Pelvis Problems: The Non-Relaxing Pelvic Floor

Hey Scarleteen! Caitlyn the pelvic health PT here, back with another chapter in the Pelvis Problems series. In this edition, we’ll be covering one of the most common problems that pelvic health physical therapists encounter: the non-relaxing pelvic floor (NRPF).

A non-relaxing, overactive pelvic floor can cause a variety of symptoms, ranging from constipation and difficulty peeing to pain with sex⁠ (sex: Different things people choose to do to actively express or enact sexuality and sexual feelings; often this involves genitals, but not always. ) and sitting. Fortunately, there’s a lot that can be done to help people with non-relaxing pelvic floors!

Here’s what I'll cover in this article:

• What is non-relaxing pelvic floor (NRPF) dysfunction?
• What are the symptoms of NRPF?
• What causes the pelvic floor to become overactive?
• How do you know if you or a loved one have NRPF?
• How can NRPF be treated?

Wait a sec…what exactly IS the pelvic floor?

Great question! If you haven’t been introduced to the pelvic floor before, you’re not alone. Everyone has a pelvic floor, but most of us don’t know where it is or what it does. Pop over to our handy guides to the Pelvic Floor and Pelvic Exams to learn the basics, then come back here.

What is non-relaxing pelvic floor dysfunction?

A non-relaxing pelvic floor (NRPF) is a common pelvic floor problem. It’s estimated to affect 50-90% of the population (!), though not everyone with NRPF will have significant symptoms. It can occur in people of all sexes and genders: if you have a pelvis, you can have a non-relaxing pelvic floor.

This condition goes by some other names, including “overactive pelvic floor”, “pelvic floor hypertonicity”, and “pelvic floor muscle tightness”. It often co-occurs with other pelvic health conditions like endometriosis and the painful peeing syndromes.

I like the term “non-relaxing” because it clearly describes what is happening: the pelvic floor muscles are chronically contracted, and they’re unable to relax fully from this contracted state. This becomes a problem when they need to perform a task that requires them to relax and lengthen—like peeing or pooping.

In addition, short, tight muscles also struggle to contract well. It may seem counterintuitive: I just told you that the pelvic floor muscles are chronically contracted. Doesn’t that mean they’re really strong?

Not necessarily. The physiology is a bit complex, but you can visualize the NRPF like a tightly coiled spring. This spring can’t stretch out⁠ (out: Short for ‘out of the closet’. When someone’s LGBTQ+ identity is known to other people.) to absorb stress and pressure, nor can it tighten further to provide extra strength and support.

Because this non-relaxing spring can’t tighten any further, the muscles of the NRPF can’t generate good quality, strong contractions. This is why some people with NRPF experience symptoms that also occur in people with weak pelvic floors, like urinary incontinence (the involuntary leakage of urine).

For some people with NRPF, chronic tension in their pelvic floor muscles can lead to pain in this area. This can cause activities like sex, peeing, and/or sitting to feel unpleasant and even painful.

Let’s learn more about the common symptoms that can signal the presence of NRPF.

What are the symptoms of NRPF?

As with many pelvic floor conditions, the symptoms of NRPF vary from person to person. Some people have only a few symptoms, while others have many. The most common symptoms can be divided into 4 overarching categories:

• Lower urinary tract symptoms (problems with peeing)
• Gastrointestinal (GI) symptoms (issues with the gut and pooping)
• Sexual symptoms
• Pain symptoms

Common Symptoms of NRPF

*Pain symptoms are typically located in the genital region: often near the front wall of the vagina⁠ (vagina: The internal passage leading from the opening of the vulva to the cervix of the uterus.) for people with vaginas, and at the perineum⁠ (perineum: The general region of the body between the anus and the testes or the anus and the vaginal opening. Some people call the perineum the "tain't.") (between the genitals and the anus⁠ (anus: The external opening to the rectum, located between the buttocks.) ) regardless of anatomy⁠ (anatomy: The body, parts of the body, or physical structure of organisms like people, animals or plants.) .

Medicine still does not have clear criteria to diagnose someone with NRPF. However, the simultaneous presence of several of the above symptoms suggests that NRPF is a likely culprit.

