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Lifestyle & Exercise > June 2002
Pelvic Floor Dysfunction
and Problem Trigger Points in Other Areas of the Body
Symptoms of pelvic
floor dysfunction (PFD) include urinary urgency and frequency, a feeling
of incomplete urination, decreased urine flow and constipation, pelvic
pain with intercourse, pain in the back of the vagina, pain in the
testicles (and/or penis), and pain in the lower back. Sound familiar?
If you read our last column you will understand that there is a debate
between doctors, whether IC is caused by PFD, or whether PFD can cause
IC. Are both theories right? There are doctors who believe that IC
is caused by different things in different people. No one really knows
What we do know
is that about 70% of IC patients don't have a normal cooperation of
parts in their pelvic floor muscles. Urination depends on muscle coordination
between the bladder and the pelvic floor muscles. The muscles of the
pelvic floor are meant to relax while the bladder contracts. However,
in PFD, the pelvic floor muscles continue to tighten when the bladder
contracts. The result is poor urine flow. Experts in PFD believe that
straining and pushing to get the last drop of urine out, further aggravates
the muscles of the pelvic floor. Thus, a vicious cycle develops.
A Case Study - Mary Jo
When Mary Jo came
to our last support group meeting she told us that she was feeling
much better. Mary Jo had been to see Susan Guynes, a physical therapist
who specializes in PFD, at Louisiana State University Medical Center.
Mary Jo was diagnosed with IC only a few months ago and has had other
health problems for many years. She has learned to be proactive with
her health-care, so getting a handle on her IC seems to come naturally.
Along with her
medication, Mary Jo practices pelvic floor relaxation exercise
every day, several times a day. As a matter of fact, she brings
a mat to work so she can practice during work hours. Mary Jo's exercise
focuses on relaxing the muscles of her pelvic floor, especially the
urethral sphincter (refer to the graphic of the pelvic floor in
our May column). In order to first locate the area of her urethral
sphincter and the surrounding tissue, Mary Jo had to stop her urine
flow during urination. This allowed her to locate her muscles and
feel how they work. Mary Jo's relaxation exercise works by tightening
specific muscles in her pelvic floor before relaxing them.
When Mary Jo tried
amitriptyline she couldn't empty her bladder completely. Her doctor
explained that her bladder was quite large and didn't drain well,
and the amitriptyline didn't help because it caused her bladder to
over-relax. Mary Jo's doctor prescribed a medication to help her to
empty her bladder and she has been taking Elmiron. Mary Jo's physical
therapist also uses pelvic floor tissue release. This
is an external rather than internal massage (or hands-on release)
of the tissue around the ramus (refer to our graphic of the pelvic
floor in our May column). I have found this soft tissue work to
be extremely helpful. I have actually experienced very bad bladder
pain subside with the release of this tissue. However, when the work
was too close to the urethra it set off my bladder symptoms.
Prevention & Other
strategies for Pelvic Floor Dysfunction
There are a variety
of techniques that can be used to address pelvic floor dysfunction,
- bladder training
(to strengthen the bladder muscles)
- internal massage
to address the perineum (the area between the anus and vagina in
women, and between the anus and base of the penis in men)
- trigger point
therapy (anesthetic agents are sometimes injected into tender points
in the pelvic floor)
- TENS unit (transcutaneous
electrical nerve stimulation to block pain, increase blood flow
and strengthen the problem muscles)
treatment (myofascial therapy and chiropractic adjustments)
- dietary modifications
(to prevent bladder spasms, constipation and dehydration)
- warm sitz baths
- stress reduction
(to reduce symptoms)
- gentle exercise
(to promote healthy digestion and elimination, and fight the pain
- postural education
sitting for only
short periods of time
- sitting only
on firm and even chair cushions (muscles shift bones and are compromised
on uneven surfaces.)· medications, such as anti-inflammatory
agents, muscle relaxants, low dose antidepressants and analgesics.
Tender Points & Trigger
PFD is thought to
be caused by trigger points or tender points in the pelvic floor. What
are these? Tender points are most commonly found in fibromyalgia patients.
FMS is defined as a widespread musculoskeletal pain and fatigue disorder
that involves sensitivity to pressure on specific areas of the body.
These sensitive areas are called tender points. When pressed, tender
points cause great discomfort, but not referred pain. A diagnosis
for FMS requires patients to have at least 11 of the 18 tender points.
that often occurs with FMS is myofascial pain syndrome (MPS). MPS
is caused by myofascial trigger points. Trigger points are tender
points that refer pain to other areas when pressed. They present
as contracted knots or tight bands. Trigger points can be caused by
surgeries and injuries (such as repetitive motion trauma), joint problems,
viral infections and the cold. When a muscle with a trigger point
is worked too hard, a secondary trigger point can develop. When trigger
points spread throughout the body, MPS may become chronic.
can be active or latent. Active trigger points may be sensitive to
palpation, but the pain is felt at a distal site (referred pain).
