Category Archives: Anatomy

Is Running Bad for a Woman’s Pelvic Floor?

As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:

4 miles in to our first half marathon!

4 miles in, and feeling great!

This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that as I approach the end of 2014, I am well on my way to better fitness.

Disney princess half

Disney Princess Half Marathon with my awesome sister, Tara and wonderful colleague, Jenna

After completing my last half-marathon, I received the following question from a previous patient of mine,

“Ok, I have to ask, after seeing your race pictures,

isn’t running bad for a woman’s internal organs??”

My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.

So… Is running bad for the pelvic floor? Let’s take a look.

When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.

But, what does the research really show?

1. Urinary incontinence during exercise is common and unfortunate.

  • Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.

2. High impact athletes often may require more pelvic floor strength than non-athletes.

  • Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.

3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals.

  • Bo 2010 found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
  • In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
  • An additional study by Braekken et. al. 2009 also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.

Is your head spinning yet?? Let’s make some sense of this research…

First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.

With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.

As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.

To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running. I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties or medication side effects which could worsen her problems.

We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…which I hate.

Kruger et. al. ICS Poster Presentation, "Intra-abdominal pressure increase in women during exercise: A preliminary study." 2012

Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012

As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in controlling intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):

  • Properly timing, well-functioning, flexible pelvic floor muscle group.
  • Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
  • Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
  • Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
  • Appropriate shoes to support her foot structure and transfer the loads through her legs
  • A great sports bra to help her use good posturing while running

Now, is there a time when a woman shouldn’t run?

Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.

  • If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
  • I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
  • The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children.
  • And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.

This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.

Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:

Vlog by Julie Wiebe providing an alternative to running:

Safe exercise for those with pelvic pain:

Tracy Sher, “Pelvic Guru” on Leaking during exercise:

Seth Oberst’s 4-post series on the Diaphragm:

What do you think? Let me know in the comments below!

Written by: Jessica Reale, PT, DPT, WCS


Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007 Oct;17(5):480-7. Epub 2006 Dec 20.

Bo K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes?

Borin L, Nunes F, Guirro, E. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013 Mar;5(3):189-93. Scand J Med Sci Sports. 2010 Feb;20(1):100-4

Jácome C, Oliveira D, Marques A, Sá-Couto P. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3.

Yes, you have incontinence. No, I do not necessarily want you to do Kegel Exercises.

This past week, I was fortunate to evaluate a nice middle-aged woman referred to me by her urogynecologist for urinary incontinence. When we first sat down, she looked at me and said, “I’m not sure why I am here. My doctor specifically told me that I have a strong pelvic floor. I really don’t think you can help me.” I smiled. I hear this same thought process on a weekly basis (See my previous article on common misconceptions of pelvic physical therapy) You see, at some point the world became convinced that from a musculoskeletal perspective, urinary leakage is always due to a weak muscle. And the best way to fix a failed muscle is to strengthen, strengthen, strengthen. But, if that’s the case, then why do I have so many patients walking into my office telling me that they have done “Kegel” exercises and still leak? Why would a patient like the one above have a “strong” pelvic floor that cannot hold back urine? Why is urinary leakage associated with low back pain and pelvic pain- disorders that we know can often include tight and irritated pelvic floor muscles?

Now, as a caveat to this article, let me say now that it is sometimes totally appropriate for a person to start a pelvic floor strengthening program. In fact, the person with a truly weak, overstretched, poorly-timing pelvic floor will likely be prescribed a strengthening program. With that being said, the truth is that the majority of patients referred to my clinic for evaluation of urinary incontinence are not issued a traditional kegel exercise program. Jenna and I actually tend to be surprised when we evaluate a new patient who truly needs to start a strengthening program for their pelvic floor at the first visit. The reason behind this is that Incontinence is not simply a failed muscle, but a failed system.