What causes a non-relaxing pelvic floor?

NRPF comes in two forms, primary and secondary. Primary NRPF develops on its own, without a clear trigger⁠ (trigger: In the context of behavior, a trigger is an experience that triggers a traumatic memory in someone who has experienced trauma.) (though it’s likely we just can’t always identify that trigger). In these cases, researchers think that NRPF may develop from learned behaviors, such as regularly holding back urine or bowel movements for long periods. This can start in childhood or develop later in adulthood.

Secondary NRPF develops as a response to a specific triggering event. Pelvic surgery or other traumatic injury to the genitals, pelvis, or lower back can trigger NRPF. Persistent pain conditions and chronic exposure to stressful or threatening situations can also kick the pelvic floor into overdrive. This may explain why people with a history of physical and/or sexual abuse⁠ (abuse: Purposeful harm or mistreatment of another person, which can be verbal, emotional, physical or sexual. An ongoing pattern or cycle of such mistreatment or harm can characterize an abusive relationship.) have high rates of NRPF.

Injury to other parts of the body can also impact the pelvic floor. Imagine that you’ve injured your right knee and you’re limping on that leg for several weeks. Over time, this imbalanced way of walking will throw off the symmetry of the muscles on both sides of your body—this includes the nearby pelvic floor muscles.

An Unbalanced System

Our muscles try to keep us safe adapt to imbalances by compensating – they become more contracted or more relaxed than usual. When a muscle is constantly contracted, the tension can restrict blood flow and the movement of oxygen and other important chemicals in and out of the muscle. In response to poor chemical exchange, the muscle develops tender points, or “knots” – these are called trigger points.

Trigger points are pressure-sensitive: they can cause pain when they are touched. The pain may be at the location of the trigger point itself, or further away, in another part of the body. This pattern helps explain how people with pelvic floor problems may also feel symptoms in other areas of the body, like their legs and back.

In some cases, the trigger points don’t cause much pain, but they can trigger other symptoms, like the sudden, urgent need to pee.

Fortunately, it’s possible to treat these trigger points to help them release. Relaxation of the trigger points can help the pelvic floor muscles relax in turn. This can help break the cycle of tension and dysfunction to relieve symptoms.

It’s also important to address the imbalances that are causing the muscles to compensate and develop trigger points in the first place. We’ll discuss approaches to this process later on.

How do I know if I (or a loved one) have NRPF?

Confirming that someone has NRPF is tricky because there aren’t clear diagnostic criteria. There’s no blood test or imaging scan that can highlight a chronically tight pelvic floor.

Like many pelvic health conditions, NRPF is a “diagnosis of exclusion”. This means that healthcare providers first need to rule out other conditions that could be causing similar symptoms, from nerve problems to bladder infection⁠ (infection: When harmful microbes, or germs, or harmful levels of microbes/germs, enter the body and multiply, causing illness. The common cold, flu viruses, sexually transmitted infections, chickenpox, impetigo, rabies and diphtheria are some kinds of infections.) . If testing for these other conditions is negative, the diagnosis of NRPF becomes more likely.

It’s also possible (and common!) to have NRPF along with another pelvic health condition. Many people with conditions like endometriosis, irritable bowel syndrome, and painful bladder syndrome also have NRPF.

These situations can become vicious cycles: the pain and symptoms of the underlying condition cause the pelvic floor muscles to tense up instinctively. The chronic tension of the muscles then exacerbates pain and other symptoms of the underlying condition, and around and around it goes…This cycle can make treatment a bit more complex, but improvement and recovery are still possible!

What to Expect During a Medical Visit

If you have any of the symptoms above, start by seeking care from your primary healthcare provider⁠ (healthcare provider: A qualified person to provide sound physical and/or mental healthcare, such as a doctor, nurse, clinician, counselor, medical assistant, midwife or other healthcare professional.) . They’ll likely order some testing to rule out other conditions, like infections, that could be causing these symptoms. If found, those conditions should be treated before continuing.

In addition to other screening tests, an examination of the pelvic floor muscles can provide valuable information. By palpating (lightly touching) these muscles, your provider can determine if the muscles have higher-than-average tone (resting tension). They may also be able to locate some of those trigger points we discussed earlier: touching the trigger point(s) may reproduce some of your familiar symptoms.

