Left: Female pelvic area; Right: Male pelvic area ( © Mayo Foundation for Medical Education and Research. All Rights Reserved. )

The pelvic area is complex. The "pelvic floor" is a group of muscles in the pelvis that are wrapped around the urinary opening, the vagina and the anus, supporting them in a hammock-like structure. These muscles are used when urinating or emptying the bowels, and during sexual intercourse, pregnancy and childbirth.

Pelvic floor dysfunction may occur if the muscles of the pelvic floor go into spasm or stop working in harmony with one another. Dysfunction may also occur if pelvic nerves become compressed, if organs sag due to lack of support, or if a problem develops in the hip or sacroiliac joint, the lower back or the coccyx.

Types of pelvic floor dysfunction include: • Urinary incontinence (leaking of urine)
• Bowel disorders (constipation or fecal incontinence)
• Bladder disorders
• Pelvic pain (in the lower abdomen)
• Pelvic organ prolapse (descending of
pelvic organs)

The causes of pelvic floor dysfunction range from injury to poor posture. In women, pelvic floor disorders may result from pregnancy and childbirth. In fact, it is estimated that at least one-third of adult women are affected by one or more of these conditions, and as women age, the likelihood of a pelvic floor disorder increases. Other causes of pelvic floor dysfunction include chronic constipation and excessive tension or incoordination of pelvic floor muscles.

To keep us continent (able to control urination and defecation), our muscles, nerves and brain all need to work together. The act of urinary voiding (emptying the bladder) requires some muscles to relax while others contract. The muscles of the pelvic floor must be strong enough to support a full bladder, yet when it is time to void, they must respond to the brain's signal to relax and allow emptying.

Three common types of urinary incontinence are:
Urge incontinence: urine leaks as soon as there is an urge to go to the bathroom.
Stress incontinence: there is loss of urine during exercise, when moving in certain ways, or from sneezing or laughing.
Overflow incontinence: the bladder never feels completely empty and urine leaks during the day and night. Despite an urge to void, only small amounts of urine are passed.

Bowel Disorders
Constipation occurs when bowel movements become difficult or less frequent. A person who has fewer than three bowel movements in a week is considered constipated. Causes may be related to diet, stress, medications, or lack of good nerve and muscle function in the bowel.

Fecal incontinence is the inability to control bowel movements. It may be the result of muscle or nerve damage, constipation, diarrhea or other conditions. The muscle or nerve damage may be associated with giving birth or aging.

The Keys to Proper Voiding
• Be comfortably seated, with the knees higher than the hips.
• Refrain from excessive straining, as it can lead to additional voiding issues.
• Make time for visits to the bathroom, since voiding can be difficult when rushed.
• Timing is important. For urination, this may mean not using the bathroom too often. However, the urge for fecal voiding should not be ignored, since it could start a cycle of constipation.
• Maintain adequate fluid and fiber intake.
• Seek treatment for pain or muscle spasm to help the pelvic floor muscles achieve a relaxed state.

Bladder Disorders
Two types of bladder disorders are interstitial cystitis and prostatitis.

Interstitial cystitis is a chronic condition characterized by bladder pressure and pain ranging from mild to severe. Although it is most common in women, it can also affect men and children.

Prostatitis is inflammation of the prostate gland that often results in painful or difficult urination. There may also be pain in the groin or pelvic area.

Chronic Pelvic Pain
Pelvic pain, which refers to pain in the abdomen below the belly button, affects quality of life. This pain can be caused by a wide range of conditions and can affect both men and women. If the pelvic pain is sudden (acute), one needs to seek immediate medical attention. Chronic pelvic pain is pain that has been present six months or longer, and can be either intermittent or constant.

Pelvic pain can be caused by the pelvic floor muscles becoming tight or when the muscles become weak, tender and shortened. Some painful pelvic floor conditions are coccydynia (pain in the tailbone area), levator ani syndrome (pain in the rectal area) and pain from a compressed pudendal nerve (located in the area behind the genitals at the base of the buttocks). Some conditions that cause pain in the vaginal area and painful sexual intercourse are: dyspareunia, vaginismus, vulvodynia and vulvar vestibulitis.

Pelvic Organ Prolapse
When any of the pelvic organs descend into or outside of the vaginal canal or anus, they are said to be "prolapsed." Prolapse can be caused by anything that creates increased pressure in the abdomen, including pregnancy, labor and childbirth, obesity, chronic coughing, constipation and hysterectomy.

How Physical Therapy Helps
If you have a pelvic floor disorder, the first step is to discuss it with your doctor. Some conditions may be treated with medication or surgery, but physical therapy is often an excellent treatment option. To receive therapy, you will need a prescription from your physician.

At Phelps Memorial Hospital Center, therapists are specially trained in treating pelvic floor dysfunction in both men and women. Treatment techniques may include manual therapy, such as trigger point release or myofascial release, or therapeutic modalities such as electric stimulation or ultrasound. Patients may also do exercises with or without biofeedback and receive education regarding diet and voiding habits.

This article was written by physical therapists Joanne Gelsi and Julie Lee in conjunction with Dr. Wei Angela Liu, medical director of the Physical Medicine and Rehabilitation Department at Phelps. Dr. Liu is introduced in this issue on page 11.

The Phelps outpatient Physical Medicine and Rehabilitation facility is located on the first floor of the 755 Medical Services Building on Phelps' campus. For a consultation with Dr. Liu or a physical therapy appointment, call (914) 366-3700


Joanne Gelsi, PT, Senior Therapist, Level II, has been a member of the Phelps rehab team since 1994. She specializes in general outpatient physical therapy treatment. She graduated in physical therapy from the University of Connecticut and has additional professional training in pelvic floor dysfunction.
Julie Lee, PT, CLT-LANA, Senior Therapist, Level II, graduated from New York University with a Bachelor's Degree in physical therapy and earned an advanced Master's in physical therapy from Long Island University. Julie joined the Phelps rehab team in 2009. She has additional professional training in pelvic floor dysfunction, and is a Certified Lymphedema Therapist (CLT-LANA).