The Female Hip and Pelvis

Figure 9-1 Female Pelvic Viscera. (From Ball JW, Dains JE, Flynn JA, et al. Seidel’s Guide to Physical Examination. 8th ed. St. Louis: Mosby; 2015.)

Female Pelvic Viscera

The urologic viscera include the bladder, inferior portions of the ureters, and urethra.9 The bladder is located anterior to the uterus, just superior and posterior to the pubic bone and symphysis. Fibrous ligaments connect the bladder anteriorly to the pubic symphysis. The urachus runs from the bladder to the umbilicus. The ureters, beginning at the renal calyxes, lie on the anterior side of the psoas muscle just lateral to the ovarian vessels and vena cava, cross the pelvic brim over the common iliac arteries, and run into the pelvis along the lateral pelvic sidewall. The ureters then enter the bladder’s trigone region (the triangular portion of the bladder base).9

The gynecologic viscera include the uterus, fallopian tubes, and ovaries.9 These organs lie centrally between the bladder and rectosigmoid colon. The three segments of the uterus are the fundus (superior portion), lower segment, and cervix. Most commonly, the uterus is anteverted (meaning the cervix angles forward) and anteflexed (the body of the uterus flexes forward) in relation to the vagina and cervix, a position that leads the uterus to rest just above the bladder. At term, a pregnant uterus increases to 20 times its usual size and weight (Fig. 9-2). After menopause, the uterus atrophies and becomes smaller than in the woman of childbearing age. The cervix is dense and fibromuscular, and it separates the uterus from and extends into the vagina.9 The cervix and upper vagina lie suspended over the pelvic diaphragm muscles at the level of the ischial spines and fifth sacral vertebra (S5).8 The fallopian tubes are bilateral structures, usually less than 1 cm thick, that extend 10 to 14 cm in length from the superior-lateral portion of the uterus.9 The distal portion of the fallopian tube is the infundibulum, with finger-like projections extending freely from this end of the tube. The ovaries lie in the peritoneum in the ovarian fossa positioned closely to the iliac vessels and ureters.9


Figure 9-2 Pregnant Uterus. (From Patton KT. Anatomy and Physiology. 9th ed. St. Louis: Mosby; 2016.)

The uterus projects several ligamentous structures (Fig. 9-3).9 The round ligaments are fibrous and muscular, located on the uterus just anterior to the fallopian tubes. The round ligaments extend laterally, pass the external iliac vessels, run into the internal inguinal ring, and finally extend into the labia majora.9 The broad ligament is a folding of the peritoneum that covers the round ligaments.8,9 The round and broad ligaments provide minimal support to the uterus.8,9 During development of a female fetus, the round ligament guides the ovaries into their correct location. Later in life, the round ligament provides a pull of the bladder in an anterior direction above the uterus. The broad ligament, a folded sheet of peritoneum covering the uterus, uterine tubes, and ovaries, divides the pelvic cavity to create the vesicouterine fossa (anterior to the uterus) and the rectouterine fossa (posterior to the uterus). The main support for the uterus and cervix is from the cardinal ligament, which attaches from the cervix laterally to the endopelvic fascia (which is attached to the pelvic bone).9 The uterosacral ligaments begin at the superior-posterior portion of the cervix and pass around the rectum bilaterally to attach to the sacral vertebrae (first through fifth) to provide some support to the cervix.9


Figure 9-3 Coronal Section of the Pelvis Showing the Ligaments Supporting the Uterus. (From Hacker NF, Gambone JC, Hobel CJ, eds. Hacker and Moore’s Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia: Saunders; 2010.)

The portion of the gastrointestinal viscera in the pelvis is the rectum, which lies along the curvature of the sacrum posterior to the uterus. The posterior cul-de-sac between the uterus and rectum may be occupied by pathologic conditions such as endometriosis, cancer, or pelvic adhesions.9

Dynamic support for the all viscera housed in the pelvis occurs through muscles, ligaments, vessels, and nerves.9 External openings of the pelvis occur through the urethra (bladder), vagina (uterus), and anus (rectum). Appropriate functioning of these systems offers bladder and bowel continence and at the same time voluntary defecation and urination. The dynamic support may undergo severe stressors, including vaginal labor and delivery9 and chronic intraabdominal pressure (e.g., chronic constipation or long-term heavy lifting).

