Pelvic floor pain, Why is this happening?

The Female Pelvic floor is an internal group of muscles which lie at the base of the pelvis, attaching from the pubic bone to the sacrum. These sit like a hammock, supporting key structures such as the pelvic organs, including the uterus, ovaries, fallopian tubes, bladder and rectum. Pelvic Floor Exercises should be completed regularly to strengthen your pelvic floor muscles and control your pelvic organs.

The Pelvic Floor Muscles should work subconsciously to support the pelvic organs, for example when standing, walking and doing higher impact activities, such as running. However, it is very common to experience pelvic floor weakness.

These muscles tighten to control the bladder and bowel, and relax to pass urine or stool, and during vaginal childbirth (POGP, 2020).

It is common to experience pain in the pelvic floor for a variety of reasons, such as pregnancy, vaginal delivery, sexual intercourse, hypertonic (tight) muscles or due to weakness.

The causes and types of pelvic floor dysfunction

Pelvic floor dysfunction is a condition which affects the ability of the pelvic floor muscles to work at full capacity and control (NICE, 2021). The symptoms of pelvic floor dysfunction may involve:

• Urinary incontinence
• Difficulty emptying the bladder
• Fecal incontinence
• Constipation
• Pelvic Organ Prolapse
• Hypertonic pelvic floor
• Sexual dysfunction
• Chronic pelvic pain

The most common causes of pelvic floor dysfunction include; pregnancy, assisted vaginal delivery, 3rd-4th degree tears during vaginal delivery, multiparity, constipation and chronic respiratory disease.

Repetitive high impact activity and exercise can also increase the load upon the pelvic floor muscles meaning strength work is imperative to prevent problems.

Urinary incontinence

Urinary incontinence affects bladder control which can lead to unintentional leakage. The main types are:

• Stress Urinary Incontinence
• Urge Urinary Incontinence
• Mixed Urinary Incontinence

The first is experienced most commonly on impact such as coughing, sneezing, laughing and jumping. This can be very common when running due to the constant impact and pressure on the bladder.

The second is experienced rather suddenly and may feel like an overwhelming sensation to empty your bladder, which often occurs at night.Mixed Urinary Incontinence is a combination of the above (NICE, 2019).

Pelvic pain

You can read a lot around the pelvic floor being too ‘weak’ and not engaging enough. You may not have heard as much around the pelvic floor being too ‘tight’ or hypertonic. This means that your muscles are in a state of overload and spasm, which creates muscle tightness and pain (Cleveland Clinic, 2023).

The pelvic floor muscle group is a region often missed when it comes to strength work and exercising.

It is often thought that your muscles may only be painful if they are too tight, and therefore they must be strong. However, if your muscles are not being specifically loaded and strengthened (often in the pelvic floor) these become overloaded, weak and tight leading to pain. This may present as an ache or cramping sensation around the pelvis, deep within the buttocks and the pelvic floor.

Urinary incontinence

Urinary incontinence affects bladder control which can lead to unintentional leakage. The main types are:

• Stress Urinary Incontinence
• Urge Urinary Incontinence
• Mixed Urinary Incontinence

The first is experienced most commonly on impact such as coughing, sneezing, laughing and jumping. This can be very common when running due to the constant impact and pressure on the bladder.

The second is experienced rather suddenly and may feel like an overwhelming sensation to empty your bladder, which often occurs at night.Mixed Urinary Incontinence is a combination of the above (NICE, 2019).

Pelvic pain

You can read a lot around the pelvic floor being too ‘weak’ and not engaging enough. You may not have heard as much around the pelvic floor being too ‘tight’ or hypertonic. This means that your muscles are in a state of overload and spasm, which creates muscle tightness and pain (Cleveland Clinic, 2023).

The pelvic floor muscle group is a region often missed when it comes to strength work and exercising.