The urethra is supported within the continence system by fascia, ligaments, as well as muscular structures. When a downward force is applied to this system as occurs with coughing, sneezing, lifting, bending, etc, these structures function in a coordinated way to compress the urethra and prevent urine from leaking. In fact, Hodges et. al. in 2007 examined musculoskeletal activation occurring when a person performed an arm movement and found that the pelvic floor muscles pre-activated to prepare the body for movement. But, from a muscular standpoint, stability of the lumbopelvic structures (organs included!) requires optimal function of the diaphragm, the deep abdominal muscles, the deep low back muscles as well as the pelvic floor muscles.

When any of these structures are not functioning well, leakage can occur. Now, the tricky part here is that optimal functioning requires both strength, flexibility and proper timing. A tight irritated muscle then becomes equally as dysfunctional as a weak over-stretched muscle. And, a strong, flexible muscle that doesn’t have the right timing contributes to a very dysfunctional system.

So, treatment for incontinence then must include retraining and reconditioning the system to ensure its proper functioning—which for me includes a bit of detective work to truly identify the faulty structures. And, when it comes down to it, typically does not include doing 100 kegel exercises a day. More often, it includes learning to relax the pelvic floor, learning to coordinate the pelvic floor with the diaphragm, eliminating trigger points and restrictions, and then retraining the motor control of the lumbopelvic girdle as a system.

So, for now, take a deep breath and relax. We’ll save Kegels for another day.

For more information, check out the following:

Written by: Jessica Powley Reale, PT, DPT, WCS

Pelvic Floor Involvement in a Female Athlete


In 2013, The International Journal of Sports Physical Therapy published a fascinating case report. “A 45-year-old female distance runner was referred to physical therapy for proximal hamstring pain that had been present for several months”. The differential diagnosis of hamstring syndrome was placed on this patient and she was treated appropriately. However, there was much more involved in her pain than just the hamstrings. “Further examination led to a secondary diagnosis of pelvic floor hypertonic disorder. Interventions to address the pelvic floor led to resolution of symptoms and return to running.”

This is a great case of the varied complaints a patient with an overactive pelvic floor may report, but when treated appropriately, patients can regain their optimal level of function.

Do you have any difficult patients where you believe the pelvic floor may be involved? Or are you a patient who is suffering from pelvic girdle pain and you think your pelvic floor might be involved? Find a local Pelvic Floor PT to help you on your journey!

Burning Itching and Pain, Oh My!

Most of us women at one time or another in our lives will see our doctor for treatment for a yeast infection. However, if you are someone who has “swore” you had a yeast infection, only to go to the doctor and have them tell you everything “looks fine”, or maybe you just self- treat frequently with over the counter meds for frequent burning and itchiness, then this post is for you! And, if you’ve ever had any “weird sensations” in your pelvis or vulvar area (see below) then this post is for you too!

While you may have heard of your pelvic floor, a group of muscles in your pelvis that are responsible for maintaining bladder and bowel control (among other things), most people don’t think much about the nerves that supply the area of your pelvis. Just like you can move the wrong way and irritate a nerve in your back, get carpal tunnel syndrome, or get compression of your sciatic nerve that can cause leg pain, the nerves in your pelvis can also become irritated!

One nerve in particular, the pudendal nerve, is responsible for supplying sensation to the clitoris, labia, and areas around the vagina and anus. In addition, the pudendal nerve also is responsible for innervating some of the pelvic floor muscles, including the urethral sphincter and external anal sphincter (which helps with bowel control). When the pudendal nerve or a portion of it, becomes irritated you may feel many different symptoms. You may feel like you have a yeast infection, are “on fire down there”, feel itchy, feel like your urethra is irritated, have clitoral pain ,experience shooting pains into your vagina, or feel like you have hemorrhoid, or feel like you are sitting on a “rock” to name a few.


So, how does the nerve get irritated? Irritation to the nerve typically happens either if the nerve is compressed, stretched, or restricted so that it does not glide normally. Nerve irritation can sometimes happen if you cycle a lot (which puts pressure on the nerve), with prolonged sitting, after working out, or after having sex. Childbirth can also stretch the nerve, causing it to be irritated. In addition, if you had an episiotomy or tore during childbirth requiring stiches, scar tissue can form, restricting the nerve and causing symptoms.