Bony Female Pelvis

The bony pelvis is a ring formed by the bilateral innominate bones (ilium, ischium, and pubis bones), the sacrum, and the coccyx.8,9 The acetabulum of the innominate (hip bone) articulates with the femoral head.8 In Chapter 1, discussion and images are provided that contrast the male and female pelvis (see Fig. 1-15 in Chapter 1). Here the focus is on the female pelvis and on describing the various pelvic shapes (Fig. 9-4). The bony pelvis may have a gynecoid, anthropoid, android, or platypelloid shape.10 Fifty percent of women have a gynecoid pelvic shape, the classic female pelvis shape: round inlet, straight sidewalls, average prominence of ischial spines, well-rounded sacrosciatic notches, well-curved sacrum, and spacious subpubic arches (>90 degree angle). The gynecoid shape is more spacious and thus ideal for delivering babies. Thirty percent of women have an android shape, with a triangular inlet (in which arrest of descent during labor and delivery is common). The android shape is a classic male pelvis shape. Twenty percent of women have an anthropoid shape, which is oval and causes the fetal head to engage in occipitoposterior position during delivery (occipitoanterior is the desirable position). The platypelloid shape is found in approximately 3% of females, and it is a flattened gynecoid shape.10 Because of its bony morphology, the classic male pelvis is inherently more stable than the female pelvis; the shape of the female pelvis promotes mobility for labor and delivery.


Figure 9-4 Female Bony Pelvis Shapes. (From Murray SS, McKinney ES. Foundations of Maternal-Newborn and Women’s Health Nursing. 6th ed. St. Louis: Saunders; 2014.)

Pelvic Ligaments

The pelvic ligaments vary in composition and function from strong supporting connective tissues to smooth, muscular, fibrous, and areolar tissues with no significant supportive role8 (see Fig. 1-17 in Chapter 1). The sacrospinous and sacrotuberous ligaments form the greater and lesser sciatic foramina,9 which allow passage of neurovascular structures from within the pelvis to the lower extremity and genital region.9 These two ligaments, along with the anterior longitudinal ligament of the sacrum, are dense and contribute to stability of the pelvic joints.8 The ligaments projecting from uterine structures are discussed previously in relation to the gynecologic viscera.

Muscles of the Pelvis

The muscles of the pelvis include the “pelvic diaphragm” and the pelvic wall muscles (Fig. 9-5).8,9


Figure 9-5 Female Pelvic Diaphragm. (From Falcone T, Goldberg JM. Basic, Advanced, and Robotic Laparoscopic Surgery: Female Pelvic Surgery Video Atlas Series (Female Pelvic Video Surgery Atlas Series). Philadelphia: Saunders; 2010.)

The pelvic diaphragm muscles include the levator ani (puborectalis, pubococcygeus, and iliococcygeus) and the coccygeus.8,9 These muscles provide the central and critical support mechanism for the pelvic viscera.8,9 These muscles begin at the lateral pelvic wall and run downward and medially to fuse centrally and posteriorly.9 Anteriorly, the levator hiatus is an opening within these muscles to allow the passage of the urethra, vagina, and anus.9 The pelvic diaphragm muscles are predominantly type I (slow twitch) fibers and normally maintain constant tone to provide support for abdominopelvic contents against intraabdominal forces.8,9 By doing so, these muscle prevent chronic strain to the pelvic ligaments and fascia.8 Type II (fast twitch) fibers of the pelvic diaphragm muscles enable performance of quick contractions to provide support with sudden increases in abdominal pressure (e.g., when coughing, sneezing, or jumping).8 When contracting (voluntarily or involuntarily), these muscles elevate superiorly; this action flexes the anorectal canal for fecal continence and voluntary control of the bladder. Relaxation of these muscles occurs only briefly and intermittently8 to allow anorectal canal straightening for fecal emptying, bladder empting, and directing of the fetal head during delivery.9 The muscles in the pelvis are hybrid (smooth and striated muscle tissue) with S2 to S4 nerve root innervation.9 The perineal membrane and perineal body are inferior to the pelvic diaphragm muscles (more superficial) and contribute to the diaphragm of the pelvis.8