Pelvic exams can be intimidating for some people with NRPF, particularly if you’ve experienced pain during previous examinations. Fortunately, there are many options to make pelvic exams more comfortable: head back to our handy guide here!

Let’s say you’re reporting a few of the symptoms in the table above. Your screening tests for other conditions come back negative. Your provider identifies increased muscle tension in your pelvic floor. All of these findings suggest that you may have a non-relaxing pelvic floor. Okay…so what can you do about it?

How can NRPF be treated?

Here’s the good news: there are many ways to manage a non-relaxing pelvic floor. Let’s discuss a few of them!

Pelvic PT

Pelvic floor physical therapy is a cornerstone of treatment for people with non-relaxing pelvic floors. PTs who specialize in pelvic health have a wide variety of tools and techniques to help you on the way to recovery. Here are some of the most common:

• Education
  • When it comes to your pelvic health, knowledge really is power. The better you understand your condition, the easier it will be to tackle its challenges. You’ll learn about your anatomy and how the pelvic floor muscles work with other body parts.
  • Your provider will ask you about your daily habits: how often you go to the bathroom, if your bowel movements are disrupted, if you have pain with various activities, etc. If they identify behaviors that may be exacerbating pelvic floor tightness, they can teach you how to change them.

• Therapeutic exercises
  • Specific, personalized exercises can help reduce tightness and tension in your pelvic floor and its associated muscles. Your PT may teach you exercises to lengthen your pelvic floor muscles and stretches to target neighboring muscle groups.
  • In addition to stretching tight muscles, you may also need to strengthen opposing muscle groups. This can help balance the body so pelvic floor tightness doesn’t keep coming back.

• Neuromuscular training and biofeedback
  • “Neuromuscular” refers to the constant conversation between your nerves and muscles. Your muscles are controlled by messages from your nerves, and sometimes this communication⁠ (communication: Various ways we express ourselves to others, such as through speech, written words or symbols, sign language, body language, touch or art.) becomes disrupted. This can lead to hypertonic, non-relaxing muscles.
  • Certain exercises can improve the communication between your muscles and nerves. Biofeedback is a common approach to neuromuscular training.
  • Biofeedback uses sensors to measure the contraction and relaxation of your pelvic floor muscles. The sensors can be inserted internally in the rectum⁠ (rectum: The internal passage between the anus and the colon; stores solid waste until it leaves the body through a bowel movement.) or vagina or placed externally on the ski around the anus. You can observe the readings on a screen so you can tell if/when you’re fully relaxing your pelvic floor.

• Manual therapy
  • Manual, or “hands-on”, treatments can help reduce tension and pain in the pelvic floor muscles. They can also address imbalances in nearby muscles and joints which may be affecting your pelvic floor.
  • Manual therapies are very diverse: your PT may suggest soft tissue mobilization, joint manipulations, trigger point release, and more. Some techniques can be particularly helpful when applied internally (via the vagina and/or rectum).
  • While this might sound intimidating, pelvic PTs are trained to maximize your comfort with all manual techniques. Additionally, you always have the right to decline or delay any treatment that your PT suggests!

• Dry needling
  • Functional, or trigger point, dry needling is a technique that targets tight, sensitive “knots” in muscles that can cause pain. Once you and your therapist have identified these trigger points, the therapist can insert a sterile, super-fine needle (similar to an acupuncture needle) into the knot.
  • When the needle reaches the knot, it often causes a “twitch”: the muscle “jumps” as the knot releases. This twitch often results in rapid pain relief. The needled muscles may be sore for several hours after the treatment. However, when the soreness fades, the muscle often feels much looser.
  • Your PT may recommend needling to the muscles of the pelvic floor, as well as other muscles in the area—like your hips, low back, etc.—that may be affecting your pelvic floor.

