The Painful Saga of Pelvic Floor Dysfunction

By Dr. Emilia A. Ripoll, M.D.
When I returned to Boulder, Colorado in 1992 after my fellowship in Urologic Oncology at the Baylor College of Medicine in Houston, I was the only female urologist in the entire city. Word spread quickly, and in no time, it seemed like I was treating every woman in Boulder County who had chronic pelvic pain, interstitial cystitis, or urinary tract issues.

“Finally!, my patients would tell me with a righteous look in their eyes, “Now, we have a woman doctor who understands our pain.”

Oh God, I thought. What have I gotten myself into?

I was armed with 12 years of rigorous medical training, internships, and residency — along with a burning desire to make a difference in the world — however, if my patients knew how little my fellowship prepared me for treating difficult cases like theirs, I don’t think they would have been so enthusiastic.

Perhaps I mistook their desperation for enthusiasm.

Many of these women had suffered from chronic urologic conditions for years, and were fed up with the lack of results (let alone empathy) they were receiving from their male doctors. Even with the unspoken bond of sisterhood, there was a lot I didn’t know.

What I did know (intuitively) was there had to be a better way to treat these painful and frustrating conditions than prescribing pain medications and anti-depressants, which only masked the symptoms and the attendant anger. In my mind, this form of treatment was worse than the conditions we were attempting to cure.

So I went on a medical vision quest to find better ways of helping these poor women. I went to UCLA and became certified in medical acupuncture. I attended osteopathic school, became a yoga instructor, and wrote a book about how to heal interstitial cystitis with yoga and acupressure. Slowly, I began cobble together treatment protocols that addressed the whole patient as well as their urologic problems.

Pelvic organs of elimination and reproductionThen, in 1996, I met Stacey Tuckwell, a physical therapist who forever changed the way I looked at the human body. Stacey taught me how the health of the pelvic floor (an interconnected web of muscles and connective tissue that forms a “pelvic diaphragm” between the sacrum and the pubic bone) greatly impacts the health of the internal organs within the pelvis.

In other words, if there were problems with the pelvic floor, almost invariably, there were problems with the pelvic organs (the organs of elimination and reproduction).

Whether the problem starts with childhood voiding issues, a snowboarding accident or a fall on the ice that led to chronic low-back pain, a difficult pregnancy/delivery that involved muscular tearing, or a spinal asymmetry like scoliosis, once the muscles of the pelvic floor become too tight, too lax, too weak, or some combination of all three, trouble ensues.

The name for this condition is pelvic floor dysfunction, and it is the root of a lot of pain and suffering.

What is the Pelvic Floor?

Another way to visualize the pelvic floor is a muscular hammock that supports the internal organs of the pelvis. If you’ve ever been in a hammock that was twisted, stretched too tight, or sagging in the middle, then you have a good idea what your internal organs feel like when the pelvic floor muscles are not functioning properly. Now imagine spending years inside this twisted, tight, or sagging hammock — no wonder it hurts!

The healthy functioning of this muscular web is vital to our well being in many ways: elimination, movement, posture, sexual function, and balance. In fact, many indigenous cultures consider this area the center of our human experience, our foundation, the “seat of the soul.” (All the more reason to keep it healthy and functioning normally.)

In general, having the right amount of muscular tone throughout the pelvic floor promotes healthy organs within the pelvis and a good sex life. Likewise, tight, lax, or uneven tone in the pelvic floor can lead to cascade of health concerns that include urinary issues, colon problems, and sexual dysfunction.

Although there are many variations of pelvic floor dysfunction, let’s look at the two most common types:

  1. Muscular tone that is too high
  2. Muscular tone that is too low

If the tone of the pelvic floor is too high (tight, contracted, in spasm) it makes it difficult to go to the bathroom (#1 and #2), diminishes sexual pleasure (dyspareunia or vulvodynia in women and testicular pain or painful orgasms in men). High tone in the pelvic floor is also a precursor to a host of inflammatory conditions of the urinary tract (female urethral syndrome and chronic prostatitis) and of the bowel (IBS and Crohn’s disease).