The pelvic wall muscles include the piriformis and obturator internus (see Fig. 9-5). These muscles are striated, and their fasciae partially cover the posterior, lateral, and inferior pelvic walls.8 From the anterior-lateral surface of the sacrum, the piriformis muscle originates to fill part of the posterior-lateral pelvis wall. The piriformis leaves the pelvic cavity by traveling through the greater sciatic foramen and inserting onto the greater trochanter of the femur. The sidewalls of the pelvis are partly occupied by the obturator internus, which originates from the ilium, ischium, and obturator membrane inside the pelvis. The obturator internus leaves the pelvis through the lesser sciatic foramen, where it makes a turn and travels on to insert onto the greater trochanter of the femur. On the surface of the obturator internus is a thickening of fascia, the arcus tendineus levator ani (ATLA), which provides the site of origin for portions of the levator ani muscles. Another fascial thickening, the arcus tendineus fascia pelvis (ATFP), covers the medial side of the obturator internus and levator ani muscles, runs from the inner pubic bones to the ischial spines, and provides a lateral place of attachment for the anterior vaginal wall.8

Female Perineum and Genitalia

The female perineum is the subcutaneous tissue that is connected superiorly (deeply) to the levator ani muscles and inferiorly (superficially) by the skin (Fig. 9-6).9 The perineum lies centrally between the ischial spines, ischiopubic rami and pubis, and coccyx. The perineum is divided into two triangles: the urogenital triangle and the anal triangle9; these two triangles are separated by an imaginary line running between the two ischial tuberosities and through the perineal body (located between the distal posterior vaginal wall and the anus).8 The perineal body serves as a fibrous attachment for the superficial perineal muscles (bulbocavernosus, superficial transverse perineal, and external anal sphincter) and the superficial portion of the levator ani that aid in genital hiatus closure.8,9 The perineal body also provides support to the distal vagina and rectum; care in repairing the perineal body is therefore important after episiotomies and perineal lacerations and during perineal reconstructive procedures.8


Figure 9-6 Female Perineum. (From Shaw RW, Luesley D. Gynaecology. 4th ed. Edinburgh: Churchill Livingstone; 2011.)

The external female genitalia are the mons pubis, labia majora, labia minora, clitoris, and vaginal vestibule (Fig. 9-7).9 The mons pubis is a fatty area that lies over the pubic bones and symphysis. The labia majora run longitudinally as two skin folds from the mons pubis toward the perineal body (just lateral to the labia minora). The labia minora are hairless and without fat; anteriorly, they meet to form the clitoral prepuce and frenulum. The clitoris lies within the clitoral prepuce and is homologous to the male penis. Innervation to the clitoris can be compromised with injury to the ilioinguinal nerve during lower abdominal transverse incisions. The vaginal vestibule is the area between the labia minora and holds the openings of the urethra and vagina.9


Figure 9-7 Female External Genitalia. (From Warren RJ, Neligan PC. Plastic Surgery, vol 2: Aesthetic Surgery. 3rd ed. London: Saunders; 2013.)

Nerves of the Pelvis

Innervation of the pelvis involves supradiaphragmatic and infradiaphragmatic portions.9 Superior to the diaphragm (supradiaphragmatic) involves control of the bladder, uterus, and rectum (including autonomic nervous system regulation of urethral and anal sphincter tone). Sympathetic input generally allows the bladder and rectum to store urine and feces (respectively) as smooth muscle sphincters contract. Sympathetic innervation arises from hypogastric plexuses (majority) and sacral sympathetic trunk (minority). Parasympathetic input causes relaxation of the bladder outlet, urethral sphincters, and anal sphincters for release of urine and stool. Parasympathetic innervation arises from the sacral spinal nerves. The autonomic nerve structures can be damaged in labor and delivery or during surgical procedures (pelvic or spinal). The infradiaphragmatic motor innervation is almost fully somatic through the pudendal nerve and its branches. The pudendal nerve arises from S2 to S4 nerve roots (Fig. 9-8). It exits the pelvis through the greater sciatic foramen, runs posterior to the sacrospinous ligament, reenters the pelvis in the lesser sciatic foramen, and then travels through the pudendal canal (along the ischiorectal fossa) with the internal pudendal artery and vein. The space between the sacrospinous and sacrotuberous ligaments is a site of potential pudendal nerve compression. The pudendal nerve branches to provide cutaneous innervation of the external genitalia, motor innervation of the urogenital diaphragm, and innervation of the striated muscles of the urethra and anus.9 These three pudendal nerve branches include the inferior rectal branch, the perineal branch, and the anterior (clitoral) branch. The nerve to the pelvic diaphragm muscles, or levator ani nerve, travels on the superior surface of the coccygeus muscle just medial to the ischial spine.8