• Electrical stimulation and other modalities
  • The thought of electricity anywhere near your pelvis might sound daunting. However, this type of electrical stimulation is designed to be comfortable and pain-relieving: it feels a bit like being tickled.
  • Electrical stimulation can be performed nearly anywhere on the body. Special electrodes allow pelvic PTs to apply it near the anus and/or within the vagina: this approach targets your pelvic floor muscles.
  • Some PTs will combine stimulation with other relaxing and pain-relieving modalities, like moist heat. The relief from these treatments is temporary, but it can give your body and mind a break from the discomfort. This allows you to focus on the interventions that will help you improve your symptoms for good.

• Relaxation techniques
  • As its name implies, the inability of the pelvic floor muscles to relax is a key problem for people with NRPF. Your pelvic PT will focus on helping you downtrain your pelvic floor: you’ll learn techniques to relax and lengthen those muscles.
  • Breathing exercises, body scans, and other mindful relaxation strategies can help reduce tension throughout your whole body – and this helps your pelvic floor relax more.

A good pelvic PT will provide multimodal treatment: they’ll tailor treatment to your needs and use a variety of strategies to help you reach your goals. Your plan of care also shouldn’t focus solely on your pelvic floor: it should address you as a whole person!

In many US states, you don’t need a physician’s referral to go to PT. During your first visit, your PT will determine if your condition is appropriate for physical therapy treatment. If additional work-up is required, your PT will tell you and recommend that you consult a different medical provider.

Important: not all PTs are pelvic health specialists. Make sure you find a PT with advanced training in pelvic floor rehabilitation. The Pelvic Rehab website is a great resource: you can search for pelvic health specialists near your home zip code.

Mental Health Impacts and Help

Living with the symptoms of a non-relaxing pelvic floor can be stressful and frustrating. Anxiety, depression, and sleep troubles are common among people with NRPF. These mental health issues can perpetuate the physical symptoms of the condition. Worsening physical symptoms then cause more emotional distress, and soon you’re caught in another vicious cycle.

Counseling can help break this cycle for many people with NRPF. Psychological therapies for NRPF can take many forms. They may be performed alone or with a partner⁠ (partner: In a sexual context, a person with whom someone is having some kind of sex. The term "partner" can be used for all kinds of relationships, not just serious ones. "Partner" can also mean the person someone is with in a romantic or familial partnership.) . Common strategies include cognitive-behavioral therapy, graded exposure to desensitize your nervous system⁠ (nervous system: The system of cells, tissues and organs that regulate our body's responses to internal and external stimuli.) , and systematic relaxation training (but those kinds are not your only options).

If you experience pain during sexual activity, your therapist may recommend that you and your partner(s) practice certain behavioral exercises. These can help your mind and body learn to associate sexual activity with pleasant sensations instead of pain. This approach can help break the cycle of fear and pain, so your muscles don’t automatically tighten in response to attempted intimacy.

Trigger Point Injections and Nerve Stimulation

For cases of NRPF that don’t fully respond to physical and psychological therapies, there are additional medical treatments that may help. Trigger point injections target specific muscles in the pelvic floor that are chronically tight and painful.

Some injections use an anesthetic and a steroid to reduce pain in the muscle. Other types of injections use Botox to make the muscle relax completely. Your provider can recommend the best option for you.

Complementary Therapies

Needles are powerful tools! Traditional Chinese acupuncture (TCA) is different from the injections and the functional dry needling techniques we’ve already discussed.

However, acupuncture can help with some people with NRPF better manage their symptoms. It appears to be particularly effective for pain associated with pelvic floor hypertonicity.

Nerve Stimulation

The nerves that communicate with your pelvic floor muscles offer another possible route for treatment. Trained practitioners can use special devices to apply electrical stimulation directly to these nerves: this is called neuromodulation.

Neuromodulation has been used successfully for a variety of pelvic floor conditions, from chronic bladder and prostate pain to nerve-related groin pain. Depending on your symptoms, it may be effective for a non-relaxing pelvic floor that hasn’t responded to other treatments.

Moving Forward with NRPF

Phew! We’ve just covered a ton of information! If you feel a little overwhelmed, don’t worry: there’s a lot to learn about NRPF, and you can’t digest it all at once. Come back to this article any time, and you’re sure to pick up new nuggets of knowledge.

Most importantly, have hope! If you or a loved one have NRPF, there are many options that can improve the condition and reduce its impact on daily life. You’ve got this!