Pelvic organ prolapse (POP) and incontinence impact the quality of daily life and alter independence in daily activities for women older than 50 years and can affect up to 75% of women 45 to 85 years old.1 Surgical treatment targeted at correcting anatomical defects has been the mainstay of medical treatment for POP; however, evidence is emerging to support conservative, nonsurgical approaches to the treatment and management of POP.2,3 Conservative approaches include pelvic floor muscle training (PFMT), lifestyle changes, and pessary. The purpose of this report is to describe the theoretical basis of a novel conservative intervention for the treatment of symptoms related to POP and incontinence in older women through the use of a case description. This conservative manage ment program combines pelvic muscle exercise with pelvic postural inversion. The case description will exemplify the treatment protocol, which may have the potential to not only reduce the severity or degree of prolapse, but also improve symptoms and quality of life in women with POP and associated urinary incontinence (UI).
WHAT IS PELVIC ORGAN PROLAPSE?
Pelvic organ prolapse is the abnormal descent or herniation of the uterus, bladder, and/or intestines from their position and attachment within the pelvic ring.4 The bladder, uterus, small intestine, and/or rectum descend from normal anatomical position simultaneously, with deterioration and descent of pelvic muscle and fascial support. Prolapse is defined by the visceral organ that is descending from its normal position in the pelvis. Cystocele is descent of the bladder, a bulge of a weakened anterior vaginal wall. Rectocele is descent of the rectum, a bulge of a weakened posterior vaginal wall down the vagina. Uterine prolapse is descent of the uterus down the vagina. First-degree cystocele, rectocele, or uterine prolapse indicates the bladder, rectum, or uterus has protruded into the vagina but is still in an elevated position (Figure 1). Second-degree prolapse indicates the organ(s) position is just above the vaginal outlet, still completely in the vagina. Third-degree prolapse indicates the organ tissue, meant to be inside the body, protrudes outside the vaginal outlet. Third-degree prolapse leads to dry, irritated, and sometimes ulcerated tissue that can be highly sensitive to contact with clothing or other materials. Uterine prolapse impacts bladder and bowel function as well as sexual response. It can lead to urethral kinking and urinary retention.1
A primary symptom of POP is the sensation of pressure and/or bulging at the vaginal opening. In more severe cases, it is possible for women with POP to feel a bulge of the organ outside the vaginal opening. Incontinence and bladder and bowel dysfunction and low back pain are common symptoms. Descent of the anterior vaginal wall (cystocele) can lead to obstructive voiding, poor urine flow, incomplete emptying, and urinary retention. Cystocele can also lead to urgency and frequency and stress incontinence. Descent of the posterior vaginal wall (rectocele) can lead to constipation, incomplete emptying, and back pain. Uterine prolapse can bring both bladder and bowel out of position with resulting urination and defecation problems.
ETIOLOGY AND RISK FACTORS OF POP
The etiology of POP is considered to be multifactorial. Primary risk factors include labor and delivery and hysterectomy. Other risk factors implicated in the development of POP and UI include menopause, aging, constipation, obesity, increased intra-abdominal pressure activities, connective tissue conditions, and pulmonary disease.5 Pregnancy and vaginal delivery are considered primary risk factors for POP and UI, and risk of developing these conditions increases with each pregnancy and delivery. During delivery stretching and tearing of pelvic muscle/fascia, destabilization of the perineal body and pressure/stretching of the pudendal nerve lead to decreased pelvic muscle tone, pelvic muscle and organ descent and dysfunction.6 Handa et al7 reported that POP and pelvic muscle relaxation were directly related to UI 5 to 10 years after childbirth. The development of POP is also directly associated with hysterectomy. Approximately 300 000 hysterectomies are performed each year.8 Removing the uterus and cervix can significantly destabilize ligamentous and fascial support for the bladder and bowel. The incidence of bladder or bowel prolapse with associated urinary dysfunction can be as high as 30% posthysterectomy.9 These same changes may explain other associated musculoskeletal symptoms associated with POP. Back pain, buttocks, leg, and foot pain were reported after hysterectomy in as many as 50% of patients.9
The incidence of POP and incontinence increases with aging and age-related pelvic muscle atrophy.10 Estrogen deficiency after 50 years old may be a primary reason for support-related pelvic floor dysfunction. With age, collagen support cells decrease in number and flexibility and the number of contractile muscle bundles decreases. With the decline in estrogen during and after menopause, support actions of the estrogen-sensitive pelvic/urogenital diaphragm and closure of the urinary sphincter muscles and urethra decrease. As the pelvic muscle and fascial system releases and descends, bladder and bowel position is altered and function is compromised.10 Pelvic muscle resting tone, and speed and intensity of contraction are decreased in relation to decreased estrogen levels and increased connective tissue stiffness.11 Denervation and devascularization, anatomic alterations, and increased degradation of collagen may lead to decreased mechanical strength that predisposes an individual to POP. This is true for other conditions and diseases affecting connective tissue, such as the chronic genetic disorder Marfan's disease.