Figure 9-8 Pudendal Nerve in Female. (From Baggish MS, Karram MM. Atlas of Pelvic Anatomy and Gynecologic Surgery. 3rd ed. St. Louis: Saunders; 2011.)

Anatomic Connections Between the Pelvis and Hip

The bony pelvis provides the major mechanism for transferring weight and forces of the trunk and upper limbs to the lower limbs.8 Additionally, it provides sites of attachment for the muscles of the lower extremities and trunk that may contribute to pain and dysfunction of the hip and pelvis.8 Understanding of the muscles that attach into the pelvis and hip joint and lower extremity is helpful in clinical management and appropriate referral of patients with pelvic and hip pain or other dysfunction8,11 (Table 9-2).


Muscles With Attachment in the Pelvis and in Lower Extremity

Muscle Pelvis Attachment* Lower Extremity Attachment* Action
Anterior Fascial Compartment of Thigh
Sartorius ASIS Medial tibial surface Flexes, abducts, and externally rotates hip
Flexes and internally rotates knee
Rectus femoris AIIS and ilium Patella Flexes hip
Extends knee
Iliacus Iliac fossa Lesser trochanter of femur Flexes and externally rotates hip
Psoas T12-L4 vertebral bodies/disks; L1-L5 costal processes
Pectineus Pectin pubis Adducts, externally rotates, and slightly flexes hip
Stabilizes pelvis in coronal and sagittal planes
Medial Compartment of the Thigh
Gracilis Inferior pubic ramus, ramus of ischium Medial tibia Adducts and flexes hip
Flexes and internally rotates knee
Obturator internus Intrapelvic surfaces of obturator membrane, pubic and ischial rami Greater trochanter of femur Externally rotates, adducts, and extends hip
Stabilizes hip joint
Adductors Pubic ramus, ischial tuberosity Adducts hip
Flexes hip (up to 70 degrees of flexion)
Extends hip (past 80 degrees of flexion)
Stabilizes pelvis in coronal and sagittal planes
Posterior Compartment of the Thigh
Gluteus maximus Sacrum, ilium, thoracolumbar fascia, sacrotuberous ligament Iliotibial tract and gluteal tuberosity Extends and externally rotates hip
Upper fibers abduct hip
Lower fibers adduct hip
Gluteus medius Ilium Greater trochanter Abducts hip
Stabilizes pelvis in coronal plane
Anterior portion flexes and internally rotates hip
Posterior portion extends and externally rotates hip
Gluteus minimus
Piriformis Anterior surface of sacrum Greater trochanter (apex) Externally rotates, abducts, and extends hip
Stabilizes hip joint
Tensor fasciae latae Anterior superior iliac spine Iliotibial tract Tenses fascia latae
Abducts, flexes, and internally rotates hip
Biceps femoris, long head Ischial tuberosity Head of fibula Extends hip
Stabilizes pelvis in sagittal plane
Flexes and externally rotates knee
Semitendinosus Medial tibia Extends hip
Stabilizes pelvis in sagittal plane
Flexes and internally rotates knee
Semimembranosus Medial tibial condyle
Ischiocondylar portion of adductor magnus Adductor tubercle of the femur Adducts, extends, and slightly flexes hip
Stabilizes pelvis in coronal and sagittal planes

*Data from Corton MM. Anatomy of the pelvis: how the pelvis is built for support. Clin Obstet Gynecol. 2005;48:611-626.

Data from Gilroy AM. Anatomy: An Essential Textbook. Thieme: New York; 2013:107, 319, 324-326.

AIIS, Anterior inferior iliac spine; ASIS, anterior superior iliac spine.

