Pelvic floor/soft tissues

Pelvic floor and soft tissues – why this is important for orthopedics

Many pelvic pains do not originate primarily from the hip joint or the bones, but from muscles, fascia and tendon attachments – i.e. the soft tissues. The pelvic floor is a central player: it reacts to posture, breathing, stress and strain, and it influences hip mobility, sacroiliac joint (SIJ) and lumbar spine. Conversely, hip or sacroiliac joint dysfunction can cause tension in the pelvic floor. A holistic view of this functional chain is therefore the core of modern, conservative orthopedics.

Anatomy: Pelvic floor and relevant soft tissues

The pelvic floor forms the end of the pelvic cavity. It consists of several layers of muscles, fascia and connective tissue that are stretched between the pubic bone, sitting bones and coccyx. It works closely with the diaphragm, abdominal and hip muscles.

• Muscles: Levator ani (puborectalis, pubococcygeus, iliococcygeus), M. coccygeus
• Fascia and connective tissue: pelvic floor fascia, pelvic fascia, perineal tissue
• Tendon attachments (entheses): attachment areas on the pubic bone, ischium and sacrum
• Neighborhood: deep hip rotators (e.g. piriformis, obturators), adductors, abdominal wall
• Vessels and nerves: relevant in orthopedics. a. in case of irritation (e.g. pudendal nerve – see nerves section)

Other soft-tissue structures with potential for pain in the pelvis include the bursa, tendons and ligaments as well as the surrounding fascia. We delve deeper into these topics on the respective subpages.

Typical complaints and warning signs

• Pressure, pulling or burning pain in the perineal area, sitting bones, tailbone or groin
• Stress-related pain when sitting, cycling, lifting, sneezing/coughing
• Feeling of tension or “knots” in the pelvic floor region
• Radiation to the lower abdomen, groin, inner thigh or sacrum
• Accompanying possible: discomfort (tingling), subjective continence “feeling of insecurity” without objective findings

Red flags – please seek medical advice quickly:

• Fever, chills, redness/warmth
• Newly occurring urinary retention or defecation disorder, true incontinence
• Blood in urine or stool, unexplained weight loss
• Severe night pain, neurological deficits, numbness in the saddle area
• Recent trauma, fall, increasing pain postoperatively

Common causes from an orthopedic perspective

• Muscular imbalance and overload: tense or weak pelvic floor muscles
• Myofascial pain syndrome with trigger points in the pelvic floor, adductors or deep hip rotators
• Enthesopathies: Irritable conditions at tendon attachments in the pubic bone/ischial bone area
• Fascial restrictions and scarring (e.g. after operations or births)
• Functional disorders of the sacroiliac joint and lumbar spine
• Causes close to the hip joint with projected pain into the pelvic floor
• Nerve irritations (e.g. pudendal nerve) – see nerves section
• Stress factors: prolonged sitting, intensive cycling, posture and breathing patterns, stress

Phases of life such as the period after pregnancy/birth or menopause also change tissue properties and can cause symptoms. Careful differential diagnosis prevents over- or under-treatment.

Delimitation: If it is not (only) orthopedic

Pelvic floor problems are interdisciplinary. Depending on the symptoms, we should consider urological, gynecological or proctological causes:

• Urology: urinary tract infections, prostate diseases, bladder dysfunction
• Gynecology: Endometriosis, organ prolapse, cycle-related pain
• Proctology: hemorrhoids, anal fissures, inflammatory diseases
• Surgery/General Medicine: Inguinal hernias, abdominal wall problems
• Neurology: Nerve compression syndromes, central causes

In our practice in Hamburg, we manage the appropriate additional or further treatment if necessary and keep an eye on the orthopedic influencing factors.

Diagnostics: structured and careful

An internal pelvic floor examination is - if at all - only carried out in a targeted manner, with information and consent and often in collaboration with specialized colleagues.

Conservative therapy: gradual and individual

The aim is to reduce pain and tension, improve coordination and resilience as well as everyday self-management. We combine evidence-based measures and closely examine their effects.

The therapy is based on your goals and is adjusted regularly. Building up your training too quickly or just “practicing tensing” can increase symptoms – a balance between relaxation and activation is crucial.

Regenerative and interventional options – with a sense of proportion

Some procedures may supplement in selected cases. The evidence is nuanced; we advise transparently:

• PRP on tendon insertions: can be considered for chronic enthesopathies; Data situation heterogeneous
• Botulinum toxin for severe pelvic floor hypertension/levator ani syndrome: only in specialized centers, off-label, careful indication
• Dry needling/trigger point acupuncture: can relieve myofascial pain; Check benefits individually
• TENS/Neuromodulation: possible option for pain modulation; evidence-based use

Regenerative or interventional measures do not replace basic therapy. We only use them after exhausting conservative options and after providing information about the benefits and risks.

Everyday life, prevention and self-help

• Sitting hygiene: changing positions frequently, interrupting long periods of sitting, if necessary a soft seat cover
• Ergonomics: neutral pelvic position at the workplace, dynamic sitting, adjusting screen height
• Breathing: calm abdominal breathing with a soft abdominal wall; Exhalation facilitates pelvic floor relaxation
• Exercise: regular walking, moderate strength and mobility training instead of prolonged inactivity
• Toilet routine: do not strain, foot support when defecating can help; sufficient fluids and a diet rich in fiber
• Training in moderation: neither permanently tensing the pelvic floor nor “forgetting” it – coordination before strength
• Stress management: integrate short relaxation exercises into everyday life

Course and prognosis

Many myofascial and functional pelvic floor problems improve significantly with structured, conservative therapy. The longer the symptoms persist, the more important it is to be patient, exercise appropriate to your daily routine and follow a gradual training plan. In the case of complex or mixed causes, interdisciplinary collaboration increases the chance of sustainable improvement. Concrete promises of healing are not possible - we rely on comprehensible steps and transparent progress goals.

Subtopics at a glance

In-depth information on specific symptoms of the pelvic floor and the soft tissues in the pelvic area:

• Pelvic floor dysfunction – coordination and dysfunction of the pelvic floor with continence or pain issues: /diseases/hip-pelvis/pelvic-floor-soft-tissues/pelvic-floor-dysfunction/
• Myofascial pelvic pain – trigger points and fascial tension as pain drivers: /diseases/hip-pelvis/pelvic-floor-soft-tissues/myofascial-pelvic-pain/
• Levator ani syndrome – persistent tension of the levator ani with deep pelvic floor pain: /diseases/hip-pelvis/pelvic-floor-soft-tissues/levator-ani-syndrome/

Co-treating structures in the pelvis:

• Muscles, tendons, ligaments: /diseases/hip-pelvis/muscles-tendons-ligaments/
• Bursa: /diseases/hip-pelvis/bursa/
• Joints / cartilage: /diseases/hip-pelvis/joints-cartilage/
• Bones: /diseases/hip-pelvis/bones/
• Nerves: /diseases/hip-pelvis/nerves/
• Trauma / injuries: /diseases/hip-pelvis/trauma/
• Systemic / inflammatory causes: /diseases/hip-pelvis/systemic-inflammatory/
• Functional / chronic pain syndromes: /diseases/hip-pelvis/functional-chronic/

Your orthopedic contact point in Hamburg

In our practice at Dorotheenstrasse 48, 22301 Hamburg, we clarify pelvic floor and soft tissue problems in a structured manner. We rely on conservative orthopedics, work together with urology, gynecology and proctology if necessary and discuss an individual treatment plan with you without unnecessary interventions.