What is the pelvic floor? Are the pelvic floor and pelvic diaphragm the same thing? What causes weak pelvic floor muscles? Whether the terms pelvic floor and pelvic diaphragm are new to you or you have known issues in this area, this blog will address all your questions including those regarding pelvic floor therapy and treatment.

What is the difference between Pelvic Floor and Pelvic Diaphragm?

Let’s start with differentiating between the pelvic floor and pelvic diaphragm. Some use these terms interchangeably, but for the purposes of this blog, we will separate them. To understand these structures requires a mini anatomy lesson, but I won’t get too geeky, promise. 

The internal portion of the pelvis is lined with muscles and ligaments that play a role in postural stabilization and physiological breathing. These soft tissue structures make up your pelvic floor. The pelvic floor consists of the pelvic diaphragm, perineal membrane, and deep perineal pouch. The pelvic diaphragm is only the levator ani and coccygeous muscles portion.

pelvic floor therapypelvic floor dysfunction

These muscles that form a bowl shape, help support the organs that sit inside your pelvis (which differ between men and women) and play a role in urinary and fecal incontinence. Specifically, in women this area is very important in pregnancy as I’m sure you can imagine! Both the pelvic floor and pelvic diaphragm are essential to our posture, stabilization, and breathing. Failure in the integrity of this structure leads to not only specific organ issues but injuries and pain in the musculoskeletal system of the body.

Why Do Pelvic Floor Muscles Weaken?

If you have pelvic floor issues then one of two things can be happening: either these muscles are too tight or under-activated but both scenarios lead to weakness in the area. Being overweight, failed postural presentations, sedentary lifestyle, injury doing certain exercises (such as weight lifting, planks, and lunges), running with a weak pelvic diaphragm, and childbirth are the main culprits that lead to patient visits in my practice.

Just as with any muscle, underuse leads to decrease muscle strength and tone. In our society, our sedentary lifestyle is the major cause of this instability as it impacts the posture from what we can see on the surface to a much deeper level that shows up in functional movement assessment.

Your pelvic floor is designed to function as part of your internal stabilizing system and works along with the abdominal diaphragm and the abdominal wall muscles. When you sit behind a computer all day, this system is not active because you end up slouching and compressing not only the abdominal diaphragm but both the pelvic floor and the pelvic diaphragm. In order to stabilize the posture and produce effective breathing, the abdominal diaphragm needs to be parallel to the pelvic floor and diaphragm. So when you slouch or do the opposite, which is a military posture with your chest sticking out, the abdominal and pelvic diaphragm are no longer parallel to each other and that is the beginning of the problem. Just for the record, there are 3 diaphragms that are crucial in the posture and proper function of the body. They are explained in this video in more detail.

The same goes for being overweight and pregnant. In both cases, excess weight in the abdominal region pulls the pelvis into an anterior pelvic tilt along with it go the pelvic floors muscles.This weakness in abdominals and pelvic floor prevent you from keeping the pelvic region in a more neutral position so with the bulging tummy comes the arching of the lower back. Since resuming this position is not easy long term and the body gets tired, the alternative is when the center of gravity is pushed forward and the lower back arches as if you have a hunched lower back. Either scenario disallows the neutral spine and the end result is the diaphragms are not stacked on top of each other and parallel to the ground.

posture correction

What is the role of Pelvic Floor in Pregnancy and Enlarged Prostate?

Now for the ladies specifically, pregnancy can be a bit taxing in this area, and some delivery methods can be traumatizing especially if forceps and c-section are the choices! Just carrying a baby will impact the integrity of the pelvic floor muscles due to the increased downward pressure as well as the increase in the lower back curvature; the more the baby grows upward and outward, the more the diaphragm is prevented from fully descending, and the more the breathing and stabilization are compromised.

In the case of complications in which forceps are used or c-section, the actual muscle tissue can be damaged. This type of injury may require alternative treatment after childbirth and pelvic floor therapies are now more popular than ever before.

In the case of an enlarged prostate, the bigger mass imposes on the pelvic diaphragm and pelvic floor internally causing frequent urination and interference with the function of the prostate gland itself. This situation goes with the enlargement of any organs situated within the pelvic inlet specifically and indirectly by those organs above the area.

What is Pelvic Floor Therapy?

Pelvic floor therapy is a term that has become a little more popular over the years. Pelvic floor therapy can be done internally or externally.

Internal as you can guess is where a therapist will manually work on the pelvic floor muscles from inside the vagina and/or anus.  Many patients are not comfortable with this approach but it may be the best choice of treatment for the muscles that are damaged. This may not be necessary in many cases, and alone will not restore functional movement, but can be helpful.

In the case of an enlarged prostate, working through the anus to address the soft tissue surrounding the prostate and massaging the prostate itself leads to a more relaxed muscle tone and a decrease in the symptoms. Once again, this is an adjunct therapy and does not address the pelvic diaphragm.

The traditional form of pelvic floor therapy on the other hand is typically done by a rehab specialist such as a physical therapist or a chiropractor that specialize in this type of work. Exercises such as Kegal’s are what you may be familiar with; Kegel is not intended to be a vagina exercise but a pelvic floor exercise, therefore, it is recommended for both men and women.

There are medical devices such as Emsella machine that is an FDA chair with electromagnetic energy focusing on the muscles of the pelvic floor and cause 400 kegel contractions per minute. Amazing tool that I find helpful and therefore have at my clinic. The issue I have is to rely on the machine as the soul ‘do-er’ of the job. That is a part-solution. Read on to see why?!

