Therapist

Can pelvic floor dysfunction be caused by stress

Oftentimes, people who experience pelvic pain do not realize stress is highly correlated to their symptoms.[1] This is a result of the pelvic stress reflex response, in which the pelvic floor muscles actively contract in response to physical, or mental stress.[1]

What Happens When the Body Is Under Stress?

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Muscular Component – Pelvic Stress Reflex Response

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The second layer of the pelvic floor includes the

  • Urethral sphincter (sphincter urethrae)
  • Compressor urethrae
  • Sphincter urethral vaginalis

These muscular structures help control the flow of urine through the urethra.[2] There is a passive and active component to the contraction of the sphincters.[2] The passive component involves transmitting intra-abdominal pressure to the urethra which mainly regulates the pressure at the neck of the bladder. The active component mainly controls the pressure distal to the bladder neck, which is important for urethral closure during stress conditions. The active component involves the reflexive contraction of external sphincter muscles. Thus, physical stress will increase the contraction via the pelvic stress reflex response which can lead to tightness and weakness of the pelvic floor muscles.[2]

Hormonal Component – HPA Axis and Cortisol

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Response of HPA axis to stressors

HPA Axis

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When the body identifies a stressor, it responds via the hypothalamic-pituitary-adrenal (HPA) axis.[3] This is a feedback system that maintains various body systems such as digestion, immune function, mood, energy and sex.[3] Upon exposure to stress, the body perceives it using the hypothalamus which then releases corticotropin-releasing hormone (CRH).[3] CRH then triggers the pituitary gland to release adrenocorticotrophic hormone (ACTH) and finally signals the adrenal gland to release epinephrine (or adrenaline), norepinephrine and cortisol.[3]

Epinephrine and norepinephrine are released immediately after the body senses a stressor and these hormones break down just as fast.[3] In contrast, cortisol is released about 10 minutes after the stressor is detected and can circulate in the body for about one to two hours after.[3]

Role of cortisol and immune function

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  • Normal levels (short-term effects): Cortisol is understood as the stress hormone of the body. Levels of cortisol vary throughout the day, increasing in the morning to help wake up the body and decreasing as the day passes.[1] Cortisol levels follow the body’s circadian rhythm which helps immune functions such as cell repair.[1] Symptoms of high cortisol levels can include anxiety, agitation, poor sleep, ‘wired but tired’ feeling and a fast pulse.[1]
  • Abnormal levels (long-term effects): When the body is under stressful conditions, constant activation of the HPA axis may occur.[1] The adrenal glands release high levels of cortisol which accumulate in the body.[1] Constant stressors demands a constant release of cortisol, thus depleting the body of nutrients needed to produce the hormone. Exhaustion occurs when the body is not capable of producing more cortisol which compromises immune function as well as increasing symptoms of pain, slower wound healing, decreased ability to handle smaller stressors, emotional issues and poor sleep.[1]

II) Impact of low cortisol levels on pelvic pain

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In numerous conditions related to pelvic pain, cortisol levels are lower than usual because the body has reached the exhaustion phase.[1] Long-term stressors have demanded the body to produce increased levels of cortisol for a prolonged time and now the body is depleted of nutrients to produce cortisol.[1]

  • Endometriosis: The amount of cortisol released to help wake up in the morning was lower among women with endometriosis compared to control groups.[4] In fact, there were overall lower levels of cortisol in the endometriosis group. As well, women who reported intense pain with sex and women experiencing infertility had lower cortisol levels than control groups.[4]
  • Interstitial Cystitis (IC): Women with IC which lower amounts of cortisol in the morning also had a higher rate of nocturnal urinary frequency (nocturia).[5] In addition, they were likely to have greater pain in the lower abdomen as the bladder became full with fluid as well as an increase in nocturia and frequency of urination throughout the day.[5]
  • Vulvovaginal Candidiasis (vaginal yeast infection): Women who experienced repeated cases of yeast infections had a lower increase in cortisol in the morning and throughout the day compared to controls.[3]
  • Vulvodynia: Women with vulvodynia had lower levels of cortisol in the morning and also had more symptoms of stress compared to control groups.[3]