So, if you notice these symptoms, what can you do about it? Obviously if your burning or irritation is accompanied by unusual discharge, a fever or other symptoms you would want to seek out your health care provider for treatment as this could signal a potential infection. But, if no red flag symptoms exist and you feel the irritation may be more of the nerve variety, seek out a physical therapist certified in the treatment of the pelvic floor. Pelvic floor treatment includes helping to relax tight muscles that might be compressing the nerve, as well as massaging or mobilizing the tissue around the nerve to help it move more freely. Sometimes, patients will feel better immediately, and other times, it takes a few visits before the symptoms subside.

And what about all of the men who might be reading this? You have a pudendal nerve as well. Pudendal nerve irritation for you can cause pain in the penis, scrotum and around the anus as well as some difficulty with erection. If you think you may be having symptoms pelvic floor therapy may help you as well!

Written by: Kim Osler PT, DPT, WCS


Ortho therapists… This one’s for you.

Jessica and I recently spoke at the South Carolina APTA’s annual conference and the topic of discussion was Pelvic Floor Dysfunction in the Orthopedic Population.

photo (1)

The information we presented was well received and I thought it may be beneficial to share some tidbits about the role of the pelvic floor in orthopedic diagnoses. So here it goes:

– Don’t assume that because you are treating “orthopedic” patients or athletes that you won’t see pelvic floor involvement.

  • The prevalence of urinary incontinence in women is 25-45% (Eliasson 2008)
  • The prevalence of urinary incontinence in men is about half that of women (12-25%) (Shamliyan 2009)
  • The prevalence of urinary incontinence in female athletes is 30- 41%. Athletes involved in high-impact sports are at a greater risk. (Jacome 2011)
  • What this means is that if you see 10 patients in a day, at least 2 women and 1 man will have some urinary complaints.

– Patients are unlikely to report symptoms of bowel, bladder, or sexual dysfunction UNLESS you ask the tough questions!

  • 90% of women do not report urinary problems to their healthcare providers if they are not directly asked. (Carls 2007)
  • Greater than 50% of community-dwelling, middle-age women experiencing symptoms of UI have NOT discussed it with their physician. (Kinchen 2003)

So how do you do this?

  • Ask direct questions! Say This: Do you ever leak urine when you cough or sneeze? Not That: So umm…… do you….umm…. Ever…well, you know…. have accidents?
  • Use professional wording. Say This: Often times, people experiencing hip pain can have difficulties with sexual activity. Are you having any problems with this? Not That: When you and your husband are, you know, doing it, does it hurt?
  • Be considerate of privacy.
  • Remember: You are a medical professional!

– The pelvic floor muscle group is responsible for WAY more than just “holding back urine, gas, or stool”.

  • The pelvic floor has a significant role in STABILIZATION of the spine and pelvis, support of pelvic organs, sexual function, and of course sphincteric control.
  • Pel & Colleagues examined how pelvic stabilization from the pelvic floor would occur with 3D simulation models in 2008. They found that the pelvic floor activation patterns provided stabilization of the coccyx and together with the transverse abdominus prevented SI shear forces when the pelvis experienced perturbations
  • The point here is that the pelvic floor is crucial to stability and for patients with core instability, incorporation of the pelvic floor into stabilization would be highly effective.

– The pelvic floor can refer pain throughout the lumbopelvic region, hips, and abdomen.

  • If you have found it difficult to accurately reproduce your patients’ symptoms, consider the pelvic floor’s possible involvement.

PF referral

  • Pain can also be reported in the hip, buttocks, lumbar spine, and suprapubic region.

