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31.05.2014, admin  
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The pelvic floor is an area on the body that is so frequently skipped over by the sports medicine community. The reason why the pelvic floor is more problematic in the female athlete compared to the male athlete is due to stress urinary incontinence. Many female athletes present to my office with complaints of pain in the pelvic floor area and have been told they have strained their groin or hamstring muscles. It has been well documented with ultrasonography of the pelvic floor musculature in female gymnasts by Kruger et al (2007) that athletes can adapt to training loads by increasing the hypertrophy of the pelvic floor muscles. Another concern that I have with this issue is athletes avoiding to hydrate well since they are concerned about urinary leakage during their practices and competitions. Overall, the pelvic floor area is important to be investigated with female athletes that present with pelvic pain, low back pain, high hamstring strains, adductor strains and athletes with urinary stress incontinence.
The treatment of injury and incontinence begins with discussing the role of the pelvic floor and its function in their sport. First identify the pelvic floor muscles (urinate and stop), empty the bladder and sit or lie down. Quicker contractions lasting only 2 seconds and relaxing and then repeating 3 sets of 10 can also be done.
Studies have shown that the transversus abdominis muscle are co-activated with the pelvic floor. Learn to perform this pelvic floor activation at rest and then build up the activity to increase the forces on the pelvic floor. If they have difficulty activating the pelvic floor then feedback by using ultrasonography and allowing the athlete to watch the monitor and seeing the muscles contract properly may be very beneficial.
When my daughter was 5 she had an operation for a urethral prolapse (we are black, this is relevant because this condition mainly occurs in black or hyspanic children ).
The pubic symphysis is a cartilagenous joint which consists of a fibrocartilagneous interpubic disc [1][6][5][7] (which had transversal and helical fibers) and the surrounding ligaments uniting the bodies of the pubic bones in the median plane. Symphysis pubic dysfunction is a condition that causes excessive movement of the pubic symphysis in the anterior or lateral direction and causes pain.[14] Both factors are possibly due to a misalignment of the pelvis. As in all dysfunctions, an early diagnosis is important to minimize the possibility of a long term problem.
Tenderness over the symphysis pubis and the sacroilliac joints are the most common clinical signs.
Palpate the anterior surface of the symphysis pubis, when the woman lies on her back, the test is positive when the pain persists for more than 5 seconds after removal of the hand.[1](se=60%, sp=99%and i-er=0,89 Kappa coefficient).
When standing on one leg the woman isn’t able to maintain the pelvis in a horizontal plane and the opposite buttocks drops.
A Patrick’s FABER sign: the examiner holds one illiac spine in a flexed position, the woman is in a supine position, then she places her heel on the heterolateral knee with the leg falling passively outwards. As a physiotherapist you can give some advice to use the body in daily life, back care and to avoid activities that put undue strain on the pelvis.
Avoid squatting, strenuous exercises, prolonged standing, lifting and carrying, stepping over things, twisting movements of the body, vacuum cleaning and stretching exercises! There is no evidence that caesarean is beneficial for women with symphysis pubic dysfunction. In the next table you can find some information of the levels of evidence of the used information to create this page on physio-pedia.
Learn about the shoulder in this month's Physiopedia Plus learn topic with 5 chapters from textbooks such as Magee's Orthopedic Physical Assessment, 2014 & Donatelli's Physical therapy of the shoulder 2012.
Hover your cursor over citation numbers to view the source in a pop-up text box or scroll to the bottom of the page for the full list.
Exercises for the pelvic floor with a focus on these two muscles have proven to be very beneficial for ED.
My pelvic floor work will help you become aware of these muscles, including the Bulbospongiosus and Ischiocavernosus.
Learning to relax the muscles of the pelvic floor is a key goal for those experiencing painful ejaculation.
La Pera and Nicastro evaluated treatment for premature ejaculation using a protocol to strengthen the pelvic floor muscles and increase conscious control. Frank Sommer, in his book VigorRobic, writes that "Men suffering from early ejaculations can delay these with the help of targeted training of the pelvic diaphragm [pelvic floor muscles]. The first step in gaining control of an area is awareness, and pelvic floor massage and bodywork is an excellent way to accomplish this. The muscles of the pelvic floor can create or refer discomfort or pain that can be felt anywhere in the penis - the base, shaft, tip, or in the urethra. These muscles, plus the Rectus Abdominis muscle in the abdomen [12] can also cause irritation or pain in the urethra. In most cases of discomfort or pain in the penis caused by muscles, excess tension and the development of trigger points are the main mechanisms through which these problems occur. Various terms are used to describe this little understood condition, including chronic scrotal pain, scrotal pain syndrome, chronic testicular pain, and testicular pain syndrome. Referred pain and an overactive, tight pelvic floor may be significant factors in the generation of scrotal pain. Beyond the role of the pelvic floor, there are muscles outside of the pelvis which can refer pain to the scrotum.