Stress Can Lead to Nonrelaxing Pelvic Floor Dysfunction (NPFD)

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It is more commonly understood that various pelvic floor disorders are due to over-relaxed muscles (e.g. pelvic organ prolapse or urinary stress incontinence). This increases the likelihood that these disorders can be identified and individuals can begin appropriate treatment.[6] In contrast, NPFD is not as easily identified because individuals can present with a wide range of nonspecific symptoms including pain, sexual dysfunction as well as problems with defecation or urination. This presentation may indicate that the pelvic floor muscles and urinary and anal sphincters require relaxation and co-ordination rather than tightening. These symptoms are likely to have negative impact on the quality of life thus clinicians can use psycho-social questionnaires to assess the variety of stressors that may be impacting the patient’s pelvic health.[6] Interventions can focus on managing stressors, such as patient education to help adopt healthy habits to control stress levels, or referring to individual to seeking further counselling if indicated by the questionnaires.[6]

Treatment Options

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Increasing cortisol levels

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It is evident that individuals with pelvic pain have factors that disrupt the usual cortisol cycle.[4] The combined effect of physiotherapy and psychotherapy treatments in women with chronic pelvic pain can help to increase cortisol levels after treatment and attain similar levels of cortisol as women without symptoms. Pelvic floor physiotherapists (PTs) can perform external and internal exams of the abdomen and pelvic area to assess if the muscles are weak or tight and administer appropriate treatment. If the muscles are weak, PTs can teach exercises to strengthen the pelvic floor. If the muscles are tight, PTs can perform internal releases of the pelvic floor muscles to help relieve the tension in the muscle and prescribe exercises to promote normal motor patterns in the muscles. Please see this Physiopedia article for more information to how physiotherapy can be the solution to addressing pelvic pain.

Relaxation, being mindful of pelvic floor

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The PT can use various strategies to increase awareness of the pelvic floor muscles in order to help the patient build self-management skills to cope with stress and contributing factors to NPFD.[6] The key is to introduce strategies early as possible, efficiently and effectively, by identifying the wide range of factors that can lead to NPFD. Strategies include patient education about factors that influence the structure and function of the pelvic floor and conducting tests to confirm a diagnosis. The PT and patient can collaboratively develop appropriate goals to address the cause of pelvic pain and increase their quality of life.[6]

Naturopathic doctors can address NPFD by examining the ‘whole picture’ and trying to identify the cause of the problem.[7] If long-term stressors are over-producing cortisol leading to the depletion of nutrients, then the body lacks specific nutrients for healthy functioning adrenal glands. The naturopath may recommend taking specific vitamins or supplements which can increase the production of cortisol.[7]

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9

    Stephens MA, Wand G. Stress and the HPA axis: Role of glucocorticoids in alcohol dependence. Alcohol research: current reviews. 2012.

  2. 2.0 2.1 2.2

    Thüroff JW, Casper F, Heidler H. Pelvic floor stress response: reflex contraction with pressure transmission to the urethra. Investigative Urology 2 1987 (pp. 124-130). Springer, Berlin, Heidelberg. Available from: https://link.springer.com/chapter/10.1007/978-3-642-72735-1_19

  3. 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7

    Petrelluzzi K, Garcia M, Petta C, Grassi-Kassisse D, Spadari-Bratfisch R. Salivary cortisol concentrations, stress and quality of life in women with endometriosis and chronic pelvic pain. Stress. 2008;11(5):390-397. doi:10.1080/10253890701840610.

  4. 4.0 4.1 4.2

    Friggi Sebe Petrelluzzi K, Garcia M, Petta C et al. Physical therapy and psychological intervention normalize cortisol levels and improve vitality in women with endometriosis. Journal of Psychosomatic Obstetrics & Gynecology. 2012;33(4):191-198. doi:10.3109/0167482x.2012.729625.

  5. 5.0 5.1

    Schrepf A, O’Donnell M, Luo Y, Bradley C, Kreder K, Lutgendorf S. Inflammation and Symptom Change in Interstitial Cystitis or Bladder Pain Syndrome: A Multidisciplinary Approach to the Study of Chronic Pelvic Pain Research Network Study. Urology. 2016;90:56-61. doi:10.1016/j.urology.2015.12.040.