Chronic constipation increases the risk of development of POP.12 The accumulated bulk of feces in the descending colon and rectum increases pressure on the posterior vaginal wall. This mechanical strain over time may contribute to the development of a rectocele. Pushing and straining to evacuate the bowel can increase the severity of a rectocele and further impair pelvic muscle support.12 Bladder dysfunction may also occur as pelvic muscle support is altered. Urinary urgency, poor urine flow, incomplete emptying, daytime leaking, and nighttime bedwetting are symptoms potentially related to constipation. Other conditions and activities that increase intra-abdominal pressure contribute to the development of POP. Obesity increases pressure on the internal organs and pelvic muscles. Chronic pulmonary disease alters breathing patterns and increases intra-abdominal pressure. Chronic coughing and sneezing can lead to loss of bladder control. Even exercise that creates cephalocaudal intra-abdominal pressure may potentially contribute to the development of POP. In theory, sit-ups and “crunch”-type exercises increase intra-abdominal pressure on the pelvic muscles and organs that can lead to uterine prolapse, cystocele, and rectocele.
Finally, the surgical treatment of POP is clearly not without potentially significant side effects. Surgical treatment of POP can contribute to new symptoms and impairments. Neurological deficits of the pelvic floor and scarring have been reported in women both pre- and postoperatively.10 Surgery for POP can lead to new symptoms of pain during intercourse. Symptoms of bladder or bowel dysfunction can occur secondary to surgery for POP, even though those symptoms were the original rationale for surgery. Bowel and bladder symptoms may change as a result of surgery. Symptoms of bladder leaking before surgery can change to urinary retention after surgery. Symptoms of constipation and incomplete emptying before surgery can change to fecal incontinence after surgery.
THEORETICAL BASIS FOR NOVEL CONSERVATIVE APPROACH: POP VIEWED AS A FAILURE OF THE “PELVIC CORE” SYSTEM
The theoretical basis for the novel conservative approach to the treatment of POP and UI described later revolves around the perspective that POP is a functional failure not only of the pelvic organ support system, but also of the associated lumbo-pelvic-hip musculoskeletal system. The combined organ and musculoskeletal systems can be described as the “pelvic core” system, including all of the structures within the lower pelvis. As one organ's descent occurs, it leads to alterations in the position of adjacent organs, fascia, and muscles. Joint mobility, biomechanical loading, and transfer of load forces are theoretically altered at the lumbar spine, sacroiliac joint, symphysis pubis, and hip joints. POP may also theoretically lead to alterations in the position and function of the respiratory diaphragm. The greater peritoneal sac surrounds the internal organs and is formed by the parietal peritoneum that lines the walls of the abdominal and pelvic cavities and includes the diaphragm peritoneum.13 The visceral peritoneum surrounds the organs and interconnects with the parietal peritoneum. Because of this relationship, the diaphragm peritoneum and diaphragm may be biomechanically altered as the visceral peritoneum and organ structures descend. Alterations in the respiratory diaphragm may result in respiratory pattern changes such as shortness of breath and increased use of accessory muscles during physical activity. Thus, POP and the “pelvic core” can impact respiration and vice versa.