The anterior fascial compartment of the thigh holds the sartorius, iliopsoas, pectineus, and quadriceps femoris muscles (refer to Fig. 1-27).8 The anterior superior iliac spine (ASIS) serves as the origin for the sartorius as it crosses the hip and runs distally to attach to the medial tibial surface. The anterior inferior iliac spine (AIIS) and the ilium just superior to the acetabulum are the sites of origin for the rectus femoris, which then inserts onto the patella and converges with other quadriceps tendons to insert on the tibial tuberosity. The iliac fossa provides the origin of the iliacus, which unites with the psoas to form the iliopsoas, which passes under the inguinal ligament and attaches to the lesser trochanter of the femur. The pectin pubis is the origin site for the pectineus, which also inserts on the lesser trochanter of the femur.8

The medial compartment of the thigh contains the gracilis, obturator internus, and adductor longus, brevis, and adductor portion of the adductor magnus (pubofemoral portion) muscles.8 From the inferior pubic ramus and ramus of the ischium, the gracilis arises and inserts into the medial tibia. The obturator membrane and pubic and ischial rami serve as origin sites for the obturator internus, which then inserts into the greater trochanter of the femur. The pubic ramus and ischial tuberosity are the origin sites for the adductors.8

The posterior compartment of the thigh is occupied by the biceps femoris, semitendinosus, semimembranosus, and hamstring portion of the adductor magnus (ischiocondylar portion) muscles8 (see Fig. 1-28). The ischial tuberosity provides the origin of all these muscles. The biceps femoris inserts into the head of the fibula, the semitendinosus onto the medial tibia, the semimembranosus onto the medial tibial condyle, and the hamstring portion of the adductor magnus onto the adductor tubercle of the femur.8 Additionally, the gluteus medius and minimus, piriformis, gemellus superior and inferior, obturator internus, and quadratus femoris travel from the pelvis to attach into the superior femur and trochanter.

In considering the muscular connections between the hip and pelvis, physiologic differences between female and male muscular systems are worth noting (Table 9-3). Adolescence brings hormonal changes that cause an increase in lean muscle mass for boys, but an increase in fat deposits for girls, without an increase in muscle mass.12 This fat deposition leads to female breast development and widening of the hips during puberty. By the mid-teen years, girls have approximately 75% of the strength that boys have.12 Additionally, women have a higher proportion of type I fibers (slow twitch) compared with men.13 Muscle performance differences have been noted that may contribute to a higher risk of certain injuries in girls and women. Female athletes demonstrate contraction of quadriceps with anterior tibial perturbation, as opposed to boys and men, who contract the hamstrings.14 Girls and women also have less ability to contract muscles around the knee when loaded internal rotation is occurring,15 and women are less able to stabilize the knee in an anterior-posterior plane.16,17 Higher rates of anterior cruciate ligament injuries are associated with a variety of factors, including poor hip-knee control with landing from a jump.12 Patellofemoral pain may be associated in differences in quadriceps activity (timing, intensity, torque production).12


Physiologic Differences Between Male and Female Muscle Systems

Feature Male Female
Adolescent hormonal changes Increase in lean muscle mass Increase in fat deposits: breast development, widening of hips
No increase in muscle mass
Strength Greater strength development 75% of the strength that males have
Muscle type Higher proportion of type II fibers (fast twitch) Higher proportion of type I fibers (slow twitch)
Stabilization Contract hamstrings with anterior tibial perturbation Contract quadriceps with anterior tibial perturbation
More ability to contract surrounding knee muscles with loaded internal rotation Less ability to contract muscles around the knee with loaded internal rotation
More ability to stabilize the knee in anterior-posterior plane Less ability to stabilize knee in anterior-posterior plane
Pain and injury Higher rates of patellofemoral pain
Higher rates of anterior cruciate ligament injuries

Data from references 12 to 17.

