When it comes to pelvic floor problems we often think of muscle weakness but what if your muscles are actually working too hard? Pelvic floor hypertonicity (also referred to as an overactive pelvic floor) is a common problem which can lead to pain, leakage and constipation. Fiona Grouber, Women’s & Pelvic Health Physiotherapist, shares her advice on addressing this common presentation.
“Now squeeze your pelvic floor as you do the next movement!” I guarantee you’ve heard this before, whether it was at your last Barre, Pilates or weights class, your instructor has told you to turn “on” your pelvic floor and then maybe they’ll mention relaxing it afterwards (whatever that means?!)
The message we often receive from the exercise industry is that if there’s a problem, it’s likely because we have weak muscles and therefore our symptoms would resolve if we had stronger muscles. This advice is appropriate when weakness is the primary reason behind our pelvic floor problem, but what happens when this instruction is given to people who are already good at activating these muscles.
Hypertonicity refers to muscles that are continuously contracting and maintaining tension when they should be letting go. Essentially, these muscles are working too hard all the time, potentially in spasm, and have difficulty returning to their full length at rest. This may lead to them being less effective when we need them to contract.
Quick overview of the pelvic floor
The pelvic floor is a group of layered muscles that sit at the base of our pelvis and structurally support our bladder, bowel and (in women) uterus. They sit like a hammock, spanning from our pubic bone at the front, to the tailbone at the back. They help with bladder and bowel function (facilitating urination and allowing effective emptying of our bowels when we want to, and to control the urge when it isn’t the right time). They also have a role in sexual function, and are required to relax when birthing vaginally. Finally, they work with other key trunk muscles to form part of our ‘core’ foundation.
Similarly, like other muscles in our body such as our glutes and biceps, they are made of skeletal muscle tissue. This means we have voluntary control over them, and we should be able to turn them ‘on’ and ‘off’ when we want to.
How do I know if I have a hypertonic pelvic floor?
Here are some of the symptoms you might experience if you have a hypertonic pelvic floor:
- Bladder leakage or urgency
- Difficulty with emptying your bladder, including pain or a slow stream
- Pain during or after penetrative sex, on inserting tampons or on gynaecological exams
- Difficulty or pain when emptying your bowels
- Chronic constipation and needing to strain
- Discomfort when wearing high waisted pants or tight clothing/underwear
The good thing is that hypertonic pelvic floor muscles can be appropriately treated. Resolving your muscle tension will also lead to resolving your pelvic floor symptoms!
What would cause Pelvic Floor Hypertonicity?
Now, we can’t purely blame incorrect instructions at the gym for hypertonic pelvic floor muscles. In fact, there are a variety of reasons that this can happen, and usually it occurs as a protective mechanism where the muscles display a guarding response. These could stem back to childhood when you were encouraged to “hold in your wee” instead of emptying when you felt the urge, be associated with chronic constipation, come from birth trauma (whether you had scar tissue or not), relate to prolonged stress and anxiety, or related to constant bracing through your abdominals and buttocks.
How can I fix it?
Just like any muscle in the body, the pelvic floor muscles can be retrained, which means we can teach hypertonic muscles to turn “on” and “off” when they need to.
Here are my top tips:
- Breathwork: The diaphragm works very closely with the pelvic floor muscles. They have a pressure relationship where when one moves the other one does too, and they are also connected through the ‘rest & digest’ nervous system. Practising belly breathing can help encourage diaphragmatic movement which in turn allows our pelvic floor muscles to let go.
- Relax your pelvic floor during workouts: We want to activate our pelvic floor (and other core muscles) prior to lifting heavy weights but then between repetitions, focus on consciously allowing them to return to their original resting point.
- Practise good posture habits (and break the bad ones): Check in on your posture and make sure you aren’t gripping your glutes, clenching your jaw or sucking in your tummy muscles all day. If these muscles are on, your pelvic floor is probably too!
- Strengthen the supporting muscles: Our bodies are great at compensating, even when it isn’t the best thing to do! In some situations, the pelvic floor muscles work extra hard when we are lacking strength elsewhere so addressing niggling back and hip pain is optimal.
- Practising gentle mobility stretches: think simple movements like cat & cow, glute stretches, child’s pose and happy baby!
- Get an individualised assessment: The best way to know if you are correctly activating and relaxing your muscles is to have a personalised assessment with a pelvic physiotherapist. Usually this involves detailed information gathering about your pain, symptoms and medical history, followed by an optional physical exam which usually involves an internal examination. This is always consented to and there are other options available for assessing your muscles if you don’t feel comfortable with this.