A novel paradigm for conceptualizing the structure and function of the “pelvic core” muscle system views the relationship of the pelvic girdle to the hips as a “deep pelvic rotator cuff” muscle system, analogous to the shoulder rotator cuff's relation to the thorax in structure and function.14 (See the Addendum.) The obturator internus and externus and adductor brevis muscles interconnect through fascia and tendon to the pelvic diaphragm muscles and attach around the hip joints. The performance of alternating obturator and adductor muscle action of midline to midrange hip outward and inward rotation may result in lifting of the “suspension bridge” formed by the pelvic diaphragm/urogenital diaphragm/sphincters and facilitate optimal pelvic muscle action to support the previously aligned organs through overflow facilitation.15 Strengthening of hip rotator muscles for the treatment of UI was studied by Jordre and Schweinle16 in a 2014 pilot study of 27 women with stress UI comparing resisted hip rotation exercises with PFMT. Significant improvements in UI symptoms and leak frequency for both groups were reported. The number of leaks in the hip rotation group decreased to a greater degree compared with the PFMT group over the 6 weeks' intervention. Although the results of this study are preliminary, they highlight the potential of strengthening not only the pelvic floor muscles but also pelvic core as a whole as a viable treatment option for incontinence and potentially other symptoms such as those caused by POP.
Postural or positional inversion of the pelvis during deep pelvic rotator cuff and pelvic core exercises is a key component of this novel approach. “Pelvic inversion” describes the positioning of the patient with hips elevated on a wedge to be higher than the chest. This elevated or inverted position theoretically uses gravity to allow the pelvic organs to move back up into the pelvic cavity, reducing strain on fascia and ligaments. Without the strain of the organs descending in the pelvis, the pelvic core muscles can theoretically work more efficiently for muscle strengthening and motor control retraining. Instruction in pelvic inversion using the wedge for organ realignment and pelvic core muscle activation through deep hip rotator muscles theoretically recreates the support system for optimal organ function.
DESCRIPTION OF THE PELVIC CORE AND PELVIC INVERSION METHOD
The pelvic core and pelvic inversion method consists of a series of specific exercises, which are performed twice daily. The program includes pelvic inversion for 5 to 6 minutes, obturator and adductor midrange resisted hip rotation exercises (10 repetitions each), and diaphragmatic breathing (5-7 breaths).
Pelvic inversion for organ realignment
The inversion wedge allows gravity to potentially assist in repositioning internal organs while the patient is in the hook-lying or supine-with-feet-on-wall position. The wedge should be 6 to 7 inches high. It elevates the hips and pelvis approximately 6 to 7 inches higher than the chest and shoulders. This position cannot effectively be duplicated using pillows because pillows compress with body weight. Inversion on the wedge and diaphragmatic breathing are thought to facilitate internal organ alignment within the abdominal cavity. With the bladder, bowel, and uterus in improved alignment, the pelvic muscle system may potentially be strengthened to support the organs in a healthy and optimal position.
Instructions to the patient
Exercise 1: Alignment on the inversion wedge
Place the wedge on the floor or on the bed or other firm surface. Slide the wedge under the hips so the highest part of the wedge is at the hip joint and the shoulders and head are off the wedge. Find a position that is comfortable with hips as high on the wedge as possible. The feet can be resting flat on the floor or on the wall or a ball etc (Figure 2).
Exercise 2: Inversion and diaphragmatic breathing
First notice the natural breathing pattern. Notice the inhale and exhale. Then notice where breathing occurs. Is there movement in the abdomen, chest, shoulders, back, neck, or jaw?
Now let the breath come naturally, thinking “Slow low breathing, inhale my stomach rises, exhale my stomach falls, quiet shoulders, quiet chest, jaw released, tongue at the bottom of my mouth,” for 3 to 4 breaths.