It is often thought that your muscles may only be painful if they are too tight, and therefore they must be strong. However, if your muscles are not being specifically loaded and strengthened (often in the pelvic floor) these become overloaded, weak and tight leading to pain. This may present as an ache or cramping sensation around the pelvis, deep within the buttocks and the pelvic floor.

Constipation

Constipation may occur due to altered bowel health, which can increase the pressure on the pelvic floor. It can also make you feel bloated, sore and fatigued around your abdomen. This can be caused by a poor diet which lacks fiber, dehydration, lack of exercise and poor toilet habits. It is very important not to strain as this can repeatedly weaken the pelvic floor from the prolonged pushing (POGP, 2020).

Difficulty starting or stopping urination

A healthy bladder can hold up to 400ml of urine and normally you will visit the toilet between 5-8 times per day. As you age, and with a weaker pelvic floor, you may need to go to the toilet through the night, which is known as nocturia (POGP, 2020).

Pelvic floor weakness and bladder irritants, such as caffeine, fizzy drinks and tobacco, can worsen bladder health, which may lead to incomplete emptying of the bladder with a lack of control.

You may feel the need to strain to start the flow of urine, or notice a dribble of urine which continues after you have stopped and wiped. This can be due to holding on too long, therefore the pelvic floor muscles have not relaxed enough. There is also a link to weakness, stress and poor bowel habits (POGP, 2020).

Reduced sexual sensation

An overactive, tight pelvic floor can cause painful penetration, as these muscles are in a state of spasm. Your symptoms may be heightened due to childbirth, prolapse and endometriosis.

Why do you have Pelvic pain when running?

When you run, you carry around 2-3 times your body weight. Breathing rate increases, there is a wider expansion of your ribcage, further engagement of your diaphragm and therefore pressure on your abdominals and pelvic floor. Your pelvic floor must contract and prevent any bearing down due to the additional load. This prevents stress urinary incontinence, for example.

It is common to experience symptoms such as incontinence when running. However, you may experience other symptoms which highlight pelvic floor dysfunction. A sign of a hypertonic pelvic floor is experiencing deep, internal pelvic pain, after running. Females often describe this likeness to menstrual cramps. You may also experience pain and tightness around the hip muscles, such as the glutes, piriformis, adductors and coccygeus (Continence Foundation of Australia, 2021).

Marathon training plans can include around 4 runs weekly alongside lower limb resistance training. Distance continues to increase over the training period and pain can worsen alongside this, if you are not doing the specific pelvic floor strength and stretching exercises.

To diagnose a hypertonic pelvic floor, it is key to visit a Pelvic Health Physiotherapist. After taking your subjective history and learning about your origin and description of pain, the Physiotherapist can do objective testing to identify the likely diagnosis. This may involve an internal pelvic floor assessment when 1-2 fingers are inserted into the vagina to assess the tone of the pelvic floor muscles. This is a quick, yet thorough examination. There may be a slight provocation of your pain during this assessment, as the hypertonic pelvic floor muscles can hold trigger points, like muscle knots, which can create pain. This is a great way to start treatment for the pelvic floor, which can be done via various manual techniques.

Pelvic floor exercises for runners

It is important to learn techniques and exercises which can reduce pelvic pain when running. This will enhance your training and help to manage pain. This can be completed as part of your strength program and alongside stretching/relaxation. Depending on your symptoms and examination, there are various exercises and stretches you can work on.

If you have a hypertonic, overactive pelvic floor, it would be beneficial for you to start with relaxation of your pelvis, abdomen and hip muscles. You can release your pelvic floor muscles manually and via stretching.

If you have a hypertonic, weak pelvic floor, it is necessary to use the above stretching, alongside further strength work to prevent symptoms of pelvic floor dysfunction.

Diaphragmatic breathing

To encourage relaxation of the diaphragm, lower abdominals and pelvic floor. Find a comfortable space and lie down with your legs straight or knees bent with your legs falling out to the side. Place your hands on your stomach and inhale for 4 seconds to feel your stomach rise up to the ceiling, hold this breath for 7 seconds, then exhale for 8 seconds. The idea is to relax your upper body and focus on controlling your diaphragm, alongside relaxation of your abdomen and pelvic floor. Repeat x4.

