Hypertonic Pelvic Floor: Why your treatment needs to go beyond breathing and stretching

If you do a quick search on how to fix hypertonic (or tense/tight) pelvic floor muscles, you will likely see suggestions to work on diaphragmatic breathing, stretches like happy baby and child’s pose, and doing nervous system relaxation. These techniques can all be a helpful piece of the puzzle in improving pelvic floor muscle function, but I often find that there are a few more pieces that may need to be addressed.

In this blog, I am going to discuss what a hypertonic pelvic floor is, how I assess for pelvic floor muscle hypertonicity, and some treatment techniques I use for patients with a hypertonic pelvic floor.

First, what is a hypertonic pelvic floor?

Your pelvic floor is a bowel of muscles in the bottom of your pelvis that play an important roles in bowel, bladder, and sexual function. Imagine your pelvic floor muscles like a trampoline. In order to support your pelvic organs, your pelvic floor muscles should have a nice baseline tension at rest, while also being able to lengthen and lift to absorb and translate forces.

Now imagine you tightened the springs on your trampoline and pulled it really taut. This taut trampoline would be more like a slab of concrete supporting your organs, meaning it wouldn’t be absorbing or translating force well with movement and pressure. When pelvic floor muscles are hypertonic, they are shortened, tense, and often painful to touch.

Symptoms you may experience if you have a hypertonic pelvic floor can include hip and/or low back pain, pelvic pain, pain with intimacy and penetration, pain with pelvic exams, constipation, difficulty fully emptying your bladder or bowels, urinary leaking, urinary urgency, and more.

How I assess pelvic floor muscle function

Assessing pelvic floor function always starts with a solid subjective assessment. This includes discussion of your past medical and surgical history, current medications, questions about your bowel and bladder function, as well as any relevant gynecological history. We also discuss your concerns, things that make your symptoms better or worse, and what your goals are.

We then complete a comprehensive objective assessment that looks at the following:

1) A thorough orthopedic assessment. We look at your overall strength, range of motion, and functional movements such as squats, hinges, single leg balance, and functional hip mobility testing to find any areas that may have limited strength or mobility affecting your pelvic floor.

2) Osteopathic listening. Your pelvic organs need to move, too. Osteopathic listening is a technique that can help guide your treatment plan to address any restrictions between your pelvic organs and their surrounding structures, which can ultimately reduce muscle guarding in your pelvic floor muscles. Check out this blog post to learn more about why visceral manipulation may be an important part of your pelvic floor therapy treatment plan.

3) Breathing and core coordination assessment. When we talk about your “core”, imagine a soda can. The top of your core is your diaphragm, the bottom is your pelvic floor, and your abdominal and back muscles make up the sides. When you inhale, your diaphragm lowers and pelvic floor and abdominal muscles lengthen. When you exhale, your diaphragm and pelvic floor muscles lift and abs gently engage.

When your pelvic floor muscles are tense, they are often unable to fully lengthen and therefore are not able to work through a full range of motion. If the muscles cannot lengthen, they become weak overtime. They can also have difficulty lengthening for tasks that require bulging of the pelvic floor muscles, such as bowel movements or a vaginal birth.

Sometimes the diaphragm, abdominals, and pelvic floor can become uncoordinated as well, which can lead to patterns that increase pressure on your pelvic floor (such as upper ab gripping). Working on diaphragmatic breathing and core/pelvic floor coordination can help improve your core pressure management and reduce stress on your pelvic floor muscles.

Check out the video below on coordinating diaphragmatic breathing with deep core bracing.

4) An internal pelvic floor muscle assessment. An internal pelvic floor muscle assessment is the best way for your pelvic floor therapist to determine if your pelvic floor muscles are hypertonic, to assess how well your pelvic floor muscles are coordinating with your breathing and abdominal bracing, and to determine how strong your pelvic floor muscles are. Check out his blog post to learn more about internal pelvic floor muscle assessment.

What does treatment look like for a hypertonic pelvic floor?

There are several treatment strategies that may be appropriate for you if you have a hypertonic pelvic floor. As always, I recommend getting an individualized assessment with a pelvic floor therapist to determine the best plan for you. Below are some of the treatment strategies I use for patients with pelvic floor muscle tension.

1) Internal muscle release work. If your muscles are holding tension, it can be helpful for your therapist to do gentle internal trigger point release or soft tissue massage to your pelvic floor muscles. Some patients may tolerate this well right away, while others may require other treatment techniques first if they are unable to tolerate the internal assessment (such as patients with vaginismus or vulvodynia).

If you get relief of your symptoms following internal muscle release work, your therapist may recommend a pelvic wand or dilators for self pelvic floor muscle work. It is important to note that if you have been seeing a pelvic floor therapist and only getting temporary relief from internal pelvic floor release work, they should be adjusting their treatment plan and/or recommending a pelvic wand for home.

2) Other manual therapy techniques. If your osteopathic listening takes your therapist to deeper structures such as pelvic or abdominal organs, treatment to those areas can be really helpful to reduce restrictions that may be causing your pelvic floor muscles to become tense. I also have seen patients improve with manual treatments such as cupping, dry needling, and instrument assisted soft tissue massage to muscles around the abdomen, back, and pelvis.

3) Nervous system regulation and downtraining. Your nervous system can be a primary driver of muscle guarding in your pelvic floor. Working with other providers such as somatic therapists, talk therapists, dieticians, and functional medicine providers can be helpful to support your overall health and nervous system.

Your therapist may also recommend stretches and mobility work, as well as breathing exercises, that can help support your pelvic floor and reduce muscle guarding.

4) Improving bladder and bowel habits. There are many lifestyle factors and daily habits that can contribute to symptom such as urinary urgency, frequency, and leaking. It is important to address both your pelvic floor muscles and improve your bladder habits to support overall pelvic health.

Constipation can also be a major driver of pelvic floor hypertonicity. If you have a history of fissures, hemorrhoids, or hard stools that cause a lot of straining, your pelvic floor muscles may be hypertonic. It is important to improve stool consistency in order to reduce straining with bowel movements. I typically recommend starting with assessing your hydration and fiber intake, using a squatty potty, and starting a morning bowel routine to support healthy bowel movements.

5) Exercise prescription. As I mentioned above, your therapist will likely suggest some mobility work and nervous system downtraining. However, it is also important that you work on core strength and coordination as well as strengthening muscles that connect to your pelvis such as your deep hip rotators, hamstrings, hip flexors, and even your scapular stabilizers. Check out this example of some strengthening exercises I prescribed for a patient with pelvic floor muscle tension.

If you think you may have a hypertonic pelvic floor and are interested in setting up an appointment for an individualized assessment, you can set up your in person or virtual evaluation here.

Blog post written by Dr. Alexis Hutchison, PT, DPT, OCS, PCES