– Kegels are NOT always appropriate

  • Kegels should only be utilized with true pelvic floor muscle weakness and this is unlikely in a patient with pelvic girdle pain. Know that trigger points in the pelvic floor will become aggravated with Kegels

– And lastly, remember:

  • ASK the tough questions, or you will not get the answers.
  • Be aware that patients with postural instability may have weakness and/or trigger points in their pelvic floor muscles.
  • Recognize that the pelvic floor and obturator internus muscle tension/trigger points can present as hip, groin, abdominal, low back or tailbone pain.
  • Don’t ignore the coccyx.
  • Educate your patients and yourself!



“Is Mine Normal?”


For guys, there is often a lot more openness when it comes to their external genitalia. Unfortunately for women, we too often hear the message that that area is private, or even dirty or shameful. And so, a lot of anxiety can exist when it comes to a female’s external genitalia. With so many things in life, we all want to be normal, look normal, and not have anything funny going on with us. It’s not uncommon for a teenage girl going to her first gynecologist appointment or a woman going to get a wax to think, “Is mine normal?” In fact, we often have ladies ask us this very question when they start seeing us in Pelvic PT.

 So, when it comes to your private parts/lady parts/vagina/vajayjay/coochie/hoo-hoo/hoo-ha/flower, how well do you know yours?

Some women may look at their genitals regularly, while others would never dare to grab a mirror and look. Regardless of where you fall on the spectrum of your comfort level with looking at your own “vagina,” if it’s news to you that what is commonly referred to as the “vagina” is technically the vulva, keep reading!

So, when it comes to your private parts/lady parts/vagina/vajayjay/coochie/hoo-hoo/hoo-ha/flower, how well do you know yours? Some women may look at their genitals regularly, while others would never dare to grab a mirror and look. Regardless of where you fall on the spectrum of your comfort level with looking at your own “vagina,” if it’s news to you that what is commonly referred to as the “vagina” is technically the vulva, keep reading!

As Dr. Lindsey Doe illustrates in her YouTube video (you will never look at a hooded sweatshirt the same after watching) the vulva refers to the external female genitalia and can be thought of as the vagina’s neighborhood. So what all is in this neighborhood?

 Mons pubis – the fat pad over the pubic bone that is normally covered in hair

Labia majora – the outer folds or “lips”

  • Run from the mons pubis in the front to the perineum in the back
  • Composed of thicker skin, fat, and connective tissue
  • Normally covered in hair

Labia minora – the inner folds or “lips”

  • Run from the fourchette (frenulum of the labia) in the back and then split at the front to form both the prepuce and the frenulum of the clitoris
  • Composed of thin skin
  • Not covered in hair
  • Lots of variation in size, shape, and coloration (even in the same woman)

Clitoris – the main erectile tissue in the female (from the same embryological tissue as the penis)

  • Plays a role in sexual function only
  • Glans – the head of the clitoris (the clitoris has a body, and legs on either side, too, but they are internal); can vary in size and shape
  • Prepuce – the “hood” of tissue that covers the glans to protect it; formed by the labia minora

Frenulum – where the labia minora meet at the front, right below the clitoris

External urethral meatus – the opening to the urethra which is the tube emptying your bladder

Vestibule – the area inside the labia minora (the “porch”), between Hart’s line and the hymen

Hart’s line – separates the labia minor from the vestibule; marked by a change in coloration (this is an imaginary line)

Glands (you won’t see these) – secrete fluids important for lubrication with intimacy; may become clogged

  • Bartholin’s glands – inside the vestibule
  • Skene’s glands – on either side of the urethral opening

Hymen – the mucosal tissue that partially or entirely covers the vaginal opening at birth; may be disrupted by various means (vaginal penetration whether through sexual intercourse, masturbation, use of a tampon; surgery; trauma; vigorous sports). Remnants of the hymen will vary significantly between women. Talli Rosenbaum, physical therapist and sex therapist, has a fantastic article about the hymen here.

Introitus – the opening to the vagina; normally closed when legs are not spread

Posterior Fourchette – where the labia minora meet in the back, behind the introitus


But while a cartoon can be a great way to visualize and learn anatomy, we are not cartoons! So if you’re worried that your labia are too big or that you have funny wrinkles somewhere, remember that your vulva is just like your face – everyone shares common features, but the details are different.