A final consideration in the connection between the hip and pelvis is related to neural connections. Several nerves travel from the lower trunk and pelvis to the hip, thigh, and perineal structures (refer to Fig. 1-6). The ilioinguinal, iliohypogastric, lateral femoral cutaneous, and femoral nerves exit laterally from the psoas muscle. The genitofemoral nerve travels through the belly of the psoas. The obturator nerve exits medially from the psoas muscle to travel through the obturator foramen. Each of these nerves can become compressed and irritated with iliopsoas tightness or involvement,11 or with anatomical changes during pregnancy.18 Additionally, the sciatic nerve passes superiorly, through, or inferiorly to the piriformis muscle; piriformis spasm or strain may result in sciatic nerve irritation.11 Compression of the lateral femoral cutaneous nerve can occur with compression between the inguinal ligament and abdomen or tight clothing, with resulting paresthesia of the lateral thigh.11 Neural connections between the hip and pelvis are discussed further in this chapter in relation to specific conditions.

Standardized Terminology of Pelvic Muscle Function

The International Continence Society formed the Pelvic Floor Clinical Assessment Group, which published standardized terminology related to pelvic diaphragm muscles in 2005.19 The intent was to develop terms related to pelvic muscle function that could be used across health care providers and facilitate clear communication among these different groups of practitioners. A multidisciplinary group was involved in establishing this terminology.

The term pelvic floor muscles describes the muscular layer of the pelvic outlet, extending from the peritoneum of pelvic viscera (most cranial) to the skin of the vulva, scrotum, and perineum (most caudal). However, in this chapter, this muscular layer is referred to as the “pelvic muscle diaphragm,” as described previously.8,9 The term diaphragm versus floor is chosen here because floor likely creates an image of a static and flat structure, whereas diaphragm contributes to the image of a bowl or funnel-shaped structure that has dynamic features. Healthy pelvic diaphragm muscles are in fact not flat, but have sturdy thick layers of bowl or funnel shapes that, when functioning properly, are very dynamic in their ability to elevate and support the contents of the trunk and pelvis while also providing continence and stabilizing the pelvic girdle joints and lower spine. This funnel of muscle normally lies horizontally, to give “floor” support when the pelvis and spine are in a neutral position (with normal lordosis).

Terminology was also established to describe pelvic diaphragm muscle function (Table 9-4). Normal pelvic diaphragm muscle function occurs when these muscles are able to contract and relax on command.19 Additionally, the muscles respond appropriately to an increase in intraabdominal pressure. For instance, if a patient coughs, sneezes, or exerts force with the trunk and upper body (as when lifting a heavy item), then the pelvic diaphragm muscles will contract to provide closure of pelvic outlets (urethra and anus, to maintain continence) and provide support to the trunk and pelvis as a deep core stabilizing muscle. With normal function, a strong and normal voluntary contraction is observed with internal pelvic muscle examination. A normal involuntary contraction is also observable and palpable as appropriate, such as with instruction to cough during examination. The ability to relax the muscle completely on command is also noted.19 With normal function of the pelvic diaphragm muscles, a person will report normal bladder, bowel, and sexual function.


Pelvic Diaphragm Muscle Function: Standardized Terminology From the International Continence Society

Pelvic Muscle Term Description of Muscle Function Signs and Symptoms
Normal muscle function

Able to contract on command

Able to relax on command

Able to contact and relax in response to changes in intraabdominal pressure as appropriate

Normal or strong voluntary and involuntary contraction

Complete relaxation on command

Normal bladder, bowel, and sexual functioning

Underactive muscle function Unable to contract adequately (or at all) on command or when required for function

Absent or weak voluntary and involuntary contraction

Urinary or anal incontinence

Pelvic organ prolapse

Loss of sexual function or sensation

Pelvic girdle or low back pain20

Overactive muscle function Unable to relax fully or adequately as needed

Partial or absent voluntary muscle relaxation

Obstructed urination or defecation

Dyspareunia or vaginismus

Pelvic pain

Nonfunctioning muscle No muscle contraction palpable with internal vaginal or rectal examination

No signs of muscle contraction or relaxation

Any dysfunctional symptom may be present

Data from Messelink B, Benson T, Berghmans B, et al. Standardization of terminology of pelvic floor muscle function and dysfunction: report from the pelvic floor clinical assessment group of the International Continence Society. Neurourol Urodyn. 2005;24:374-380.