Emsella Chair

Pelvic Floor Dysfunction and Emsella Chair

Your body is designed to function with all the muscles and joints working together in a harmonious pattern to create movement. So no one muscle or joint works in isolation, yet in the rehabilitation of the many body parts, we see treatments isolated to the area of complaint. This is why so many treatments are unsuccessful, or only providing relief for a short period of time. The truth is that when one area of the body is not functioning properly, all the other areas are affected as well. Treating only the area of dysfunction works well but not long term because the ‘feeders’ of the problem are still existing.  What I just described is known as Functional Movement and is discussed in full detail in the video below.  

If functional stability of the pelvic floor is the issue then a kegel (isolated exercise) is not going to help the issue. 

The role of Breathing in Pelvic Floor Dysfunction

The sign of life, once we are born, is that first breath we take, so it’s safe to say breathing is pretty important and something you want to make sure is done efficiently. Unfortunately, just about everyone is breathing incorrectly which means their pelvic floor is not active! It is clear that we are all alive but it is a matter of function vs dysfunction, ideal vs ‘good enough’. The latter leads to pain, a decrease in quality of life, and interference with the things we enjoy doing.

Proper breathing is like creating a barrel with the pelvic floor serving as the bottom of the barrel and the abdominal diaphragm being the top. The sides of the barrel are the front, sides, and the back of your torso between the two diaphragms. Take the time to watch the video below because it is absolutely crucial for you to understand this mechanism regardless of the reason why you are reading this blog.

This system not only serves a purpose in breathing, but also in stabilization and the pelvic floor plays a vital role. You cannot have a strong pelvic floor without a strong pelvic diaphragm and THAT is being missed in the treatment of the related issues and the issues that typically are not looked at as a related issue.

Aside from injuries directly affecting the pelvic floor and diaphragm, our lifestyle is a HUGE negative contributor to the pelvic floor and diaphragm. As seen in the video above, the signaling between the vocal, abdominal, and pelvic diaphragm is crucial in not only stabilization but breathing. Clearly, despite our postural decline, we are staying alive so something else has to initiate that signaling; that something else is typically the neck muscles in the front. When this way of signaling becomes your default method, the pelvic floor and diaphragm are not used properly, and remember at the beginning of this blog I said lack of use or overuse leads to weakness. Now you have on your hand a dysfunctional diaphragm, leading to dysfunctional movement at every level. From this point on, every pain and injury becomes a fair game!

Think back to the many times you have had issues with your joints and muscles, injuries or pain; think of the many times you or someone you know has had issues with bladder, uterus, ovaries, and/or prostate issues. Why is it that the first line of assessment and treatment is not the pelvic diaphragm and breathing? It makes no sense to me as it can save lost time and resources, maintain quality of life and relationships.

The effective and the most successful method of treatment in most of these cases is to assess the integrity of the 3 diaphragms in breathing and the functional movement neither of which is new to you but a long last resource that you were using so well at the beginning of your life. This is not teaching you something new but ‘reminding’ your nervous system how it once was.

The blueprint of movement is something you are born with and through Brain based Neurology and Postural assessment, the map of the brain when it comes to movement, sensation, and stabilization, called homunculus, is evaluated. With Functional movement methods such as Dynamic Neuromuscular Stabilization (DNS) the coordination of functionality of each body part is compared to how we all moved as babies and any deviation from that is a signal for grounds of dysfunction. The very basic of DNS is the pelvic floor and pelvic diaphragm function and the first system established in the proper breathing system.

Can Pelvic Floor Dysfunction cause Lower Back Pain?

Earlier we discussed how the entire body is connected and functions as a whole rather than each area in isolation. Each section has its role to play and job to do, so if one group of muscles is no longer doing its job, because of your lifestyle of let’s say sitting, the job of that muscle group must still be done. This means that the task of the failed area gets assigned to an alternative muscle or group of muscles. This is how pathological or dysfunctional movement patterns are developed

While I am using the example of Lower back here given that lower back pain is the leading cause of pain among all muscles and joints, the dysfunction applies to headaches, pain between shoulder blades, shoulder, hip, knee and ankle pains as well. Dysfunctional movement can occur in every part of your body that is a part of musculo-skeletal system.

When for whatever reason you are not engaging the pelvic diaphragm,  the pelvic floor function is compromised. This is the base of your spine, your ‘backbone’ your yoga chakra, where your body is stabilized over your legs! Any dysfunction in the movement of the legs and stabilization of the lower part of the torso, below the abdominal diaphragm leads to undue excess stress in the supportive structures. If in this example, the lower back muscles are the only true supporters of the lower body, then it is similar to you doing most of the departments’ tasks with hardly any support. Add the time value to this and you can easily imagine how overwhelmed you would get. No wonder there is a nagging pain in the lower back, there is a pain in running or performing your sport, there is sleep disturbance and lack of energy. The list goes on and on!

If you have had chronic musculoskeletal and postural issues and some treatments work but are short term, look into the pelvic diaphragm and functional movement and don’t think internal pelvic floor therapy is the long term solution.

To learn more about this type of rehab and why it works visit my Website for more information and check out the rest of my Youtube Channel for some great exercises and Ergonomic Tips to lessen the damage done.

Dr. Shakib