Exercise 3: Abdominal action through diaphragmatic breathing
Now with inhale, let the abdomen rise. Then with exhale gently pull the belly button toward the spine. Repeat that pattern for 5 to 10 breaths.
Pelvic core exercises for bladder and bowel support
The pelvic core exercises utilizing obturator internus and externus and adductor muscles to facilitate pelvic diaphragm and sphincter action may potentially create automatic unconscious alignment of the inferior abdominal organ support system by activating pelvic and hip muscle synergy patterns. In another clinical observation by the author using internal sensor electromyography (EMG) biofeedback, midrange hip internal and external rotation exercises resulted in activation of the pelvic floor muscles by overflow of the pelvic and urogenital diaphragm.17
Instructions to the patient
Exercise 1: Active pelvic core exercise
Position: Supine with hips on the inversion wedge. Rest feet on the wall so knees are straight and comfortable.
Action: With heels touching, roll knees and toes out with inhale for a count of 5. Knees roll out to hip width. Next, exhale and return knees and toes to the neutral position for a count of 5 (Figure 3).
Exercise 2: Pelvic Core-Resisted Adductors
Position: Supine with hips on the inversion wedge. Rest feet flat on the floor. Place a ball 6 to 7 inches in diameter between the thighs with knees and feet hip width apart.
Action: Inhale in this position. Then exhale and rotate knees in on the ball, flattening the sides of the ball and holding for a count of 5. Toes rotate in like a windshield wiper at the same time. Next, inhale and rotate legs out to neutral for a count of 5.
Exercise 3: Pelvic core-resisted obturator internus/externus
Position: Supine with hips on the inversion wedge. Place feet together with heels and big toes touching. Wrap an exercise band around the thighs while gently squeezing the knees together. Fasten with a clippie or knot.
Action: Roll legs out on the band, knees rolling out hip width and toes rotating out like a windshield wiper for a count of 5. Keep heels touching to simultaneously activate the obturator internus and externus muscles. Then inhale and return legs and toes to the neutral position for a count of 5.
Pelvic inversion with breathing and pelvic core exercises are performed together twice daily. The pelvic core exercises progress from 5 repetitions to 10 repetitions.
A 76-year-old woman was referred by her urogynecologist to physical therapy with a diagnosis of uterine and bladder prolapse grades 2 to 3 and associated UI. Her chief complaint was urine leakage with activity. This symptom was so distressing that she had begun to decrease her exercise activity. She also reported low back pain with prolonged standing, which interrupted her activities. She lived independently with her husband in a 2-story household.
- Stress UI: Urinary leaking with bending, lifting, hurried walking
- Urinary frequency: Toileting every 1 to 2 hours during the daytime
- Urgency UI: Leaking urine before arriving at the toilet to urinate
- Feeling of incomplete emptying: Double voiding at times
- Terminal dribbling: Dribbling urine at end of stream
- Nocturia: Nighttime frequency 2 to 3 times/night
- Occasional constipation: 1 to 2 times/month
- Bulge at vaginal introitus: With lifting
- Low back and foot pain: With prolonged standing
Duration of symptoms: 3 years
Pregnancy: 3 births—vaginal deliveries, transient incontinence (<1-month duration) with the last 2 pregnancies
Menopause: 52 years old, mild sleep disturbance, hot flashes, and mood changes
Occupation: RN, retired at 65 years old
Fitness level: lifelong walking 2 to 3 miles/day 3 days/week; swimming 1 day/week; aerobics class with abdominal crunches 2 days/week; Kegels 25 daily for past 3 years
Sleep pattern: 8 hours of total sleep, waking 2 to 3 times to toilet
Retirement activities: cared for mother with cerebral vascular accident (CVA), lifts, transfers daily, gardening, church
Medical history: high blood pressure—150/100 mm Hg
