Pelvic floor dysfunction

What does pelvic floor dysfunction mean?

The pelvic floor forms the muscular end of the pelvis. It stabilizes the trunk and pelvis, ensures continence and supports abdominal and back function. Pelvic floor dysfunction occurs when these tasks are no longer performed adequately - for example due to pelvic floor muscles that are too weak, too tense or work uncoordinated, weak connective tissue or painful myofascial trigger points.

A broad distinction is made between two patterns: hypotonia (weakness) with continence problems or a feeling of drooping and hypertension (overactivity/tension), which is often accompanied by pelvic pain, micturition disorders or painful sexuality. Mixed forms are common.

Anatomy and function of the pelvic floor

The pelvic floor consists of several muscle layers (including levator ani with puborectalis, pubococcygeus, iliococcygeus) and connective tissue. It works closely with the diaphragm, abdominal muscles, buttocks and hip muscles. Breathing, posture, hip mobility and the position of the pelvis influence its tension and strength.

• Stability: support of the pelvic ring and lumbar spine
• Continence: Closing mechanism of the urethra and rectum
• Pressure equalization: coordination with the diaphragm (IAP = intra-abdominal pressure)
• Sexual function: muscular support and blood circulation
• Movement: fine interaction when coughing, lifting, sports

Poor posture, hip joint restrictions, blockages of the sacroiliac joint or myofascial tension can disrupt pelvic floor function - an important orthopedic starting point.

Typical symptoms

Complaints are diverse and cannot always be clearly assigned to one organ. Often several symptoms exist at the same time.

• Pelvic pain, pain in the perineal area, coccyx, lower abdomen
• Micturition problems: urge to urinate, frequent urination, difficulty starting, dribbling
• Urinary incontinence: Stress (coughing, running) or urge incontinence
• Stool problems: constipation, straining, incomplete emptying, fecal incontinence
• Feeling of pressure/sinking in the vagina or anus, possibly palpable bulging
• Painful sexuality, erection or ejaculation problems
• Back pain associated with coughing/pressing or prolonged sitting
• Feeling of pelvic instability, trunk giving way when lifting

In men, pelvic floor dysfunction often presents as chronic pelvic pain syndrome with prostatitis-like symptoms without infection.

Causes and risk factors

The development is usually multifactorial. In addition to connective tissue quality and hormonal influences, lifestyle, neuromuscular control and orthopedic factors play a role.

• Pregnancy and birth, weak connective tissue, menopause
• Operations in the pelvis (e.g. prostate surgery), pelvic floor injuries
• Chronic cough, strong straining due to constipation
• Overweight, heavy lifting, high-performance sports with impact loads
• Pelvic ring or coccyx trauma, hip/lumbar spine dysfunction
• Neurological diseases, peripheral nerve irritation
• Constant stress, fear, protective postures with increased muscle tone
• Scars, myofascial trigger points and fascial adhesions

Often there are over- and under-function zones at the same time: a tense part of the pelvic floor can inhibit the activation of other areas.

When should I seek medical advice? Warning signs

If you notice any of the following signs, you should seek immediate medical attention to rule out more serious causes:

• Acute urinary retention, fever, chills
• Blood in urine or stool, unexplained weight loss
• Neurological deficits (e.g. numbness in the breeches area), new fecal incontinence
• Sudden, very severe pain after trauma
• Increasing progression of symptoms despite rest

The measures described below do not replace an individual medical examination.

Diagnostics in our practice

We combine orthopedic functional diagnostics with a pelvic floor-oriented anamnesis. The aim is to record tone, strength, coordination and influencing factors from the hips, lumbar spine and pelvic ring.

Not every examination is necessary in every case. We discuss the procedure transparently and individually.

Conservative therapy – a structured step-by-step plan

Conservative treatment is the first choice. It includes training, relaxation, behavior modification and pain management. Clear goals, regular exercises and follow-up checks are important.

Interventional or surgical measures are only considered if there is a clear indication and after conservative therapy has been exhausted. We provide neutral advice on this and refer you to the appropriate specialist discipline.

Specific training and relaxation exercises

Effective pelvic floor training is precise, breathing-coordinated and relevant to everyday life. The first few weeks are for perception and correct control, only then does the increase follow.

