Low Back Pain and Pelvic Floor Dysfunction

Low back pain (LBP) is pain localized to the lumbar region, with or without radiation to the lower limbs, where the cause is often unknown.¹ The association between LBP and pelvic floor dysfunction (PFD) is increasingly recognized in the literature, particularly in women.² However, the specific characteristics that define this correlation remain unclear. Pelvic floor dysfunction occurs when the pelvic floor muscles do not contract appropriately, which may lead to urinary incontinence, genital prolapse, fecal incontinence, and other sensory and voiding disorders of the lower urinary and GI tracts.³ PFD is a complex condition that may be characterized by weakness, poor endurance, increased tone, shortened length, or overactivity.² Studies show that individuals with LBP have reduced pelvic floor function compared with those without LBP.⁴

Epidemiology and Etiology

LBP is one of the most common musculoskeletal disorders; up to 70–80% of the population will experience at least one episode in their lifetime. Causes are multifactorial—trauma, disease, or poor posture—yet only ~15% of cases can be attributed to a specific cause.⁴ There is often poor concordance between pathology, pain, and functional loss.⁴

Over 25% of all women and more than one-third of women over 65 experience PFD. True prevalence is likely higher due to study heterogeneity, lack of standardized definitions, and under-reporting.⁵ Although PFD is a physiological condition, psychosocial consequences can be significant and markedly reduce quality of life. The prevalence of PFD is expected to increase by 50% over the next 30 years due to population aging among women.⁵ Etiology is commonly multifactorial and includes anatomical, physiological, genetic, reproductive, and lifestyle factors.¹⁵

Key risk factors:

• Pregnancy and childbirth

• Age

• Hormonal changes

• Overweight/obesity

• Lower urinary tract infections

• Prior pelvic surgery

A longitudinal study showed that women with urinary incontinence, GI problems, and breathing disorders had an increased risk of developing LBP compared with women without such issues.⁶ This is thought to reflect changes in morphology and altered motor control in the “core” musculature (including respiratory and continence muscles) that stabilize the spine and pelvis.⁷

Anatomy

Lumbopelvic stability system: Bony/ligamentous structures, muscular compression forces, and the nervous system together stabilize the lumbar spine and pelvis. This includes lumbar vertebrae, pelvis, pubic symphysis, and sacroiliac joints. The diaphragm, transversus abdominis, pelvic floor muscles (PFM), and multifidus act synergistically to regulate intra-abdominal pressure and tension in the thoracolumbar fascia—key for postural control.⁸

The pelvic floor forms the inferior boundary of the abdominal cavity and supports the pelvic organs.⁵ PFMs are the body’s only transverse load-bearing muscle group and work as a unit to prevent leakage during lifting, sneezing, coughing, and laughing. PFMs, deep abdominals, and multifidus also stabilize the lumbar spine via a feedforward mechanism responding to load changes.⁴ ⁷

Clinical Presentation

Common features in patients with LBP and PFD:

• Middle-aged or older women

• Vaginal delivery (risk increases with parity)³

• Overweight/obesity⁵

• Lumbopelvic pain

• Urinary incontinence

• Chronic constipation

• Chronic pelvic pain

• Dyspareunia (pain with intercourse)²

Studies show women with PFD often display posterior pelvic tilt and reduced lumbar lordosis. Sacroiliac pain can reduce motor control in the PFM.⁴ Men can also experience PFD, though less commonly due to anatomical differences; the male pelvis is more compact, allowing faster proprioceptive feedback and muscle recruitment.⁹

Differential Diagnoses

Because PFD and LBP often present with nonspecific symptoms and poor pathology–symptom concordance,⁵ consider:

• Cauda equina syndrome

• Sexual dysfunction

• Urinary tract infection

Assessment

Anamnese

History

A thorough history is essential to screen for red flags and to understand functional impact. Use questions to uncover signs of PFD:

• How often do you urinate? (Normal: every 2–4 hours or 6–8 times/day)

• Do you leak with coughing, sneezing, laughing, or physical activity?

• Do you experience a sudden strong urge to urinate that leads to leakage?

• Do you have difficulty reaching the toilet in time?

• Have you ever lost control of your bowels?⁹

For LBP, use the Oswestry Disability Index (ODI) to assess disability. Based on results, select a treatment strategy aligned with a classification system or an impairments-based approach.

Physical Examination

• Posture observation

• Palpation

• Neurological screening

• Active lumbar and hip range of motion

• Lumbar joint mobility

• Exclude hip involvement (Scour Test, FABER). A cross-sectional study² indicates that a Forced FABER may predict pelvic floor tenderness—a sign of PFD.