Body mass index: 24.9, height: 64˝, weight: 145 lb
Medications: high blood pressure diuretic (Lasix), multivitamin, previous trial of Detrol for symptoms of overactive bladder (she reported side effects of constipation and confusion so the patient self-discharged this medication)
Surgical procedures: none
Previous interventions: medication—Detrol, Kegel exercises—instructed by her doctor and nurse, 10 repetitions three times per day sitting/supine, 8 weeks' duration, minimal change in symptoms
Physical examination findings:
- Vaginal examination revealed descent of anterior/posterior vaginal wall (bulge) at vaginal introitus with bearing down in lithotomy position
- Low back pain during forward bend left > right, finger tips 2 from floor
- Limited hip internal rotation left > right 5° versus 10° active range of motion (ROM)
- Pelvic muscle action—EMG sensor—resting: 1.5 mv, isolated contraction: 7 mv
- Posture erect aligned with abdomen held tight
- Weight—body mass index 24.9, weight 145 lb
- Bladder and bowel diary—3-day record summary Toileting hourly daytime—once/day strong urge, others just in caseToileting 2 times nightly—waking with urgePad use—1 to 2 light pads per dayBowel pattern—every 2 days, firm, cracked consistency, mild straining—once a month 3 to 4 days with more straining
Course of treatment
The patient attended physical therapy for 8 visits, once a week for 8 weeks. During the first session the evaluation was completed. Instruction and demonstration of pelvic inversion with diaphragmatic breathing (for 5-6 minutes) and obturator and adductor midrange resisted hip rotation exercises (5 repetitions, hold for 5 counts, rest for 5 counts) was completed. The patient performed the inversion and exercise without discomfort. Abdominal sit-up and crunch-type exercises were discontinued. Walking, 20 to 30 minutes a day, was prescribed. During subsequent visits, pelvic core exercises and pelvic inversion were reviewed. Exercise repetitions were increased by 2 each week to a maximum of 10 repetitions performed twice daily. Postevaluation was completed during the last treatment.
There was no active attention to pelvic floor contraction when the rotator cuff system was facilitating pelvic muscle action automatically. This may be similar to the shoulder rotator cuff muscles, sequentially firing at an unconscious level to support the humeral head in the glenoid fossa during shoulder motions.
Goals: time frame: 4 to 8 weeks
- Eliminate incontinence. Reduce the number of episodes of urine leakage from 2 to 3 leaks/day to 0 leak/day.
- Eliminate constipation. Increase the frequency of bowel movements from 1 time every 2 to 3 days to 1 time every 1 to 2 days with no straining.
- Improve daytime and nighttime toileting frequency. Reduce the number of daytime micturitions from hourly to every 3 to 4 hours, and reduce nighttime frequency of urination from 1 to 2 times/night to 0 to 1 time/night.
- Eliminate back pain during standing for 30 minutes and during forward flexion.
- Eliminate presence of bulge at vaginal introitus when examined in the lithotomy position.
- Improve pelvic muscle recruitment as measured by sEMG from 7 to 15 mv.
Outcomes: after 8-week program
- Eliminated UI to 0 leak per day.
- Eliminated constipation with report of daily or every 2 days bowel movement without straining.
- Improved toileting frequency during the daytime to every 3 to 4 hours and during the nighttime to 0 to 1 time/night.
- Eliminated back pain during standing for 30 minutes and during forward flexion.
- Eliminated the visible bulge at the vaginal introitus during examination in the lithotomy position.
- Improved pelvic muscle recruitment as measured by sEMG—resting: 1.5 to 2.5 mv; isolated contraction: 7 to 8 mv; rotator cuff pelvic action: 7 to 15 mv.
Long-term follow-up: In a follow-up by phone 1 year after discharge, the patient reported that she continued to perform the exercise program 2 to 3 times per week. She remained symptom-free with all activities at that time.