If the tone of the pelvic floor is too low (lax, relaxed, loose), both kinds of incontinence can occur as well as a sagging of the organs within the pelvis, which can lead to persistent pelvic pain in both sexes and pelvic organ prolapse in women.

Truth in Generalizations about Pelvic Floor Dysfunction

There is an old joke among urologists that men are “tight asses” and women are “loose,” meaning that men tend to develop tighter pelvic floors, while women (especially after pregnancy) tend towards lower tone.

There is some truth to this generalization.

More often than not, men who have pelvic floor dysfunction tend to suffer more from chronic tightness (as opposed to laxity). Part of this prevalence is because men are more often employed in physical labor than women. With manual labor comes an increased risk of injury to the low back and sacrum, which frequently are the cause of pelvic floor dysfuction. Men are also more likely to participate in contact sports and other activities that carry a high risk of low back and sacral injury: snowboarding, skiing, mountain biking, rock climbing, and martial arts.

Interestingly, injuries often occur on a particular side of the body, which can lead to a condition where one side of the pelvic floor has significantly higher tone than the other.

According to Choices in Health’s physical therapist, F.E. Boswell, “The number of people with injuries on just one side is interesting. Lets say it starts off with fracture of some bone as a child on the right side, later in life the right shoulder has issues, then an appendectomy, followed by a gallbladder … all of which are on the right side, which is weird.”

Boswell adds that men with low tone in their pelvic floor are uncommon in her practice. “This condition is rare and maybe due to neurological involvement, but it can also be seen in men with chronic constipation, overstraining, abuse of suppositories, bowel issues, or intestinal issues of Crohn’s disease and IBS.”

In women, the biggest causes of pelvic floor dysfunction are pregnancy and delivery — both of which put substantial strain on the pelvic floor. In order to accommodate the developing fetus, the female body produces the hormone relaxin and boosts the production of estrogen. Both of these hormones loosen pelvic ligaments, which expands the pelvis. Despite having a more accommodating pelvis, just the weight of carrying a child for nine months or an uncomplicated delivery can create laxity in the pelvic floor. This laxity is exacerbated by complications during delivery (or deliveries), especially if pelvic floor muscles tear during delivery.

After delivery, it can take 3-4 months for the pelvic floor muscles to knit back together (longer if the mother is breastfeeding). Post-partum pelvic floor muscles frequently develop what is known as “stretch weakness.” This condition occurs when the muscles do not regain their previous tone or strength. Fortunately, a daily exercise regime under the guidance of a therapist or trainer who specializes in pelvic floor issues usually resolves “stretch weakness.”

If nerve and/or muscle fibers were damaged during delivery, however, a weakened pelvic floor may require a longer recovery period and additional therapies such as electrical stimulation to repair these damaged fibers.

Because the pelvic floor muscles control the urinary sphincter, a loose or weak pelvic floor in women frequently leads to stress urinary incontinence. According to a 2001 study by Dr. Victor Nitti, severe urinary incontinence occurs twice as often in women as men. Additional studies also show that the occurrence of urinary incontinence increases in both sexes as we age, but the age-related increase is greater for women.

Building a Better Pelvic Floor

The best way to strengthen lax pelvic floor muscles is with biofeedback and/or electrical stimulation in a health practitioner’s office with the help of a physical therapist, physician’s assistant, nurse practitioner, or nurse.

Biofeedback provides patients with a better sensation of what a strong contraction of the pelvic floor feels like. Patients can also see the strength of their contractions and the muscles involved in them on a screen, which give immediate feedback about how much and where the patient needs to improve. Biofeedback is a great tool for regaining pelvic floor tone. We use it regularly at Choices in Health.

Electrical stimulation works best with patients who have very weak or damaged pelvic floor muscles. Depending upon the patient’s needs, different frequencies and stimulation programs are used to revive the damaged nerve and muscle fibers, then teach these tissues how to contract normally again. Electrical stimulation also helps patients with chronically contracted pelvic floor muscles. In this situation, the external electrical stimulation overrides the nervous system’s message to contract, which over time, helps retrain the muscles to fully relax.

