Painful pelvic floor muscles & common gynae conditions

Levator myalgia (LM) or painful pelvic floor muscles (PFMs) are caused by a variety of issues: musculo-skeletal or postural issues, PFM injury or inflammatory conditions such as endometriosis and irritable bowel syndrome.

Altered biomechanics in the feet, knees and hips, scoliosis, extended, prolonged sitting, and unequal weight bearing may lead to stress/strain of pelvic floor and core musculature. This may result in hypertonicity and pain in the pelvic floor. Levator myalgia may also occur after birth injury, pelvic surgery, chronic constipation and sexual abuse. 

In the article ‘Levator Myalgia’, Adams et al (1) report that ‘hypertonicity and pain of the PFMs are proposed to create visceral symptoms by direct mechanical compression of organs and through somato-visceral convergence. Tight and hypertonic PFMs that do not relax contribute to constipation, impaired inhibition of detrusor contractions and delayed voiding. Inflammation or noxious stimuli in muscle can be transmitted to the spinal cord where neighboring nerve ending from the pelvic organs can transmit the noxious stimulus back to the visera.

This study concludes that LM is a prevalent condition in uro- gynaecology practice and is associated with approximately 50% greater bother in urinary, defecatory and prolapse symptoms.

The findings highlights two important issues:

  • ‘Women with LM suffer significantly more bother and a greater impact on quality of life from pelvic floor disorders and are at risk of co-morbid conditions such as depression, fibromyalgia and narcotic pain medication dependence’.
  • The importance of examining the PFMs (not only for strength, endurance, tone, coordination, timing) for pain and trigger points in women with pelvic floor disorders.

This issue is highlighted clinically in a current client referred by her GP for treatment of typical prolapse symptom she related as a ‘vaginal dragging sensation’. She had a history of endometriosis and episodes of nighttime ‘deep bowel pain’.

Ten years earlier she developed chronic left sided sacro-iliac pain and sciatica, which slowly resolved after stopping the power bar classes at gym. Internal examination revealed marked tenderness and rigidity in sections of her left levator ani and obturator internus muscles. Local pressure over these painful, rigid muscles caused the ‘deep bowel pain’ and a lower abdominal aching sensation.

At the second session she reported no vaginal dragging sensation and further releases were done on the areas causing the ‘deep bowel pain’.

Starting this client on a PFM strengthening program (advised for improving prolapse symptoms) would not have addressed the issues associated with her myalgia. Future treatment will progress with postural education, releasing tight buttock and spinal muscles and strengthening gluteus medius weakness, before coordinating pelvic floor and core muscle strength and endurance, and functional exercise training.

Levator myalgia: why bother? Adams et al. Int Urogynecol J. (2013) 24:1687-1693