If you’re still worried, check out British artist Jamie McCartney’s installation “The Great Wall of Vagina.” He has cast hundreds of vulvas, and through art has made “the sexual nonsexual.” No two look the same. Included in the collection are several male-to-female and female-to-male transgendered individuals, but chances are you couldn’t pick them out because of the vast differences among all vulvas.

 So don’t fret, your vulva is normal, just the way it is.

Note: Please know that this post is not meant to imply that ALL variations are normal. Knowing what your vulva looks like when it’s healthy can be helpful so that you can recognize any changes that may occur. Dermatological conditions and sexually transmitted infections (STIs) may change the appearance of your vulva or cause pain, itchiness, or burning in this area. If you are concerned about a potential disease process, please consult your physician. 

*For more resources on pelvic anatomy, check out this excellent post by our friend and colleague, Tracy Sher, on Pelvic Guru!


This guest post is written by Leigh Welsh, a third year Doctor of Physical Therapy student from Duke University, currently completing a 12-week rotation with Proaxis Therapy in Pelvic Health with Jessica Powley, PT, DPT, WCS. Leigh has been an excellent addition to our team, and we are confident that she will make a fantastic clinician.

So… What Exactly is The Pelvic Floor?

The pelvis is a complicated and fascinating structure in the body. From a musculoskeletal perspective, it is the central component of your body. A well-functioning pelvis is necessary to walk, bend forward, stand up, and roll over. In addition, the organs of the pelvis work in coordination with the muscles, ligaments, tendons and connective tissues to ensure healthy urinary, bowel, sexual and reproductive functions. Basically, the pelvis rules. It’s crucial. It’s a beautiful part of the body. And, it’s often forgotten, misunderstood, and unappreciated until something goes wrong.


Really, think about it. How often have you thought about your pelvis? Men, how many times to do you stand in front of the toilet and feel thankful that your muscles are relaxing right as your bladder contracts to empty? Ladies, how many times do you have sex and thank your muscles for stretching and contracting to help sex feel good for you? How many times do you walk up stairs and recognize that your muscles are perfectly supporting all of your joints around your pelvis to help you take those steps without pain? Unless you have a problem with your pelvis, you probably have answered “never.” Don’t feel bad. You’re not alone. Most people don’t recognize the fascinating complex structures within their pelvis until they have problems with it. And at that point, it can feel like a dark hole—complicated and unknown. That’s where we come in!

First and foremost, you must understand the role of the pelvis and the muscles at the base of our core.

male 1female 1

These beautiful muscles (clearly, a pelvic PT bias 😉 ) serve many roles including sphincteric control, supporting the pelvic organs, stabilizing the pelvis as part of the core, and improving sexual function.

Most of the patients we treat are familiar with the role of the pelvic floor in maintaining continence (not leaking). These muscles wrap around the urethra, rectum, and vagina (in females), and in order to maintain continence of urine and feces, they must contract. Conversely, in order to completely empty our bowels and bladder they MUST fully relax. When the muscles do not function properly–whether they aren’t contracting well or aren’t relaxing well– we see problems in both urinary and/or bowel function. A pelvic floor therapist can help you to coordinate these actions to facilitate complete emptying and achieve continence if necessary.

Secondly, the muscles of the pelvic floor support the bladder, rectum, and in females, the uterus. When these muscles are weak, patients are at increased risk for pelvic organ prolapse (POP). POP occurs when the fascia, ligaments and muscles of the pelvic floor no longer support the pelvic organs resulting in the drop (prolapse) of the pelvic organs from their normal position (FDA). People can develop prolapse of the uterus, bladder, rectum or small intestines. According to Varma et al. “Women aged 50 and older are 6 times as likely as men to present with rectal prolapse. Although it is commonly thought that rectal prolapse is a consequence of multiparity, approximately one-third of female patients with rectal prolapse are nulliparous. The peak age of incidence is the seventh decade in women, whereas the relatively few men who have this problem may develop prolapse at the age of 40 or less”. Some risk factors for POP include childbirth, the aging process, genetic predisposition, connective tissue disorders, obesity and frequent constipation.

