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 problemsexternal link, opens in a new tab that pelvic health physical therapists encounter: the non-relaxing pelvic floor (NRPF).
A non-relaxing, overactive pelvic floor can cause a variety of symptomsexternal link, opens in a new tab, ranging from constipation and difficulty peeing to pain with sex 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 problemexternal link, opens in a new tab. It’s estimated to affect 50-90% of the populationexternal link, opens in a new tab (!), though not everyone with NRPF will have significant symptoms. It can occur in people of all sexes and gendersexternal link, opens in a new tab: if you have a pelvis, you can have a non-relaxing pelvic floor.
This condition goes by some other names, including “overactive pelvic floorexternal link, opens in a new tab”, “pelvic floor hypertonicityexternal link, opens in a new tab”, and “pelvic floor muscle tightness”. It often co-occursexternal link, opens in a new tab 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 complexexternal link, opens in a new tab, but you can visualize the NRPF like a tightly coiled spring. This spring can’t stretch out 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 contractionsexternal link, opens in a new tab. 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 areaexternal link, opens in a new tab. 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 personexternal link, opens in a new tab. Some people have only a few symptoms, while others have many. The most common symptoms can be divided into 4 overarching categoriesexternal link, opens in a new tab:
- Lower urinary tract symptoms (problems with peeing)
- Gastrointestinal (GI) symptoms (issues with the gut and pooping)
- Sexual symptoms
- Pain symptoms
Common Symptoms of NRPFexternal link, opens in a new tab
Urinary | Gastrointestinal | Sexual Issues | Pain* |
Incomplete bladder emptying | Constipation | Pain with sexual activity | Pain with sexual activity |
Painful peeing | Painful pooping | Difficulty reaching orgasm | Pain with peeing |
Leaking urine during activity (like exercise or sneezing) | Incomplete bowel movements | Difficulty with erection | Pain with pooping |
Strong urges to pee (may cause leaks) | Fecal incontinence (losing control of bowels) | Difficulty with ejaculation | Pain with sitting |
Frequent urges to pee | Pain with contact to the genitals | ||
Weak urine stream (may stop/start) | Pain during a gynecologic exam |
*Pain symptoms are typically located in the genital regionexternal link, opens in a new tab: often near the front wall of the vagina for people with vaginas, and at the perineum (between the genitals and the anus) regardless of anatomy.
Medicine still does not have clear criteria to diagnoseexternal link, opens in a new tab someone with NRPF. However, the simultaneous presence of several of the above symptomsexternal link, opens in a new tab suggests that NRPF is a likely culprit.
What causes a non-relaxing pelvic floor?
NRPF comes in two forms, primary and secondaryexternal link, opens in a new tab. Primary NRPF develops on its own, without a clear trigger (though it’s likely we just can’t always identify that trigger). In these cases, researchers think that NRPF may develop from learned behaviorsexternal link, opens in a new tab, such as regularly holding back urine or bowel movements for long periods. This can start in childhood or develop laterexternal link, opens in a new tab in adulthood.
Secondary NRPF develops as a response to a specific triggering eventexternal link, opens in a new tab. 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 have high rates of NRPFexternal link, opens in a new tab.
Injury to other parts of the bodyexternal link, opens in a new tab 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 compensatingexternal link, opens in a new tab – 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 chemicalsexternal link, opens in a new tab 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 touchedexternal link, opens in a new tab. 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 areasexternal link, opens in a new tab of the body, like their legs and back.
In some cases, the trigger points don’t cause much pain, but they can trigger other symptomsexternal link, opens in a new tab, 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 relaxexternal link, opens in a new tab 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 criteriaexternal link, opens in a new tab. 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 exclusionexternal link, opens in a new tab”. This means that healthcare providers first need to rule out other conditions that could be causing similar symptoms, from nerve problems to bladder infection. 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 conditionexternal link, opens in a new tab. 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 instinctivelyexternal link, opens in a new tab. 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. They’ll likely order some testing to rule out other conditionsexternal link, opens in a new tab, 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 toneexternal link, opens in a new tab (resting tension). They may also be able to locate some of those trigger pointsexternal link, opens in a new tab 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 treatmentexternal link, opens in a new tab for people with non-relaxing pelvic floors. PTs who specialize in pelvic health have a wide variety of tools and techniquesexternal link, opens in a new tab 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 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 approachexternal link, opens in a new tab 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 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 painexternal link, opens in a new tab in the pelvic floor muscles. They can also address imbalances in nearby muscles and jointsexternal link, opens in a new tab 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 moreexternal link, opens in a new tab. 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 musclesexternal link, opens in a new tab 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”external link, opens in a new tab: 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 areaexternal link, opens in a new tab—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-relievingexternal link, opens in a new tab: 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 modalitiesexternal link, opens in a new tab, 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 musclesexternal link, opens in a new tab.
- Breathing exercises, body scans, and other mindful relaxation strategies can help reduce tension throughout your whole bodyexternal link, opens in a new tab – and this helps your pelvic floor relax more.
A good pelvic PT will provide multimodal treatmentexternal link, opens in a new tab: 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 PTexternal link, opens in a new tab. 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 websiteexternal link, opens in a new tab 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 commonexternal link, opens in a new tab among people with NRPF. These mental health issues can perpetuate the physical symptomsexternal link, opens in a new tab 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 formsexternal link, opens in a new tab. They may be performed alone or with a partner. Common strategiesexternal link, opens in a new tab include cognitive-behavioral therapy, graded exposure to desensitize your nervous system, 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 exercisesexternal link, opens in a new tab. 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 injectionsexternal link, opens in a new tab target specific muscles in the pelvic floor that are chronically tight and painful.
Some injections use an anesthetic and a steroidexternal link, opens in a new tab to reduce pain in the muscle. Other types of injections use Botoxexternal link, opens in a new tab 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 needlingexternal link, opens in a new tab techniques we’ve already discussed.
However, acupuncture can help with some people with NRPF better manage their symptomsexternal link, opens in a new tab. It appears to be particularly effective for painexternal link, opens in a new tab 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 neuromodulationexternal link, opens in a new tab.
Neuromodulation has been used successfully for a variety of pelvic floor conditionsexternal link, opens in a new tab, from chronic bladder and prostate pain to nerve-related groin pain. Depending on your symptoms, it may be effective for a non-relaxing pelvic floorexternal link, opens in a new tab 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!