Pelvic Floor Health in Hypermobility

Estimated reading time: 8 minutes Pelvic floor dysfunction is something I am familiar with in my own experience and something experienced by many of my clients. Let’s dive deep and learn more about the role of this structure.

Here’s my personal story of my pelvic floor issues. After the birth of my second son, things started to change. Let’s just say running and jumping was out of the question. I felt weak, out of control, and extremely upset. My GP sent me to a women’s health physio. I was given pelvic floor exercises that involved squeezing and holding in the pelvic floor. I did these religiously three times a day for weeks.

At each appointment, I would be strapped up to a machine and pelvic floor strength assessed. Every week I got worse. Every week I got more upset. I was discharged because the physios didn’t know how to help me.

Thankfully I found a pelvic floor expert a three-hour drive away. She diagnosed me with a hypertonic pelvic floor. No wonder I was getting weaker. The more I squeezed and pulled up my pelvic floor, the more fatigued the muscles became. They couldn’t support me. The muscles gave up.

But at last, I had an answer. Pelvic floor exercises that contract may not always be the right strategy for everyone. I didn’t know I had EDS then, but I now see this pattern a lot in my EDS clients too. In my experience, many people with hypermobility and EDS end up with imbalances and pain related to a hypertonic pelvic floor. There can be many reasons for this imbalance which we will explore in this article.

What is the pelvic floor?

The pelvic floor consists of the bony opening of the pelvis, muscles, fascia, ligaments, connective tissue, and nerves. It provides support for the abdominal and pelvic organs (1, 2, 3). The pelvic floor muscles extend from the pubic bone at the front of the pelvis to the tailbone at the back of the pelvis and from one sit bone to another. Warning: the image below contains diagrams of sexual organs.

• There are superficial muscles including the bulbospongiosus, bulbocavernosus, perineal muscles, and external anal sphincter muscles (2, 3)
• The deep pelvic floor includes the coccygeus, levator ani muscles, obturator internus, and piriformis
  • The pelvic diaphragm is composed of the coccygeus and levator ani muscles (puborectalis, Pubococcygeus, and Iliococcygeus (4).

Functions of the pelvic floor include (2, 3, 5, 6):

• Organ support: it supports both the abdominal organs including the rectum, and the pelvic organs such as the bladder and uterus.
• Closure of the urethra and anus based on muscle tone (subconscious control): the pelvic muscles will contract and relax to control the release of urine and feces.
• Voluntary opening of sphincters: like in urination as well as voluntary control of holding urine. This helps in the process of defecation and maintaining continence.
• Making stool: they play a crucial role in the process of defecation. As the pelvic floor muscles support the rectum, they help coordinate with the abdominals and the diaphragm to facilitate the movement of the stool through the rectum and out of the body. For ease of this process, the pelvic floor muscles must relax. Dysfunction in the muscles could lead to constipation or fecal incontinence.
• Sexual function: these muscles play a role in sexual sensation and function.
• Postural support: they contribute to the stability of the pelvis and spine and form part of the so called ‘core’ muscles. But these are not the only muscles we should be focusing on for ‘core stability’. My YouTube video discusses  The Truth About Stability  in more detail.
• In coordination with other muscles surrounding the abdomen, it controls and generates intra-abdominal pressure: This refers to the pressure within the abdominal cavity. It is generated by the interaction of the abdominal wall muscles, the diaphragm and the pelvic floor muscles. This pressure will vary depending on our posture, breathing patterns, and physical exertion. I found breathwork to be one of the most helpful tools in helping resolve my pelvic floor issues. If we try to use the pelvic floor muscles as a stabilizing muscle that is in contraction all the time, it never has the opportunity to relax. A tight and fatigued pelvic floor could let you down under stress (stress incontinence) – like running, jumping, and sneezing.
• Plays a role in pelvic girdle stability: SI joint issues can be influenced by the pelvic floor muscles. A hypertonic pelvic floor can destabilise the SI joint.
• Pregnancy and childbirth: The pelvic floor plays a crucial role during this time of life. It supports both the mother and the baby. It has to support the uterus as it expands to accommodate the growing baby. As baby gets heavier, the pelvic floor comes under increasing pressure. In preparation for childbirth, the pelvic floor muscles will have stretched and become more flexible. This elastic quality is essential to allow the baby to pass through the birth canal (all the more reason not to do too much ‘core stability’ bracing – you need those muscles to be able to relax when the time comes).