Underactive pelvic diaphragm muscle function causes the muscles to be unable to contract adequately or at all on command or as needed for function.19 Thus, the muscles do not provide adequate closure to pelvic outlets, potentially resulting in urethral leakage of urine or anal leakage of feces, liquid, mucus, or gas. Additionally, the muscle may not provide adequate support to the pelvic organs, and this situation may result in pelvic organ prolapse (descent of a pelvic organ below its normal location).19 Various types of pelvic organ prolapse can occur and may involve the bladder, urethra, rectum, lower intestine, cervix, uterus, or perineum (Table 9-5). This lack of muscular support may also contribute to low back pain, pelvic girdle pain, and inadequate core muscle control for a variety of functions.20 Finally, lack of adequate pelvic muscle contraction may contribute to a decrease in sexual function because contraction of the pelvic diaphragm muscles contributes to sexual sensation and orgasm.21,22 However, sexual function is multifactorial, and other factors may result in or contribute to a lack of desired sexual function.


Types of Pelvic Organ Prolapse in Female Patients

Prolapse Type Description
Apical prolapse Descent of cervix and uterus inferiorly into vaginal canal (causing vaginal canal to invert on itself); in extreme cases, cervix and uterus may protrude externally through vaginal opening
Cystocele Descent of bladder into anterior vaginal wall
Urethrocele Descent of urethra into anterior vaginal wall; typically occurs with cystocele
Rectocele Descent of rectum into posterior vaginal wall
Enterocele Descent of lower intestine into vaginal wall (variable locations)
Anal prolapse Descent of anal tissues externally through anus
Rectal prolapse Descent of rectal tissues externally through anus (causing inversion of rectum on itself)
Perineal descent Bulging of perineal tissues inferiorly away from pelvis and trunk

Overactive pelvic diaphragm muscle function causes the muscles to be unable to relax adequately or at all for necessary functions that require a “release” of the muscles and an opening of the pelvic outlets.19 This lack of relaxation may cause the urethra to have an inadequate opening to release urine, possibly resulting in hesitancy of the start of the urinary stream, “staccato” urination in which the stream stops and starts, a weak or “spraying” urinary stream, urinary urgency, or incomplete emptying of the bladder. In extreme cases, overactive muscles can cause complete obstruction of urination, although this is most likely to result after trauma to the pelvic muscles and urethral structures. Anal and bowel function can also be affected because the overactive muscles obstruct the lower rectum and anal region, thus possibly resulting in difficulty releasing gas or feces, chronic constipation, or incomplete evacuation of feces. Finally, overactivity can cause muscle tension, myofascial pain and trigger points leading to pelvic pain symptoms, and obstruction of the vaginal opening (introitus) leading to vaginismus. Vaginismus, as described later, is a condition in which entry into the vaginal opening and canal is painful, and in some cases impossible, such as for insertion of a tampon or of a penis for sexual activity. Similar to vaginismus is dyspareunia, which is pain with sexual activity. Dyspareunia is often associated with pain during intercourse, but it can also occur with arousal or orgasm without sexual penetration. This pain with sexual activity may also occur in areas away from the vagina and pelvis, such as the lower abdomen, low back, buttocks, hips, and thighs.

The Connection: Pelvic Diaphragm Muscles and Low Back, Pelvic Girdle, and Hip Pain and Conditions

This section of the chapter begins to examine the various patient populations in which the female pelvis is a factor in lumbopelvic-hip complex dysfunction and symptom development. The different patient classifications that are described through the remainder of the chapter are summarized in Table 9-6.


Summary of Chapter Key Findings in Female Patients With Lumbopelvic-Hip Complex Dysfunctions*

Patient Classification Patient Profile Common Mechanisms Interventions, Rehabilitation, and Programming
Connection: pelvic diaphragm muscles and low back, pelvic girdle, and hip pain

Lack of research to identify common demographics

May or may not have bladder, bowel, or sexual symptoms

Symptoms also may occur in pelvis or refer to distal structures

Aging sacroiliac joint referral

Obturator internus muscle contribution to anterior groin or posterolateral hip pain and to bladder urgency or frequency

Pelvic diaphragm muscle involvement in pelvic girdle symptoms

Poor pelvic diaphragm muscle recruitment or substituting Valsalva for muscle contraction

Addressing deep stabilizing core muscles with nonspecific low back pain (transversus abdominis, multifidus, pelvic diaphragm muscles, breathing diaphragm): focus on slow, controlled contraction with body awareness