Neither biofeedback nor electrical stimulation perform miracles overnight; however, after a course of treatment, patients consistently report substantial improvement.

Good exercise is a viable option.

If the cost of biofeedback or electrical stimulation is outside your financial means at the moment, a 30-minute Internet search of “Kegel exercises” will provide you with more than enough information to get started on a simple home program of pelvic-floor strengthening.

I have two recommendations concerning Kegels:

  1. Before you start doing Kegels, confirm that you actually need to be doing them. For example, in working with patients who have high tone in their pelvic floor, F.E. Boswell recommends a treatment plan that includes myofascial stretching, joint mobilization, manipulation, and a home therapy — not Kegels.
  2. Make sure you are doing Kegels correctly. Doing them incorrectly can do more harm than good.

Whether the pelvic floor issues occur in men or women, are a result of injury or pregnancy, express themselves as muscular tightness or laxity, develop on the right side or left, the goal is reestablishing proper balance and tone to the pelvic diaphragm. Once that occurs, the health of the entire body is likely to improve.

As Dr. Rodney Anderson, co-author of A Headache in the Pelvis with Dr. David Wise, puts it, “Our goal is to give patients a new quality of life, a reduced level of pain, and eventually completely eliminate it.”

Here are my 7 recommendations for pelvic floor health and prevention:

  1. Click on this link to the “Anderson-Wise/Stanford Protocol,” and familiarize yourself with the gold standard of pelvic floor care (more to come on this important topic).
  2. Before embarking on a therapy program to improve the health of your pelvic floor, consult with a knowledgeable health practitioner who understands the connection between musculoskeletal issues, pelvic floor health, and the health of the internal organs of the pelvis.
  3.  If you have a job that requires several hours of sitting a day, set a timer for every hour and take a mini exercise break: walk around the office, do some chair yoga, a few stretches, maybe even a Pilates exercise or two.
  4.  Speaking of Pilates, I think Pilates is the best exercise format for balancing all the core muscles, including the pelvic floor. Egoscue is another excellent exercise modality. Egoscue improves pelvic floor health by improving lower back and sacral strength, mobilization, and stabilization.
  5.  Maintaining a healthy weight helps reduce all sorts of health issues, including stress urinary incontinence. Staying lean puts less stress on the pelvic floor.
  6.  Constipation can be both the cause and the result of pelvic floor problems. If you tend towards constipation, consult with a dietician who understands how constipation can affect the pelvic floor.
  7.  Do something that makes you smile every day. It makes life’s little indignities a lot easier to bear.


Below is a list of supplements and homeopathic medicines that I have found helpful in improving urinary and pelvic floor health. Obviously, there are many others. These are the ones I use most frequently in my practice:

Supplements that May Improve the Effects of Pelvic Floor Dysfunction

Aloe/200x
– These Aloe vera capsules are perhaps the most effective over-the-counter treatment for urinary issues such as interstitial cystitis, prostatitis, and female urethral syndrome.

Bi-Carb Formula – This formulation reduces the acidity of urine, which brings great relief to people suffering from bladder and urinary tract inflammation.

Quercetin + Nettles
– The quercetin relieves allergic reactions in the urinary tract, while nettles act as an anti-inflammatory agent. The net effect is a calming of the urinary system.

UT Synergy – This product contains exceptional anti-microbial properties that prevent the adhesion of microbes the lining of the urinary tract. Its patented flower extracts have powerful anti-inflammatory and cancer-fighting properties.

Homeopathic Medicines that May Assist with Symptoms of Pelvic Floor Dysfunction

Akutur – This spagyric/homeopathic preparation is very helpful in soothing and clearing bladder and urinary tract infections.

Apo-Infekt – Works in synergy with Akutur to overcome microbial infections.

Proscenat – Formulated specific to help overcome prostate congestion, infection, and inflamation.

UpelvaHelps bring pelvic floor muscles into balance (relaxes tone if it is too tight, enhances tone if it is too low), relieve pelvic floor congestion in women, and assists with overcoming prostatitis in men.