Given the high tone and overactivity of the pelvic floor often reported in cases of chronic scrotal pain, as well as the documented ability of certain muscles to refer pain to the scrotum, massage and bodywork can be an effective approach to this condition.

The term dyspareunia is defined as the occurence of pain during sexual intercourse, and it is almost always associated with women. One component of male dyspareunia can be muscular tightness in the pelvic floor and a lack of conscious control.
Even when there are no issues with performing the physical act of engaging in sex, when pelvic pain is present, there will be diminished appreciation and pleasure from the experience. Research literature is increasingly confirming the important role of the pelvic floor muscles in sexual health and dysfunction.
It is important to bear in mind that pelvic floor exercises require motivation, consistency, and a commitment of time. NOTE: For those men who do not live in Northern California and are unable to travel here, I offer consultations via phone. Pelvic floor anatomy graphics created with Inkscape, a free and open source graphics software program. Thyssen et al (2002) found in the female athlete that 56% of gymnasts, 43% of ballet dancers, 40% or aerobic athletes, 31% of badminton athletes, and 30% of volleyball athletes had stress urinary incontinence. Research has highlighted the role of the pelvic floor in stability of the lumbar spine and pelvis. Obviously, this can have negative effects on the performance and muscular function of the athletes if they do not hydrate well. Contract the pelvic floor muscles, hold the contraction for 10 seconds and repeat 3 sets of 10 and repeat 5 times a day at least. For example, have the athlete learn to do the contractions while sitting, standing, walking, jogging, and jumping. The range of hip motion (abduction and external rotation) could be limited in function of the pain.[1]This loss of abduction function can give a waddling gait. This is also known as Trendelenburg’s sign.[1] (se=60%, sp=99% and i-er= 0,63 kappa coefficient). This test is positive when there is a pain in the sacroilliac joint.[1](se=40%, sp=99%, i-er= 0,54 kappa coefficient).
People with pubic symphysis dysfunction use elbow crutches (grade of evidence A)[1][3][16], pelvic-support devices (grade of evidence A) [17][5][7] (although often used there is no published evidence for their efficacy)[1] and prescribed pain reliefs (be careful taking NSAIDS while pregnant)[1].
Women with pubic symphysis dysfunction should give birth in an upright position, with knees slightly open. Kegel's) from early pregnancy are supposed to reduce the risk to develop symphysis pubic dysfunction. In the first column you can see the name of the author of the resource, in the next you can read the level of evidence and in the last you can find the grades of evidence. Physiopedia is not a substitute for professional advice or expert medical services from a qualified healthcare provider. The relevance of the pelvic floor muscles is discussed in each section, as well as the role that massage and bodywork, pelvic floor muscle exercises, or both can play in improving these conditions.
The physical process of erection is largely a circulatory event, initiated and assisted by the nervous system.
You will learn how to contract the entire pelvic floor with an emphasis on these two muscles, and I will give you a home exercise protocol for improving strength and tone.
My massage and bodywork approach is to help you do this by gently engaging and stretching these muscles to address tension and return to normal tone and function. Awareness includes learning where these muscles are, what they do, and how to consciously contract them in isolation. As is the case with painful ejaculation, it can be hard to grasp that there may be nothing wrong with the urethra itself when your mind is telling you it feels painful. Keoghane and Sullivan write that "Dysfunction of the pelvic floor muscles can lead to overactivity. These include the Internal and External Obliques in the abdomen, the Quadratus Lumborum in the low back, and sometimes the Gluteus Medius and Minimus which span the hip joint. Awareness is always the first step, and I will help you become aware of your tension and work with you to gently stretch and relax these muscles. However, a male version has been discussed in several papers and warrants further investigation. Massage and bodywork as well as pelvic floor exercises can play a significant role in managing or resolving dysfunction as noted in the above discussions, with a subsequent improvement in overall sexual function. For some men, greater strength will help you manage your symptoms better but may not fully resolve them. The Role of Pelvic Floor Physical Therapy in the Treatment of Pelvic and Genital Pain-Related Sexual Dysfunction. Treatment of Erectile Dysfunction by Perineal Exercise, Electroyographic Biofeedback, and Electrical Stimulation.
A Headache in the Pelvis: A New Understanding and Treatment for Chronic Pelvic Pain Syndromes, 6th ed.
Anodyspareunia in Men Who Have Sex with Men: Prevalence, Predictors, Consequences and the Development of DSM Diagnostic Criteria.