This case description illustrates a novel approach to the conservative treatment of POP and UI. Support for conservative intervention strategies as an alternative or an adjunct to surgery for the treatment of POP and UI is emerging in the literature.18 Kotarinos and Kotarinos18 suggested that the body of evidence to support physical therapy treatment for POP is “coming of age” in her review of recent research. The most recent Cochrane review concluded that PFMT has a positive effect on POP symptoms as well as POP severity.19 This encouraging trend is dampened by conflicting or cautious results. For example, in one randomized controlled study, there was long-term improvement in POP and incontinence but not at a clinical significance level when using isolated pelvic muscle contraction exercises compared with watchful waiting.20 The conflicting results suggest that perhaps there are additional components of conservative interventions that could be included to improve outcomes.
Studies of pelvic floor muscle exercise and POP have also been conflicting as to improvement of symptoms and organ position.20–22 In a study of 130 women with POP, a 24-week one-to-one pelvic muscle training with self-instruction manual led to greater improvement in POP symptoms compared with using a self-instruction manual alone.21 In a multicenter randomized controlled study of 447 women with POP, one-to-one pelvic muscle pelvic muscle training and POP education (5 visits over 16 weeks) self-reported fewer prolapse symptoms compared with a control group provided information from a life-style advice leaflet only. Although this improvement was at a significant level, a substantial group of women in the experimental group reported no improvement.2 Braekken et al22 reported improved POP stage and bladder and rectum position in the pelvis in the PFMT group compared with the education group. More women in the exercise group had improvement in the POP-Q stage (19% vs 8%). No significant change was seen in a subgroup of women with prolapse below the hymen. The exercise group (59 women) reported significantly reduced urinary frequency and bothersome symptoms compared with the control group (50 women). This positive outcome of the case description may imply that the addition of “pelvic core strengthening” and “pelvic inversion” to PFMT may further improve women's responses to conservative intervention strategies.
Theoretically, if pelvic inversion realigns the organs, then including pelvic inversion and hip midrange rotation exercises has the potential to improve POP and incontinence symptoms and enable women to more actively participate in a variety of daily activities, and improve quality of life. Broadening a conservative approach to treatment of POP and incontinence has the potential to increase the number of women who benefit, because this approach can be broadly applied in clinical practice. This approach has the potential to decrease barriers for practitioners and patients because of the lack of need for the clinic to perform a vaginal palpation and lack of the need for the patient to perform isolated contractions of the pelvic muscles. This case study clinical commentary can be used as a stimulus for further exploration of these concepts.
Strengths of this report
This novel approach, pelvic inversion with pelvic core exercises is a noninvasive approach to treating the symptoms of POP and UI. Results are seen within 2 to 8 weeks of exercise. There are few adverse side effects. Participation in pelvic muscle strength exercises may be challenging for the older woman. The exercises in this program are easily reproduced and visible to the patient compared with isolated pelvic muscle contractions. The time commitment for the patient is not excessive, 5 to 6 minutes twice daily. The approach can be used throughout all cultural and religious norms because internal examination or insertion of vaginal devices is not necessary. The program can be implemented by non-pelvic-trained physical therapists and occupational therapists. It can be integrated into other physical and occupational therapy programs (ie, total hip protocol, total knee protocol, and low back pain protocol).
Limitations of this report
Several limitations of this report were identified. There is no research data on whether pelvic inversion actually realigns organs or other soft tissue as proposed. A second limitation is there is no research data on the mechanism of improvement of bladder, bowel, and POP symptoms. The question remains whether the improvement is the result of pelvic muscle hypertrophy as in PFMT, pelvic tissue stiffness, or improved pelvic muscle postural resting tone.
Suggestions for future research study
Research in treatment of POP and incontinence using pelvic inversion compared with no inversion is needed. Research in treatment of POP and incontinence using pelvic inversion and isolated pelvic muscle exercises compared with pelvic inversion and pelvic core muscle exercises without isolated pelvic muscle contraction is needed to help direct treatment for women. Does PFMT or pelvic core plus inversion result in longer duration of positive outcomes? Research using imaging is needed to determine whether observable realignment of organs occurs with inversion or whether other mechanisms are affecting POP symptoms. Another important area of research is to determine the mechanism that causes changes in symptoms. Is it postural tone change in the pelvic muscle structures, hypertrophy of pelvic muscles, stiffening of the entire fascia support within the pelvis, or some other factor?