Active trigger points hurt when the involved muscle is used, and very
active trigger points can hurt when the muscle is at rest. Only when
pressed, do latent trigger points hurt. Latent trigger points can
contribute to muscle shortening and weakness, causing restricted movement.
Latent trigger points can also become active when the involved muscles
are overstretched or overused. Devin Starlanyl, M. D., in her Fibromyalgia/Myofascial
Pain Syndrome Handout (1994), says that muscles with latent trigger
points give out when stressed.
trigger points includes most of the treatments listed for PFD . Trigger
point therapy, injections of numbing agents such as lidocaine or procaine
into the site, are often used. Anesthetics make it possible for a
therapist to stretch the sore muscle or group of muscles without hurting
the patient. Muscles are also loosened with a technique called "spray
and stretch." The cold spray numbs the muscles and allows them
to be painlessly stretched in order to regain their range of motion.
These treatments are offered at physical therapy clinics that work
with FMS patients. Improvement can last for weeks, or even months.
However, IC patients who suffer with chemical sensitivity may be sensitive
to the cold spray. IC patients should also probably avoid numbing
injections that contain epinephrine, which can set off bladder spasms.
Which Muscles Are Most
The postural muscles
of the body are most affected by trigger points, which occur in the
neck, the scapula (the wing bone), the soft tissue of the thoracic
and lumbar spine (the ribs and low back) and the sacroiliac joint
(where the sacrum, the triangular composite bone at the bottom of
the spine, meets the ilium, the hip bone).
THE NECK AND
SHOULDERS (see the graphics below)
is an important muscle for rotation, flexion and extension of the
head. According to Dr. Starlanyl, trigger points in the sternocleidomastoid
muscle can cause FMS patients to suffer with chronic runny noses and
sinus infections. Dr. Starlanyl theorizes that this is a mechanical
problem that happens during sleep, when stuffiness in the nose moves
from side to side while rolling side to side. As a result, the post-nasal
drip runs down the back of the throat and makes patients susceptible
to sinus infections.
caused by trigger points in the sternocleidomastoid muscle are deep
ear pain and/or stuffiness in the ear, and migraine headaches. Cold
drafts can cause trigger points to occur in this muscle.
rotates the scapula upward during shoulder and arm movements, such
as lifting with the hands or holding an object overhead. This large
muscle covers the area up and down, and between the spine of the scapula
and the spinal column. The trapezius originates at the base of the
skull. Trigger points for migraines are located in the upper trapezius.
muscle attaches the scapula with the arm. Like the trapezius, it is
a leverage muscle. It is effective in fixing the scapula when bringing
the arm from a position straight out in front of
the body to a position straight out to the side. It is also used when
drawing the arm from a position straight out in front of the body
down to the side of the body.
The splenius cervicis arises with the semispinalis from the thoracic
spine, and is one of the "bandage muscles" that extends
and rotates the head in concert with the opposite sternocleidomastoid
capitus is also a deep muscle of the back that extends and rotates
the head (side to side) and the spinal column. Both the splenius cervicis
and the semispinalis capitus serve to stabilize the bones of the spinal
column. They influence posture, flexion and extension of the spine.
*The neck area
is vulnerable for sympathetic nerve injury and trauma. Injury (such
as whiplash) and trauma to the neck can lead to FMS and trigger points.
is a deep muscle that attaches the back of the iliac crest (where
your thumbs rest when you put your hands on your hips) to the bottom
back rib. This muscle is used when bending over forward, or to the
side to lift an object or scrub a tub. If the 12th rib (bottom rib)
is tender from trigger points it may contribute to pleuretic symptoms.
Muscle pain in the quadratus is sometimes confused with kidney pain,
abdominal or lung problems.
on the gluteus medius see our May column.
Gaye is an author and IC patient & support group leader who
has been involved in IC work for years. In 1990 she published
"Stretch Into a Better Shape" and produced a stretching
and exercise video for IC patients in 1993. She is a specialist
in Aston-Patterning movement and muscle re-education.
over ten years of clinical and health care management position.
He is currently the Administrator of Maison Hospitaliere, located
in New Orleans. Andrew holds a Ph.D. in Special Education, a
M.A. of Health Adminstration, M.A. of Clinical Psychology.
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