organ, in specific symptoms often confused with more well-known conditions such as Cystitis, Candida, and vaginal infections.

Deep dive: Causes of pelvic contracture

Symptoms

What are the symptoms of pelvic contracture?

The contracture of the pelvic muscles compresses veins, arteries, and nerves, causing distress and fragility of the pelvic tissues. The nerve signals will malfunction, altering the sensations perceived in this area and the functioning of the innervated organs.

As a consequence, there will be trigger points (areas of the muscle that are tense, rigid, and very painful, with pain radiating to nearby or connected areas) and tender points (areas of pain also caused by pressure, but less intense, more localized, and not radiating).

In addition to pain (also referred to as "intimate burning"), pelvic floor hypertonicity can cause:

• urological symptoms: slow, intermittent, spraying, or forced urinary flow, sensation of incomplete emptying, post-void dribbling, urgency, frequency, tenesmus, pain, and cystitis
• rectal symptoms: blocked defecation, constipation, sensation of incomplete fecal emptying, rectal heaviness, anal and perineal pain
• genital symptoms: dyspareunia, vaginismus, burning, pain, vaginal infections, anorgasmia, vulvodynia

Deep dive: Symptoms of pelvic contracture

How can I tell if I am contracted?

The diagnosis of pelvic floor contracture is made by a neurologist, urologist, or gynecologist through a medical examination, which includes:

• Visual observation of the genital area. Areas of redness, small abrasions, scars (for example from episiotomy), or reduced vaginal opening (in case of pelvic floor hypertonia or tight anatomical conformation) are identified. You will be asked to contract the genital area (as if holding urine) and relax it (as if pushing) to visually assess the voluntary motor activity of the pelvic floor.
• Manual evaluation of the pelvic floor muscles. The experienced doctor, inserting fingers into the vagina, examines the thickness of the levator ani muscle bundles and their reaction to stretching. Muscle tone in patients with contracture is increased, limiting both the ability to contract and to relax.
• Assessment of sensitivity and pain. Both the vulvo-vestibular area (through a swab test) and the levator ani muscle (through digital pressure in the vagina) are evaluated.

Through trigger points (points in the contracted muscle where pain originates), the painful symptom can radiate to other areas; therefore, it is also useful to evaluate the sacroiliac joints, the hips, the pubic area, and the spinal region at the lumbar, sacral, and coccygeal levels.

The condition of the pelvic floor can also be assessed with electromyography, urodynamic testing (which also detects contraction of the pelvic muscles during urination), and by ruling out other obstructive causes (kidney stones, strictures, tumors, etc.).

Treatments and therapies

How can the pelvic muscles be relaxed?

Relaxing the pelvic muscles allows the remission of pain and the restoration of altered functions (urinary, bowel, sexual).

This goal is achieved through a series of techniques, tools, and rehabilitative exercises carried out in the clinic under the supervision of a qualified professional, which allow the woman to become familiar with her pelvic muscles, learn to control them, and relax them.

Unfortunately, professionals capable of treating pelvic floor contractures are still few in our country, so make sure that the therapist you turn to does not focus only on muscle strengthening, but is familiar with all relaxation techniques.

If, due to these difficulties, you cannot find a professional to rely on, you can perform exercises and massages at home by following the instructions of those who have already undergone rehabilitative treatments.

Deep dive: Treatment of pelvic contracture

Bibliography

1. “Assessment of levator hiatal area using 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: randomized controlled trial.” Del Forno S, Arena A, Pellizzone V, Lenzi J, Raimondo D, Cocchi L, Paradisi R, Youssef A, Casadio P, Seracchioli R.
2. “A Systematic Review of Intravaginal Diazepam for the Treatment of Pelvic Floor Hypertonic Disorder.” Stone RH, Abousaud M, Abousaud A, Kobak W.
3. “Pelvic floor electromyography in men with chronic pelvic pain syndrome: a case-control study.” Hetrick DC, Glazer H, Liu YW, Turner JA, Frest M, Berger RE.
4. “Active and Passive Components of Pelvic Floor Muscle Tone in Women with Provoked Vestibulodynia: A Perspective Based on a Review of the Literature.” Thibault-Gagnon S, Morin M.