• Assess the sacroiliac joint (Posterior Shear Test, Gaenslen’s Test)

Most patients with combined LBP and PFD benefit from stabilization strategies. Prioritize the patient’s primary complaints before proceeding to a full pelvic floor exam.

Full Pelvic Floor Examination

• Vaginal palpation: qualitatively assess contraction as correct/incorrect. Digital exam provides valuable insight into the relationship between lumbopelvic pain and PFM function. Pelvic floor tenderness was the most common finding in the study,² followed by PFM weakness.

• Transabdominal ultrasound: evaluates voluntary and involuntary activation of PFM and transversus abdominis.

• PFM strength grading: use a perineometer and/or needle EMG for quantitative data.⁴ ⁷ ¹⁰

Medical Management

Pharmacologic Therapy

Pharmacotherapy targets incontinence symptoms rather than PFD directly. Aim: increase urethral pressure by stimulating striated and smooth muscle in the urethra.¹¹ For LBP, analgesics or corticosteroid injections may provide symptom relief but do not address PFD or the underlying cause of LBP.

Surgical Treatment

Consider surgery when symptoms persist despite conservative care (e.g., physiotherapy) and substantially affect daily life.

Procedures for PFD include:

• Pubovaginal sling

• Artificial urinary sphincter implantation

• Mid-urethral sling¹²

Physiotherapy Management

Physiotherapy for LBP with PFD includes pelvic floor training, manual therapy, biofeedback, movement pattern retraining, and behavioral modification. Manual therapy and biofeedback increase pelvic floor awareness and improve contraction/relaxation control and strength.

Pelvic floor control is crucial for preventing urinary incontinence and treating pelvic pain. Evidence shows pelvic floor training plus biofeedback outperforms training alone; electrical stimulation may further enhance effects.¹³ ¹⁴

A study by Xia B et al.¹⁵ found pelvic floor exercises plus routine care improved pain and function more than routine care alone. PFMs can also be activated via co-activation of abdominal muscles; conversely, abdominal “hollowing” or “bracing” can reflexively activate PFMs.⁷ ¹⁶

An RCT⁷ comparing routine physiotherapy with and without added pelvic floor training in 20 women with chronic LBP showed improvements in PFM strength/endurance and reduced pain/disability, but no significant between-group difference, suggesting that adding PFM training to routine care does not always yield superior outcomes.

Nevertheless, there is good evidence to include exercises that promote neuromuscular control of the pelvic floor and deep abdominals.¹⁷ PFM training is also well supported as conservative treatment for stress incontinence.⁸

Exercise Progression for PFD and LBP¹⁸

Diaphragmatic Breathing

• How: Sit upright, one hand on chest and one on abdomen; breathe quietly, allowing the abdomen to rise.

• Goal: Reduce upper-chest lifting and increase IAP.

• Dose: Continuous, integrated into daily activities.

Tonic Activation

• How: Fingers medial to ASIS for tactile feedback; activate transversus abdominis (co-activates PFM).

• Goal: Sustained PFM activation via TrA.

• Dose: 5 reps, 5×/day; progress to 30–40-second holds.

Muscle Strengthening

• How: Supine, perform ADIM with maximal PFM activation (“stop the flow”).

• Goal: Strengthen PFMs/abdominals to enhance spinal stability.

• Dose: Hold 3–5 s, count aloud.

Functional Expiratory Patterns

• How: Sitting, steady nasal exhalation with concurrent PFM activation.

• Goal: Train PFM responses to functional challenges (sneeze/cough).

• Dose: 5 repetitions.

High-Impact Activities

• How: Gradually reintroduce patient-specific high-impact tasks with PFM activation.

• Goal: Transfer activation patterns to daily life.

• Dose: Individually progressed.

Lumbar Stabilization Training¹⁹

Transversus Abdominis

• Abdominal bracing: 8-s holds × 20

• Bracing + heel slides: 4-s × 20

• Bracing + leg lifts: 4-s × 20

• Bracing + bridge: 8-s × 30

• Standing bracing: 8-s × 30

Multifidus

• Quadruped arm lift + bracing: 8-s × 30

• Quadruped leg lift + bracing: 8-s × 30

• Quadruped alternating arm/leg + bracing: 8-s × 30

Obliques

• Side plank (knees bent): 8-s × 30

• Side plank (knees straight): 8-s × 30

  
  

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