POP and UI can cause significant negative impact on women's quality of life. Conservative treatment options for POP and UI involving internal vaginal examination of the pelvic floor and isolated PFMT that are typically provided by physical therapists trained in examination and treatment of the pelvic floor may not be readily available to older women under the care of physical and occupational therapists practicing in typical geriatric clinical practices. This novel approach to conservative treatment of POP and UI offers an alternative approach that can be provided by therapists who do not or cannot perform vaginal examination. Alternative options in the prevention and treatment of POP and incontinence for postmenopausal women are needed so that more women can access them and potentially experience improvement in symptoms. The goal of this alternative conservative approach to treatment is to optimize functional and structural musculoskeletal support of the pelvic organs and pelvic floor, to minimize symptoms of POP and UI, to improve functional outcomes in daily living activities, and to improve quality of life and health in older women.
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2. Hagen S, Stark D, Glazener C, et al. Individualized pelvic floor muscle training in women with pelvic organ prolapse
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. Int J Gynaecol Obstet. 2007;98:248–251.
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ADDENDUM The Pelvic Rotator Cuff: Anatomy and Function
The pelvic rotator cuff (PRC), a theoretical concept described by Hulme,17 includes the following muscles:
- Obturator internus and externus
- Pelvic diaphragm (levator ani)
- Urogenital diaphragm
- External urinary and anal sphincters
- Adductor longus and brevis (Figure 4)
The obturator internus muscle attaches within the pelvis along the lateral aspect of the arcuate tendon and substantially covers the obturator foramen attaching around its internal border. It interconnects with the pelvic diaphragm muscles at the arcuate tendon.15,17 The obturator internus exits the pelvis at a 130° angle through the lesser sciatic notch and attaches to the posterior superior aspect of the greater trochanter of the femur.14
Typically, the obturator internus muscle is described as a midline outward rotator of the hip. A second function of the obturator internus is indirect support through the pelvic diaphragm of bowel, bladder, and uterus. A third function is dynamic stability of the lumbosacral and sacroiliac joints in upright posture and walking.
The obturator externus muscle substantially covers the obturator foramen attaching around its outside border. It travels to the posterior aspect of the femur and attaches to the posterior inferior aspect of the greater trochanter of the femur. The obturator externus functions to outwardly rotate and adduct the hip from midline to midrange (hip width). This muscle keeps the feet under the hips while the knees and hips outwardly rotate from midline to midrange. The obturator externus theoretically communicates with the obturator internus through the foramen facilitating tone and support for pelvic organs.
The pelvic diaphragm (levator ani) muscle attaches within the pelvis anteriorly to the pubic rami, laterally to the medial aspect of the arcuate tendons, and posteriorly to the sacrum and coccyx. The pelvic diaphragm is bowl shaped and composed of loops running from pubis to sacrum. Pubococcygeus, iliococcygeus, and puborectalis are loops within the pelvic diaphragm muscle. These loops run in a sling-like fashion from the pubic rami, and arcuate tendon on one side to unite with fibers from the opposite side and then to connective tissue that attaches the loop to the sacrum and coccyx posteriorly.14,15 Fascia evolving to ligament envelops the bowel and extends laterally across the pelvic diaphragm to the arcuate tendon bilaterally. This ligament transfers force from the pulley system of the obturator internus and arcuate tendon to the anorectal angle, facilitating elevation and closure of the rectum until it is time to empty. The pelvic diaphragm muscle has a preponderance of slow twitch, type I muscle fibers. It functions as a postural muscle of the trunk and pelvis, maintaining consistent resting tone to support internal organs, close the outlets for bowel and bladder and assist in sacroiliac and lumbosacral joint alignment and upright stance. This resting tone helps maintain the anorectal and bladder angles necessary for bowel and bladder continence 24 hours a day. The pelvic diaphragm resting tone relaxes/inhibits during urination so the urethra is open for urine to pass through. When having a bowel movement the pelvic diaphragm sling relaxes/inhibits so the rectum and anus are a straight tube to allow feces to pass through. The pelvic diaphragm functions as a postural muscle under autonomic nervous system and subcortical control.