In regards to stabilization, the pelvic floor muscles are essential. This muscle group sits at the base of the pelvis and works in harmony with the diaphragm (breathing muscle), transverse abdominus (deep core stabilizer), and multifidus to provide stability prior to and during movement. This combination of muscles work sort of like a soda can to maintain a pressurized pelvis and core to allow for stability of the lumbopelvis. We wrote more about this role of the pelvis in our post, here.


Lastly, the muscles of the pelvic floor play a crucial role in sexual function. We will post more about this at a later time, but for now, know that the pelvic floor is important in women to stretch and allow for penetration and also to contract to provide pleasure and orgasm. In men, the pelvic floor contracts to assist in erection and relaxes to allow for ejaculation.

There you have it! We hope this blog post helps you to better understand how these muscles function.

Written by: Jenna Sires PT, DPT and Jessica Powley PT, DPT, WCS

The Prostate: What Does it do? And What Happens When it is Removed?

A large majority of our patients include men who have, or are about to undergo a prostatectomy. I thought it would be fitting to educate not only these patients, but the rest of us on the function, and repercussions of removing this vital structure.

First of all… what in the world is the prostate? And what does it do? Well, the prostate is a gland in the male reproductive system found below the bladder and in front of the rectum. The prostate surrounds the urethra, the tube through which urine flows.

Prostate Anatomy

This walnut sized gland contributes to the production of seminal fluid. During orgasm, this seminal fluid helps carry sperm out of the man’s body as part of semen. (

Why do men have this gland removed you might ask?…. Primarily due to cancer of the prostate. Cancer begins in cells, the building blocks that make up all tissues and organs of the body, including the prostate. Normal cells in the prostate and other parts of the body grow and divide to form new cells as they are needed. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn’t need them, and old or damaged cells don’t die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. (

According to the National Cancer Institute, there will be 238,590 new cases of prostate cancer in 2013 and ~ 29, 720 deaths in the United States. That is a lot of cancer, and if treated via a prostatectomy, that is a TON of males who may need the help of a skilled pelvic floor physical therapist.
During a prostatectomy a surgeon removes the prostate gland from the surrounding tissue. The seminal vesicles, two small fluid-filled sacs next to the prostate, are sometimes also removed. The surgeon tries carefully not to damage nerves and blood vessels. Once the prostate is removed, the surgeon reattaches the urethra to a part of the bladder called the bladder neck. Following the surgery, a urinary catheter is left in the bladder to drain urine.

Some risks of this procedure include:
– Difficulty controlling bowel movements (bowel incontinence)
– Difficulty controlling urine (urinary incontinence); Incidence after radical prostatectomy varies from 2.5-87%. At 6 months 5-72% (Cooperberg J Urology 2003; 170: 512-515)
– Erection problems (impotence)
– Injury to the rectum
– Urethral stricture (tightening of the urinary opening due to scar tissue)

Now, as the urethra and bladder neck are healing the control of urinary continence is left to the pelvic floor muscles.


These muscles wrap around the urethra and rectum, maintaining continence, and must fully relax to allow complete urine and bowel emptying (Check out this amazing video to learn more about this muscle group). Many men benefit from pelvic floor muscle retraining prior to surgery to increase their awareness, strength, and endurance of the pelvic floor. Research has also shown that men who participate in skilled PT pre-operatively are less likely to struggle with chronic urinary incontinence (Burgio J Urology 2006; 175: 196-201).

The sad part is, post-operatively, many men are not even informed that PT is an option to improve continence. They may struggle with the embarrassment of leaking urine, difficulty returning to work, depression, and the list goes on and on.

Do you know someone with prostate cancer or who has had their prostate removed? If so, guide them to the National Institute of Cancer, show them this blog, and remember that education is key to improving our quality of life and general health.

Written by: Jenna Sires PT, DPT

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