Fascia ball release

You can use a fascia ball to release pelvic floor tightness. You get a medium sized fascia ball and sit on this for 1-3 minutes, relaxing into the ball. When you then stand up, you should feel lighter and a ‘lift’ off your pelvic floor.

You can also use a trigger point ball to release your glute and hip muscles, for around 2-3 minutes per side.

Pelvic floor strengthening

Pelvic floor muscle strengthening should be tailored to the individual if you are experiencing symptoms of pelvic floor dysfunction. For general strengthening alongside a running program, it is important to strengthen your fast and slow twitch muscle fibers. You want to start your exercises in a comfortable position, such as on your back with your knees bent, or sitting.

• Fast contractions can be completed at a count of 1, engaging your pelvic floor and feeling a lift from your back to front passage, then releasing completely. Completing around 10-20 repetitions in one go, up to three times per day.
• Slow contractions can be completed by engaging your pelvic floor and holding this contraction for up to 10 seconds, relaxing completely for 4-5 seconds and repeating until fatigue of up to 10 repetitions.

Form is extremely important and you do not want to be holding your breath, squeezing your glutes or legs and you should start at a slower pace if this is the case.

Hip and glute strengthening

Pelvic strengthening is imperative for pelvic floor support in a running regime, with a focus on lower abdominals, glutes and single leg weight-bearing exercises such as:

• Glute bridges 3 sets of 15-20
• Single leg glute bridges 3 sets of 8-12
• Abdominal deadbugs 3 sets of 10-12
• Lunges with a rotational twist 3 sets of 10-15
• Single leg squats 3 sets of 10-12

Summary

To conclude, pelvic floor dysfunction is highly prevalent in the female population. These symptoms can be heightened during high impact activity and running training regimes.

Although pelvic floor dysfunction and pain is common, it is not something you should have to live with. You can be given tools to reduce this pain and prevent aggravation in the future.

A hypertonic pelvic floor is common when running as there is an increased load placed upon the body at a weekly rate. Your muscles have to keep up with the increased demand which creates overload, tightness and pain.

Seeing a Pelvic Health Physiotherapist can help fully assess your symptoms, guide your recovery and issue you a subjective relaxation and strengthening pelvic floor program.

References

Introduction
(POGP, 2020):
Reed, P., Mann, K. and Osborne, L.A., 2020. Pelvic floor muscle training services across the UK: a
benchmarking survey of POGP members. J Pelvic Obstetr Gynaecol Physiotherapy, 126(Spring),
pp.49-57.

The causes and types of pelvic floor dysfunction
(NICE, 2021):
guideline NG210, N.I.C.E., 2021. Pelvic floor dysfunction: prevention and non-surgical management.

Urinary Incontinence
(NICE, 2019):
guideline NG123, N.I.C.E., 2019. Urinary incontinence and pelvic organ prolapse in women:
management.

Pelvic Pain
(Cleveland Clinic, n.d.)
Cleveland Clinic. (n.d.). Hypertonic Pelvic Floor: Symptoms, Causes & Treatment.[online] Available at: https://my.clevelandclinic.org/health/diseases/22870-hypertonic-
pelvic-floor.

Constipation
(POGP, 2020)
thepogp.co.uk. (n.d.). Bowel Health. [online] Available at:
https://thepogp.co.uk/patients/pelvic_health_advice/bowel_health.aspx

Difficulty starting or stopping urination
(POGP, 2020)
thepogp.co.uk. (n.d.). Healthy Bladder. [online] Available at:
https://thepogp.co.uk/patients/pelvic_health_advice/healthy_bladder.aspx

Why do you have pelvic floor pain when running?
(Continence Foundation of Australia, 2021)
Continence Foundation of Australia. (n.d.). Pelvic floor. [online] Available at:
https://www.continence.org.au/about-continence/continence-health/pelvic-