Over the past 35 years I have mainly worked with female athletes with the last 27 years as a part of the USA Gymnastics National Team Medical Staff.  During these past decades I have discovered that the pelvic floor is a common area of injury not only for the gymnast but for many other female athletes. Eliasson et al in 2002 and 2008 demonstrated that 80% of elite female athletes with a mean age of only 15y.o.
Start investigating the muscles of the pelvic floor and you may start finding that the hamstring is not the true source of the pain.  Start asking questions about urinary stress incontinence and you may start finding a correlation between athletes with persistent musculoskeletal pain of not only “high hamstring strains” but also of lumbago and you may find a correlation.

Dysfunction of the pelvic floor as evidenced by stress urinary incontinence could indicate poor lumbo-pelvic stability. When they have an understanding of the function, they are more motivated to treat the problem properly.  Education also may need to include the coaching staff. I also have them start every core exercise with setting the pelvic floor first then finish the activation of the abdominals and then and the gluteal muscles last. This is necessary to facilitate the delivery of the fetus.[1] With symphysis pubis dysfunction the joints become more relaxed and allow instability in the pelvic girdle. Therefore the mid-wife is the first who gets to know the complaints.[1] In recent years we can see an increased level of cases of pubic symphysis dysfunction.
Deep abdominal exercises increase the core stability and this prevents women to develop pelvic or back pain in pregnancy (grade of evidence A). Simply put, adequate blood must flow into the penis, and it must be trapped there to maintain rigidity. Beyond its specific influence on ED, a strong yet supple pelvic floor can enhance overall sexual response and the experience of pleasure. Sommer's book includes exercise protocols with clear graphics, but note that the translation from the original German has a few quirks [16]. A strength building exercise program can then be instituted to improve tone and function - and better ejaculatory control.
The authors describe symptoms as "a dull, throbbing, unilateral pain in the scrotum that may worsen throughout the day.
These anal muscles are continuous with other muscles of the pelvic floor, and contractions of them are, for most of us, inseparable from pelvic floor contractions. They are, however, easy to do, have no negative side effects, and can have beneficial effects in other areas such as core support and urinary integrity.
That being said, I think that the male athlete’s pelvic floor should not be overlooked too.
However, since females have a much shorter urethra compared to males, under stress, the female may have issues with urinary leakage.
By performing musculoskeletal diagnostic ultrasound and MRIs, damage to the pelvic floor musculature can be documented when trauma is suspected. I ask about stress urinary incontinence with all my athletes that present with these injuries and I have found that those that have been more resistant to recovery have a higher rate of urinary incontinence than those that do not have this complicating factor.
To allow proper hydration, the medical staff needs to educate the coaches to value of allowing their athletes to urinate several times during a practice and competition.
This emphasizes the importance of an individual treatment.[1] There are many other symptoms like a discomfort sense onto the front of the joint.
Pelvic muscle floor exercises can be progressed by starting off with a small number of repitions and gradually increasing the seconds to hold on a contraction. Maintaining good muscle tone and the ability to fully contract and relax these muscles improves sexual functioning and and enhances the perception of pleasure. This process is facilitated by the pelvic floor, especially the Bulbospongiosus (sometimes called Bulbocavernosus) and Ischiocavernosus muscles.
When no evidence of an infection can be found, muscular referral should be examined as a possible cause. The pain might radiate to the perineum and inner thigh and can be exacerbated by cycling and horse riding.
The same reciprocal relationship applies to relaxation, meaning that learning to relax the pelvic floor muscles will correspondingly relax the anus. Activities of running and jumping and other high impact activity to the body can create stress urinary incontinence.  So many female athletes have this issue, yet are hesitant to discuss this with anyone since they may feel embarrassed. This correlated with more challenging skills and increased leakage towards the end of a training session indicating reduced muscular endurance of the pelvic floor. Proper exercises are also beneficial so that the athlete has the kinesthetic awareness and control of the pelvic floor musculature. Another symptom is the ability to hear some click of the lower back, hip joints and saccroillial joints if the patients position changes.[14] Another symptom is the difficulty in some movements like the ab- and adduction.
Conversely, chronic tension or persistent weakness can lead to dysfunction and pain, as well as a diminished sensory experience and lack of sexual feelings. Even when radical interventions are done, pain is often not resolved, suggesting a source of the pain other than the testicles.
It is important to keep in mind, however, that there are other factors that can be responsible for male dyspareunia, including psychological factors, size of the penetrating object, and lack of lubricant. However, once a trusted medical professional questions them about urinary leakage, the story begins to unfold.
The exercise program he used in the study was based on his VigorRobic protocol, outlined in his book VigorRobic: Increased Potency Through Specific Fitness Training [16].
This muscle can also refer pain to the tip of the penis and the urethra as well as to several other sites. Symptom-giving pelvic girdle relaxation of pregnancy, postnatal pelvic joint syndrome and development dysplasia of the hip.

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