The anal sphincter muscles include the internal anal sphincter, which is a smooth muscle ring that is surrounded by the external anal sphincter, which is a striated/smooth muscle ring. They both function to maintain feces in the rectum through resting tone closure pressure. In addition, the puborectalis loop of the pelvic diaphragm interdigitates with the external anal sphincter, influencing its tone and facilitating continence through formation of the anorectal angle.
The urogenital diaphragm muscle group is positioned in the anterior 2 thirds of the region between the symphysis pubis and coccyx. It attaches to the symphysis pubis, pubic rami, perineal body, and ischial tuberosities. The muscles that form the urogenital diaphragm include the deep transverse perineal interconnected by fascial planes with the external anal sphincter and the smaller superficial transverse perineal muscle. The bulbospongiosus and ischiocavernosus muscles are also included in the urogenital diaphragm muscle group. The bulbospongiosus muscle originates from the symphysis pubis and forms a sling around the urethra and vaginal openings to attach distally at the perineal body with the transverse perineal muscle and external anal sphincter muscle. The ischiocavernosus muscles originate on the ischial tuberosities and attach on the symphysis pubis. The urogenital diaphragm muscles interdigitate via fascia and connective tissue with the pelvic diaphragm and via the perineal body with the external anal sphincter. The urogenital diaphragm has a preponderance of fast twitch, type II muscle fibers, which contract quickly and forcefully but also fatigue relatively quickly. Its primary function is to facilitate erection of the penis and clitoris during sexual activity. Secondarily, it closes the urethra at the distal end to prevent a few drops of urine from leaking out during coughing or sneezing. The external urinary sphincter is imbedded in the urogenital diaphragm and assists in maintaining its resting tone closure. It is not a primary postural support muscle.
The adductor longus and brevis muscles attach to the medial aspect of the femur and to the pubic rami adjacent to the urogenital diaphragm attachment. The adductor muscle attachment on the pubic rami juxtaposes the attachment of the pelvic diaphragm. The adductors do not interdigitate with the pelvic diaphragm muscle, so when they contract there is no direct caudal force exerted on the PRC. Instead, there is an overflow of electrical activity from the adductors into the pelvic diaphragm during adductor contraction. Besides adducting and inwardly rotating the femur on the pelvis, they facilitate pelvic diaphragm action to support internal organs, symphysis pubis, and sacroiliac joints.
Pelvic Rotator Cuff Function
The adductor and obturator muscles function in alternating reciprocal action to facilitate postural tone of the pelvic diaphragm for organ support.15 At completion of the PRC “obturator action” phase, the obturator internus and externus muscles are in a shortened position with the hips in midrange outward rotation. The adductors reciprocate function during the “adductor action” phase to lengthen the obturator internus and externus muscles and produce hip inward rotation to midline. Then the “obturator action” phase begins again. It is a constantly reciprocating “Roll for Control” action at the hip from midline to midrange rotation (hip width) and back to midline that enables the PRC muscle system to accomplish functions of organ support, lumbosacral and sacroiliac joint alignment, and standing balance dynamic stability.
The pelvic diaphragm, urogenital diaphragm, and sphincters are not isolated muscles that attach from bone to bone contracting to move one bone on another bone through joint action. Their structural attachments are muscle to fascia to tendon to muscle to ligament to other muscle before connecting to bone. As such, they form a dynamic pelvic muscle force field, not a pelvic floor for postural function.
In summary, PRC functions with a rhythmical balance of midline to midrange internal and external rotation involving the prime movers of obturator internus/externus and adductors that facilitate pelvic diaphragm and sphincter tone to provide organ support, outlet closure, sacroiliac alignment, and standing balance stability. These muscles function as an interdigitated and interrelated synergistic unit for dynamic support and optimal bladder and bowel function.