  6. 6.0 6.1 6.2 6.3 6.4

    Faubion SS, Shuster LT, Bharucha AE. Recognition and management of nonrelaxing pelvic floor dysfunction. InMayo Clinic Proceedings 2012 Feb 1 (Vol. 87, No. 2, pp. 187-193). Elsevier. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3498251/pdf/main.pdf

  7. 7.0 7.1

    Priolo, A. Stress, Cortisol and Pelvic Pain. 2018. Retrieved from https://www.proactiveph.com/blog/2018/05/16/stress-cortisol-and-pelvic-pain.html

As a urogynecologist and co-director of the Center for Pelvic Health, I specialize in female pelvic medicine and reconstructive surgery. Here I answer some common questions related to pelvic health and explain how pandemic-related anxieties can affect pelvic health.

What is the pelvic floor and why is it important to take care of it?

The pelvic floor is a complex of muscles and connective tissue structures that support and stabilize the pelvic organs. These include the bladder, urethra, bowel, uterus and vagina. The pelvic floor plays a very important role ensuring that pelvic organs function properly and performs sexual functions, along with the storage and emptying of urine and feces.

Who is affected by pelvic floor disorders?

Women are at much greater risk for pelvic floor disorders than men. The greatest damage to the pelvic floor usually happens during a vaginal birth, so pregnancy and vaginal delivery are significant risk factors. Pressure within the abdomen and pelvis — from chronic constipation, chronic cough, chronic straining during heavy lifting — can contribute to these problems. People with connective tissue disorders, like Ehlers-Danlos or scleroderma, for example, or who have undergone pelvic surgery or radiation, are also at increased risk.

Age is another significant risk factor, since people undergo tissue atrophy as they age.

How does a sedentary lifestyle affect the pelvic floor?

Prolonged sitting, especially in a “wrong” position, can negatively affect the pelvic floor. For example, weakening may happen when sitting in a slouched or relaxed position, or, sitting in another strained position may cause muscle contraction and tightness and result in pelvic pain and lower back pain. Prolonged sitting can potentially damage nerves that can contribute to painful disorders.

Have you had patients complain of pelvic floor issues during the pandemic?

Stress and anxiety can lead to tightening of the pelvic floor muscles, which can result in pain or high-tone pelvic floor dysfunction. Some people have dubbed this phenomenon the “pandemic pelvis.” We know the pandemic has been a high-stress period, and it could contribute to exacerbation of these symptoms in people more prone to anxiety and stress.

What are some signs that your pelvic floor might be in trouble?

When people start noticing leakage of urine with coughing, sneezing, exercising, or subtle small movements, or people experience urinary urgency, this could be a sign to be seen by a doctor. Other warning signs include difficulty emptying the bladder or bowels, losing gas or stool when not desired, or feeling pressure or pain in the pelvic or vaginal area including during intercourse.

If you have digestive problems that persist or often recur, experience frequent constipation or diarrhea, or both, it is time to visit a doctor.

What are some things you can do to help strengthen or protect your pelvic floor?

With people who experience vaginal birth, the more prepared they are, the better. I would compare it to a professional athlete — they recover better from injuries than a non-athletic person because they’re conditioned and prepared.

People can strengthen their pelvic floor muscles before and during pregnancy by doing pelvic floor exercises. During the delivery, pelvic floor muscles should be protected as much as possible and properly repaired if a damage occurs.

There is no gold standard for pelvic floor exercises, but we generally recommend people do Kegel exercises three times per day, with the goal to perform 10 muscle contractions that last 10 seconds each.

We know that exercise keeps us healthy, but we usually ignore the pelvic floor muscles. Just like fitness coaches, there are specialized physical therapists (PTs) for pelvic floor muscles, and those people are the best resource to guide patients through this process.

At the University of Chicago Medicine, we have a multispecialty group within our Center for Pelvic Health, including urogynecologists, urologists, colorectal surgeons, pelvic floor physical therapists, gastroenterologists, minimally invasive gynecologists, and more.

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