Dysfunction in this group of muscles can lead to urinary or fecal incontinence, pelvic organ prolapse, and sexual dysfunction. But if Kegels are not always the answer, how do we avoid dysfunction with hypermobility?

How does hypermobility impact the pelvic floor?

Pain in the pelvic floor may occur due to the muscles, ligaments, and tendons providing functional adaptations for other issues in the pelvis, hips, and spine (5). For example, the pelvic floor can often try to act as a trunk stabiliser. This leads to tightness not just in the pelvic floor but with all its close relations like the hip, low back, and abdominal muscles. In turn, this presents as tightness and pain.

As I mentioned, I quite often hear of people with hEDS/HSD being diagnosed with hypertonic pelvic floors. It is currently defined as “an increase in muscle tone related to contractile or vasoelastic compontents associated with contractile activity and/or passive stiffness in the muscle” (2). Basically, muscles in the pelvic floor can become too tight.

Hypertonic pelvic floor is often associated with (2):

• Urological problems
• Gynecological problems.
• Gastrointestinal problems
• Sexual problems
• Chronic pelvic pain

Experts say it can be a primary problem – just a hypertonic pelvic floor – or an adaptation to things like acute or chronic injury to a part of the pelvic floor, pelvic surgery, traumatic vaginal delivery, traumatic injury of the back or pelvis, chronic stress, pelvic pain, gait disturbances, or trauma (2).

Pelvic floor dysfunction is not a condition unique to hypermobility, but there seems to be an increased likelihood of experiencing pelvic issues in EDS/HSD. Researchers found that women with generalized Hypermobility Spectrum disorders (including hEDS and HSD) that had pelvic pain, were 3.5 times more likely to have pain with vaginal intercourse, 7.5 times more likely to have low back pain, 3.8 times more likely to have stress urinary incontinence, 4.7 times more likely to have irritable bowel syndrome, and 3.1 times more likely to have hip pain (5).

Pelvic organ prolapse has also been associated with the pelvic floor – this is hypothesized to be related muscle deficits or pelvic floor connective tissue problems (7). It has also been found that EDS/HSD is associated with pelvic organ prolapse (8), and pelvic organ prolapse may be more severe in women with joint hypermobility syndrome (9).

Men (and people assigned male at birth) with hypermobility may also struggle with pelvic floor issues including chronic prostatitis, chronic pelvic pain syndrome, urinary/fecal incontinence, and sexual dysfunction (1).

How to recognise it

People with pelvic floor dysfunction can present with a wide range of symptoms from pelvic organ prolapse to bladder and bowel problems to perineal pain and chronic pelvic pain (3). Symptoms of pelvic dysfunction can include (and are not limited to) according to the Internation Urogynecological Association/International Continence Society (10):

• Urinary incontinence
• Increased urinary frequency
• Overactive bladder
• Nocturia (interruption of sleep to urinate one or more times)
• Symptoms with voiding (hesitancy, slow stream, incomplete emptying, leaking)
• Pelvic organ prolapse symptoms
• Sexual dysfunction
• Fecal incontinence
• Constipation
• Lower urinary tract pain or other pelvic pain
• Recurrent urinary tract infections

Diagnosis of a hypertonic pelvic floor is tricky because many of the symptoms of a hypotonic and a hypertonic pelvic floor are similar. The pelvic floor and pelvic floor dysfunction is complex. I highly recommend working with a pelvic floor physiotherapist who has extra training in these conditions, preferably one that is familiar with EDS/HSD. They can evaluate pelvic floor muscle function, tone, injury, and pain. According to pelvic floor PT Annie Squires, the goal of pelvic floor PT is to restore muscle balance.

You may be invited to undergo a urodynamic test. I went through this procedure and although not a pleasant experience, it will be useful in understanding how well the bladder and urethra store and release urine.