• Find the control: gently tense and relax in the supine position, imagine “holding the urinary stream – holding back gas” without cramping the buttocks and stomach
• Breathing coordination: Inhale – pelvic floor relaxed; Exhale – activate the pelvic floor, soften your ribs, relax your neck
• Dosage: 3-4 times per week, 3 sets of 8-12 repetitions; Increase in holding times (up to 10 seconds) and in everyday life (coughing, lifting)
• Hypertonicity: focus on relaxation, longer exhalation (4-6 seconds), stretches hip flexors, adductors, glutes; progressive muscle relaxation
• Train strength chain: lateral hip stabilizers, deep abdominal muscles, back extensors; Balance and posture
• Biofeedback/electrical stimulation: selectively for activation problems or very weak muscles via cooperation partners

Quality over quantity: Incorrect pressing or flexing over the abdominal, buttocks or thigh muscles can increase discomfort. Supervision by specialized physiotherapy is recommended.

Lifestyle, everyday life and workplace

Small changes in everyday life relieve the pressure on the pelvic floor and support healing.

• Nutrition: 25-35 g fiber per day, drink enough; If necessary, mild stool regulation after consultation
• Toilet hygiene: Stool under your feet (knees above hip height), take your time, don't press
• Cough management: Cough into a cloth, bend your torso slightly, activate gently as you breathe out
• Weight and exercise: regular, moderate activity; Build up shock loads slowly
• Ergonomics: dynamic sitting/standing, breaks for pelvic floor relief
• Stress reduction: sleep, breathing exercises, behavioral therapy support if necessary

Sport is possible and useful. Selection and intensity depend on symptoms and level of training. We advise you on a gradual return to running, jumping or strength training.

Special situations: after birth, after prostate surgery, during sports

After birth: Tissue healing takes time. An early focus on breathing, awareness and gentle activation makes sense; More intensive training only takes place after individual approval. If there is a feeling of prolapse, additional gynecological care including pessary care can help.

After prostate surgery: Continence training (pelvic floor plus bladder training) improves function. Biofeedback and structured exercise plans support the return to everyday life and sport.

In sports: strength, timing and pressure management are crucial. We check hip and trunk function, reduce incorrect loads and plan to increase loads.

• Return-to-run protocols with continence checks
• Lift with exhalation and neutral core
• Progression from low impact to high impact after freedom from symptoms

Interdisciplinary collaboration

Pelvic floor dysfunction transcends specialist boundaries. To provide targeted care, we work with urology, gynecology, coloproctology, pain medicine, physiotherapy and – if necessary – psychotherapy.

• Specialized pelvic floor physiotherapy (including biofeedback)
• Urology/gynecology for incontinence, prolapse, postoperative issues
• Coloproctology for defecation disorders
• Imaging (e.g. pelvic floor MRI) via partner centers
• Pain medicine for multimodal concepts for chronic pain

In this way, we ensure that conservative measures are exhausted and invasive options are only considered when appropriate.

Prognosis and course

With consistent conservative therapy, symptoms often improve within weeks to a few months. Stable, lasting effects arise through regular training, relief in everyday life and the treatment of accompanying muscular imbalances.

The course and duration are individual and depend on the initial findings, comorbidities and training continuity. A realistic, step-by-step plan increases the chances of success - we cannot give any guarantees.

What we do for you in Hamburg

In our orthopedic practice at Dorotheenstrasse 48, 22301 Hamburg, we combine findings-based, conservative treatment of the musculoskeletal system with pelvic floor-specific strategies. We examine the hips, lumbar spine, pelvic ring and myofascial structures, create an individual exercise and relief program and, if necessary, coordinate pelvic floor-specific physiotherapy and other specialist disciplines.

• Thorough orthopedic examination with a focus on the pelvis/hips/lumbar spine
• Education and training planning (including breathing and pressure management)
• Cooperation with specialized pelvic floor therapists in Hamburg
• Interface management to urology, gynecology and coloproctology
• Progress checks and adjustment of the program

The aim is to improve functionality that is relevant to everyday life with as little effort as possible - serious, evidence-based and without exaggerated promises.

Prevention and common mistakes

• Don't strain: stool regulation and correct toilet posture
• Lift loads with exhalation and close to your body
• Build up high shock loads slowly and according to symptoms
• If you are in pain: think about relaxation/down training early on instead of just strengthening
• Regular breaks from sedentary work and changes in posture

A common mistake is to only want to increase strength when faced with pain or urge symptoms. In the case of hypertension, this worsens symptoms. Therefore, the first step is to correctly classify the tone with an adapted program.