The Most Common Functional Disorders and Factors Affecting Female Pelvic Floor

Abstract

The pelvic floor (PF) is made of muscles, ligaments, and fascia, which ensure organ statics, maintain muscle tone, and are involved in contractions. This review describes the myofascial relationships of PF with other parts of the body that determine the proper functions of PF, and also provides insight into PF disorders and the factors contributing to them. PF plays an important role in continence, pelvic support, micturition, defecation, sexual function, childbirth, and locomotion, as well as in stabilizing body posture and breathing, and cooperates with the diaphragm and postural muscles. In addition, PF associates with distant parts of the body, such as the feet and neck, through myofascial connections. Due to tissue continuity, functional disorders of muscles, ligaments, and fascia, even in the areas that are distant from PF, will lead to PF disorders, including urinary incontinence, fecal incontinence, prolapse, sexual dysfunction, and pain. Dysfunctions of PF will also affect the rest of the body.

Keywords: incontinence; myofascial; pelvic floor; pelvic floor disorders; risk factors.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 2

DeLancey’s three levels of vaginal support. The graphic shows a top view of PF with the levels of uterine support. The levator ani acts as an active sustaining component [10,11]. This muscle, particularly puborectalis, which is one of its parts, not only supports the vagina but also keeps the stool continent. The puborectalis muscle forms the Parks angle (Figure 3) or anorectal angle, by wrapping between the rectum and the anus [12].

Figure 1

Layers of PFM: (A) superficial PF, (B) middle PF, and (C) deep PF. 1—Ischiocavernosus muscle; 2—sphincter ani externus muscle; 3—bulbospongiosus muscle; 4—deep transverse perineal muscle; 5—superficial transverse perineal muscle; 6—puborectalis muscle; 7—pubococcygeus; 8—iliococcygeus.

Figure 3

Parks angle. Depending on the position of the body, the puborectalis muscle creates different anorectal angles. In the standing position, the muscle forms an acute angle, ensuring continence, while when passing stools, the angle between the anus and rectum increases to approximately 110–130°, due to the squatting position. As shown in the graphic, the sitting position does not allow for complete relaxation of the puborectalis muscle.

Figure 4

Graphic presentation of the functions of the diaphragm and PF during breathing. (A) The diagram shows the inhalation, concentric diaphragm function (blue arrow), and eccentric PFM function (gray arrow) (B).

Figure 5

Relationship of PF with other structures and their functions. (I) The figure depicts the cooperation of PF with the diaphragm. PF works together with the diaphragm and takes part in respiration. During inhalation (a), the diaphragm descends caudally, as does PF, whereas during exhalation (b), the diaphragm relaxes and becomes cephalic and the PF contracts. This allows maintaining optimal intra-abdominal pressure [8,15,22]. Any disturbance in the synchronicity of the diaphragm and PF will result in pressure changes and subsequently dysfunction of other areas (e.g., disturbances in peritoneal drainage or postural stability) [21,25]. (II) The figure depicts the role of PF in stabilizing the body posture. PF together with postural muscles, such as abdominal, gluteal, and multifidus muscles, ensures proper stabilization. Its activity is influenced by the tension of the other core muscles. PF is also connected to the trunk by the transversalis and thoracolumbar fascia [19,20,21,22,23,24]. Myofascial disorders in this complex can change the PF tension and result in painful menstruation or intestinal disorders leading to chronic constipation. However, primary dysfunction of the PF will lead to disturbances in the entire pelvic–lumbar complex, affecting the stabilization and body posture [21,25]. (III,IV) The figure depicts that proper functioning of the PF is also influenced by the myofascial connections with the extremities. PF is connected to the lower extremity by a fascia associated with the gluteal muscles and the internal obturator muscle. These muscles control the actions of the hip joint, and thus regulate the biomechanics of the lower limb. Abnormal tension in the buttock area will disturb the movements of the hip joint, causing changes in the mechanic load on the lower limb and locomotion. Additionally, dysfunction of the hip joint and the entire lower limb will predispose to PF disorders [8,18,24]. As the gluteal muscles also play a role in postural stability, disturbances in stabilization will also lead to disorders of these muscles. PF is connected to the upper limb complex as well as the cervical spine and face through the following fascia: transversalis, mediastinal, and cervical. Therefore, disorders in this myofascial tract may lead to dysfunctions of the upper limb and diaphragm and also bruxism [8,21,25].

Figure 6

The most common PFD among women.

Figure 7

Functions of PF, and factors affecting PF.