Hypermobility and the Pelvic Floor: Assessment and treatment of pelvic pain and dysfunction.

The pelvic floor is a hammock of muscles, ligaments, and fascia that stabilizes the pelvis, supports internal organs, and controls continence. Like all connective tissues in individuals with Hypermobility Spectrum Disorder (HSD) and hypermobile Ehlers-Danlos Syndrome (hEDS), the structural components of the pelvic floor are lax. This generalized tissue vulnerability leads to a high prevalence of pelvic pain and dysfunction, demanding specialized care from a pelvic health physical therapist (PT).

For the hypermobile client, pelvic floor issues are not just about muscle weakness; they are about connective tissue failure combined with neuromuscular compensation.

The Mechanism of Dysfunction

The altered collagen structure affects the pelvic floor in two primary ways:

1. Laxity and Support Failure: The ligaments and fascia supporting the bladder, uterus, and rectum are loose, increasing the risk of Pelvic Organ Prolapse (POP) and issues like stress urinary incontinence (SUI) and urgency. The foundation is literally unstable.
2. Compensatory Hypertonicity: Paradoxically, the pelvic floor muscles (PFM) often become hypertonic (chronically tight and spastic). When the surrounding stabilizing systems (deep core, pelvic ligaments, and SI joint) are unstable due to hypermobility, the PFM clench defensively to try and “hold everything in place.” This protective spasm leads to chronic pain, painful intercourse (dyspareunia), and difficulty fully emptying the bladder or bowels.

Key Assessment Red Flags for the PT

When taking a subjective history, a PT should specifically ask about these symptoms, which may otherwise seem unrelated to musculoskeletal pain:

• Incontinence: Urinary leakage during coughing, sneezing, laughing (SUI), or difficulty making it to the bathroom in time (urgency/overactive bladder).
• Voiding Issues: Frequent urination, feeling like the bladder or rectum is not fully emptying, or straining to pass a bowel movement.
• Pain: Pain in the pelvic region, tailbone (coccyx), low back, or perineum that is persistent or worsens with sitting.
• Sexual Dysfunction: Painful intercourse (dyspareunia).
• Feeling of Heaviness: A sensation of dragging or pressure in the pelvis, often indicative of prolapse.

Treatment Protocols: Prioritizing Relaxation and Endurance

Treatment must follow a sequence that addresses the protective spasm before introducing strengthening. Aggressive Kegel exercises applied to a hypertonic pelvic floor are often painful and counterproductive.

1. Down-Regulation and Relaxation

The immediate goal is to calm the hypertonic PFM and the nervous system that is driving the protective clenching.

• Diaphragmatic Breathing: Teach the patient to coordinate deep, three-dimensional breathing with the pelvic floor. The PFM should gently lengthen (eccentrically lower) on the inhale and gently return to baseline on the exhale. This is foundational for releasing spasm.
• Positional Release: Use postures that gently open the pelvic outlet (e.g., child’s pose, supported squat) combined with heat or external soft tissue mobilization to the hip abductors and rotators (which influence PFM tension).
• Internal Manual Therapy: A specialized pelvic PT may use internal techniques to address trigger points in the PFM, explicitly teaching the patient to relax the muscles on demand.

2. Endurance and Motor Control

Once the muscles can relax, training must shift to low-load endurance within the functional range, emphasizing proper recruitment patterns over maximal strength.

• Sub-Maximal Contractions: Prescribe “mini-Kegels” or gentle internal lifts, focusing on holding the contraction for 5-10 seconds at a very low intensity (e.g., $30\%$ of maximum effort). This targets the Type I slow-twitch endurance fibers crucial for static support.
• Coordination with Core: Integrate PFM contraction with the Transversus Abdominis (TA) activation. This co-contraction is vital for dynamic stabilization, ensuring the inner core unit fires synchronously to brace the trunk before movement.

3. Support and Postural Integration

Address the systemic hypermobility in conjunction with the pelvic floor training.

• External Support: Recommend supportive garments or garments (e.g., a sacroiliac belt) if SI joint instability is contributing to chronic PFM guarding.
• Functional Training: Integrate PFM/TA activation into functional movements, such as carrying a weight, standing from a chair, or preparing for a cough or sneeze (the “Knack”). This trains the PFM to contract preemptively—the essential skill for managing SUI.
• Addressing Prolapse (if present): If POP is identified, treatment focuses heavily on avoiding high-impact activities (which increase intra-abdominal pressure), optimizing bowel/bladder habits, and working with a physician to determine the need for a pessary while continuing core and PFM endurance training.

By recognizing the dual nature of pelvic floor dysfunction in hypermobility—laxity requiring support, and spasm requiring release – Joint hypermobility physiotherapist Gold Coast can provide transformative care, significantly improving pain, continence, and quality of life.