Avoiding cues for “bracing” or “drawing in” toward umbilicus (inhibits deep core muscles)

Progressing muscle training to functional movement and positions

Addressing posture and positions: optimal neutral or “tall” postures promote core muscle function

Chronic pelvic pain

4%-20% of women

Ages 15-50 yr

Up to 60% have not received a specific diagnosis

Up to 20% have not had diagnostic testing

Risk factors: psychosocial issues, miscarriage, long menstrual cycles, pelvic inflammatory disease, abuse history (sexual, psychological, physical)

Altered postural habits

33%-35% of diagnostic laparoscopies reveal no pathologic features

Pain may arise from musculoskeletal, gynecologic, urologic, gastrointestinal, or neurologic systems

Increased sensitization in the nervous system

Musculoskeletal and neural focus: intrapelvic compression or injury of nerves

Pelvic diaphragm muscle underactivity causing decreased support of joints and structures

Pelvic diaphragm muscle overactivity causing trigger points, decreased introital size

Sacrococcygeal joint injury or strain

Surgical trauma

Reduction of stressors to involved neural structures (postures, positions, use of cushions)

Education in chronic pain development and pain science

Encouraging multidisciplinary team approach to address physical and psychological factors

Encouraging holistic approach (e.g., including stress management, sleep hygiene, relaxation techniques, diet)

Muscle training and reeducation to address motor control problems: core muscle focus with normalized breathing patterns

Progression of muscle training to dynamic movement and functional movements

Physical agents and manual therapy used as needed, with care for patient to not become “dependent” on passive treatments

Neural mobilization techniques and reduction of stress to neural tissues with positioning education

The prenatal woman

20% of all pregnant women experience pelvic girdle pain, with pain between the iliac crests and gluteal fold, decreased tolerance to prolonged activities or postures (“fidgety”), “catch” in hip

Other common pain conditions include muscle overuse conditions, round ligament pain, trochanteric bursitis of the hip

TOH is rare but can occur specifically to pregnancy

Preterm labor may be misdiagnosed as benign lumbopelvic pain

Urinary symptoms may develop

Hormonal changes contribute to increase in lumbopelvic-hip laxity

Increase in laxity can lead to poor motor control

Postural changes of increase in lumbar lordosis, anterior pelvic tilt, forward head posture

Overuse conditions with increase in use of hip abductors, hip external rotators, hip extensors, ankle plantar flexors

Round ligament undergoes considerable stretch with growth of uterus and may lead to anterior groin pain, particularly with sit to stand or quick transitional movements

Trochanteric bursitis may result from increase mass and side-lying sleep position

TOH (rare) may develop from hormonal and biomechanical factors, with sudden and severe pain in hip joint and difficulty bearing weight on affected side

Preterm labor may cause “cramping” in low back or abdomen

The growing uterus compresses bladder and pelvic diaphragm; pelvic joint laxity creates challenges for pelvic diaphragm muscles; these may contribute to incontinence

Sacroiliac support belt if load transfer tests are positive (e.g., ASLR)

Pregnancy abdominal support belt to alleviate round ligament pain

Strengthening of transversus abdominis and deep core muscles to improve motor control and reduce pelvic girdle, low back, and round ligament pain

Addressing deep stabilizing core muscles (transversus abdominis, multifidus, pelvic diaphragm muscles, breathing diaphragm) with focus on slow, controlled contraction with body awareness

Avoiding cues for “bracing” or “drawing in” toward umbilicus (inhibits deep core muscles)

Progressing muscle training to functional movement and positions

Addressing posture and positions: optimal neutral or “tall” postures promote core muscle function

Reassurance that pelvic girdle pain symptoms can be managed with motor control techniques

Normalizing posture to reduce strain on hip abductors, adductors, external rotators, extensors

Avoiding asymmetrical postures (e.g., cross-legged sitting or stance with weight toward one leg)

Manual therapy to address trigger points or pain relief of joints

Use of heat or cold therapies (except directly over abdomen)

Education in transitional movement patterns or control, sleep positioning, and supports

Targeted pelvic diaphragm muscle training as needed for bladder or bowel symptoms

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Apr 27, 2020 | Posted by in ORTHOPEDIC | Comments Off on The Female Hip and Pelvis

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