Best practices to manage pelvic floor issues

• It may be helpful to address central sensitization and nociplastic pain
• Unwinding the pelvis – trying to bring balance to the whole structure.
  • We need to unwind the pelvis and teach it that it is safe to move. This takes time, as you are dealing with some of the deepest muscles – be patient and gentle.
  • The pelvis is obviously a key structure to these issues, but working on whole-body integration, which the IMM focuses on, can really help. Everything is connected to everything else. The pelvic floor muscles are going to be influenced by other muscles around the pelvis.
• Work on stability and mobility in the muscles around the pelvis. If you have laxity in the pelvic floor or have pelvic prolapse, Kegels may be the right thing to be doing. Again, the tone of the pelvic floor can be assessed by a women’s health physiotherapist or PT.
• Breathwork to address bracing and guarding
  • For a hypermobile body, bracing or guarding is a common occurrence in daily life. This inhibits the breath. I call this guarding false stability because either we think it’s helping, or we are not even aware we do it. To be told to brace or guard more before doing an exercise is going to lead to more tension and pain. That’s why I never tell my clients to pull in their abs or ‘activate their core’.
  • Learn to do diaphragmatic breathing effectively – not just pushing the belly out. To belly breathe, we must learn to expand the thoracic spine first.
• Learning the intimate relationship between the diaphragm and the pelvic floor. As you inhale, the diaphragm expands (contracts) – the pelvic floor expands (relaxes). I have added a pelvic floor meditation to The Zebra Club for this.
• Postural tone and integration. If we have a slumped, collapsed posture this may be putting extra pressure on the pelvic floor. Our breathing will be compromised and our intra-abdominal pressure may impact the healthy function of the pelvic floor muscles.
• Working with a pelvic floor physical therapist
  • We have a presentation by EDS-aware Pelvic Floor Physical Therapist, Annie Squires and Orthopedic Physical Therapist, Aiko Callahan in the Resource Section of The Zebra Club app going into more depth about these issues.
• Work with a urogynecologist who can address other types of pelvic floor dysfunction
  • Of note, MCAS (and subsequent targeted treatment) has been associated with dyspareunia, vaginitis, and dysfunctional uterine bleeding (11)

I have added both pelvis and pelvic floor classes to The Zebra Club app. The Hips and Pelvis collection under Programs is a great place to find these classes. Members can also find a pelvic-floor meditation in the audio meditations section of the app. I have several videos on breathing over on my YouTube Channel if you’d like to explore the power of your breath too.

FAQ

Can hypermobility cause pelvic floor issues?

Pelvic floor dysfunction is quite common in hypermobility. This can result in a variety of issues including GI problems, gynecological issues, urological issues, pelvic pain, pelvic organ prolapse, and sexual dysfunction.

What are the symptoms of hypermobility pelvis?

A hypermobile pelvis can cause a range of symptoms like pelvic girdle pain, joint instability, pelvic floor issues like urinary leakage, painful intercourse, painful walking or climbing stairs, and pain standing for long periods of time.

How to tell if the pelvic floor is tight or weak?

It is very difficult to tell if a pelvic floor is tight (hypertonic) or weak (hypotonic). There is a lot of symptom overlap between the two.  The only real way of knowing is by working with a pelvic floor specialist physical therapist who can assess the muscles.

Literature Review and Research by Catherine Nation, MSc, PhD

Works Cited

1. Cohen, et al. (2016) The Role of Pelvic Floor Muscles in Male Sexual Dysfunction and Pelvic Pain. Sexual Medicine Reviews.
2. Reijn-Baggen, et al. (2022) Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sexual Medicine Reviews
3. Quaghebeur, et al. (2021) Pelvic-floor function, dysfunction, and treatment. European Journal of Obstetrics, Gynecology, and Reproductive Biology.
4. Presentation by Annie Squires and Aiko Callahan: Pelvic Floor Physical Therapy Consideration in hEDS/HSD. October, 2022.
5. Hastings, et al. (2019) Joint Hypermobility among Female Patients Presenting with Chronic Myofascial Pelvic Pain. Journal of Physical Medicine and Rehabilitation.
6. Raizada & Mittal (2008). Pelvic Floor Anatomy and Applied Physiology. Gastroenterology Clinics of North America.
7. Hafizi, et al. (2013) The association between women’s pelvic organ prolapse and joint hypermobility. Journal of Pakistan Medical Association.
8. Viet-Rubin, et al. (2015) Association between joint hypermobility and pelvic organ prolapse in women: a systematic review and meta-analysis. International Urogynecology Journal.
9. Mastourodes, et al. (2013) Lower urinary tract symptoms in women with benign joint hypermobility syndrome: a case–control study. International Urogynecological Journal.
10. Haylen, et al. (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) Joint Report on the Terminology for Female Pelvic Floor Dysfunction. Neurourology and Urodynamics.
11. Afrin, et al. (2019) Successful mast-cell-targeted treatment of chronic dyspareunia, vaginitis, and dysfunctional uterine bleeding. Journal of Obstetrics and Gynecology.

Jeannie Di Bon

Jeannie Di Bon is a movement therapist, educator and author specializing in hypermobility, Ehlers-Danlos Syndrome and chronic pain. She is the founder of The Zebra Club app and the creator of the Integral Movement Method.