The Most Common Functional Disorders and Factors Affecting Female Pelvic Floor

Screening for Incidence and Effect of Pelvic Floor Dysfunction in College-Aged Athletes

Background

Pelvic floor dysfunction (PFD) occurs when muscles of the pelvic floor become weakened, impaired, or experience tension leading to a variety of complications. Due to the reactive nature and high demands of many sports, athletes are at increased susceptibility and of particular interest concerning PFD.

Hypothesis/Purpose

The purpose of this study was to explore the prevalence of PFD among college-aged athletes, assess how PFD impacted athletic performance, and identify contributing factors for increased likelihood of PFD in athletes.

Study Design

Cross-Sectional Study.

Methods

All fully active LVC NCAA Division 3 athletes were recruited for screening for PFD using the Cozean Pelvic Dysfunction Screening Protocol and were surveyed on their self-knowledge of PFD. Athletes who scored ≥ 3 on this tool completed an additional survey, created by the investigators, to identify the impact PFD had on their athletic performance and personal life and were then randomly assigned to one of three investigators to undergo a noninvasive coccygeal assessment to determine underactive, overactive, or normal pelvic floor muscle (PFM) activity.

Results

Fifty-three Division III male and female athletes between the ages of 18-25 years old participated in the study. Statistically significant differences were found between Cozean scores and demographic factors of age (p \<0.001), gender (p \<0.05), self-knowledge of PFD (p \<0.001), and sport (p \<0.001) among all participants that contributed to the increased likelihood of PFD. Thirteen athletes scored ≥ 3 on the Cozean with the 92.3% experiencing under/over active PFM activity and the majority indicating that PFD significantly impacted their athletic performance and quality of life.

Conclusion

The results indicate that older female NCAA Division III college athletes who participate in swimming and who possess self-knowledge of PFD are more likely to experience PFD. Additionally, these athletes are likely to encounter a significant impact on their athletic performance and quality of life. These results provide preliminary evidence on the need of PFD awareness and assessment among college athletes.

Level of Evidence

Level 3b.

Technologies for Evaluation of Pelvic Floor Functionality: A Systematic Review

Pelvic floor dysfunction is a common problem in women and has a negative impact on their quality of life. The aim of this review was to provide a general overview of the current state of technology used to assess pelvic floor functionality. It also provides literature research of the physiological and anatomical factors that correlate with pelvic floor health. This systematic review was conducted according to the PRISMA guidelines. The PubMed, ScienceDirect, Cochrane Library, and IEEE databases were searched for publications on sensor technology for the assessment of pelvic floor functionality. Anatomical and physiological parameters were identified through a manual search. In the systematic review, 114 publications were included. Twelve different sensor technologies were identified. Information on the obtained parameters, sensor position, test activities, and subject characteristics was prepared in tabular form from each publication. A total of 16 anatomical and physiological parameters influencing pelvic floor health were identified in 17 published studies and ranked for their statistical significance. Taken together, this review could serve as a basis for the development of novel sensors which could allow for quantifiable prevention and diagnosis, as well as particularized documentation of rehabilitation processes related to pelvic floor dysfunctions.

Ultrasound imaging of core muscles activity in multiparous women with vaginal laxity: a cross-sectional study

Vaginal laxity (VL) is a common condition among multiparous women, especially those who have delivered vaginally. Since pelvic floor muscles (PFMs) work synergistically with other core muscles, physical therapy protocols that aim to treat VL should train the PFMs in combination with other core muscles. To investigate the activity of core muscles in multiparous women with and without VL, and its relation to sexual function. An observational, cross-sectional study. The study included 100 multiparous women, who were divided into two groups according to their scores on the vaginal laxity questionnaire (VLQ). Women who scored between 1 and 3 on the VLQ were categorized as having VL (n = 48), while those who scored between 5 and 7 were placed in the control group (n = 52). The primary outcomes were PFM displacement, diaphragmatic excursion, transversus abdominis activation ratio, and lumbar multifidus thickness measured by ultrasound imaging. The secondary outcome was sexual functioning, evaluated using the Arabic female sexual function index (ArFSFI). The VL group had significantly lower PFM displacement (mean difference (MD) - 0.42; 95% confidence interval (CI) - 0.49 to - 0.33; p = 0.001), diaphragmatic excursion (MD - 2.75; 95% CI - 2.95 to - 2.55; p = 0.001), lumbar multifidus thickness (MD - 10.08; 95% CI - 14.32 to - 5.82; p = 0.02), and ArFSFI scores (MD - 9.2; 95% CI - 10.59 to - 7.81; p = 0.001) in comparison to the control group (p < 0.05). Nevertheless, the transversus abdominis activation ratio demonstrated no significant difference between the two groups (MD 0.06; 95% CI - 0.05 to 0.17; p = 0.33). Multiparous women with VL had significantly lower PFM displacement, diaphragmatic excursion, lumbar multifidus thickness, and sexual function index scores than women in the control group. The only exception was transversus abdominis activation, which did not differ significantly between the VL and control groups.

Is there a synergistic relationship between diaphragm and pelvic floor muscles in pregnant women?

OBJECTIVE

The aim of this study is to examine whether there is a synergistic relationship between the diaphragm and pelvic floor muscles (PFM) in pregnant women.

MATERIAL AND METHODS

Our study was carried out as a cross-sectional study in primigravid pregnants in the second and third trimesters. Superficial electromyography (EMG), 2D/3D ultrasonography (USG), pulmonary function test (PFT), PERFECT, maximum expiratory pressure (MEP) and inspiratory pressure (MIP) measurements were used to evaluate pelvic floor and diaphragm muscle functions during pregnancy. Mann-Whitney U test was used to show the change in the second and third trimesters, and Spearman correlation was used to determine the relationship.

RESULTS

No correlation was found between the EMG data of the PFM and diaphragm, or between the USG data of the PFM and diaphragm in all participants, in the second and third trimesters. In the third trimester of the study, diaphragmatic thickness and levator hiatal area (LHA) decreased and both diaphragm and PFM % MVC EMG parameters increased. In the third trimester, FVC, MIP, MEP decreased, and nonsignificant increase in FEV1, FEV1/FVC and peak ekspiratuar flow(PEF) were detected. A significant correlation was found between pelvic floor levator hiatal area USG and FEV1/FVC in both trimesters (r: 0,577p: 0,004).

CONCLUSION

There may be a synergistic relationship between the diaphragm and PFM in pregnant women, the relationship may weaken as pregnancy progresses, and there may be no coactivation relationship between the two muscles. In order to prevent the occurrence of pelvic floor dysfunction during pregnancy and to increase the effect of rehabilitation programs, the relationship between the diaphragm and the PFM should be determined and more studies should be conducted.

Prevalence of Pelvic Floor Disorders in Parous Women from the Tibet Autonomous Region: A Cross-Sectional Study

Purpose

Pelvic floor disorder (PFD) seriously affects the everyday life of women. This cross-sectional study aimed to evaluate the prevalence and risk factors for postpartum PFD in women living in the Tibet Autonomous Region (TAR).

Methods

Parous women who attended the outpatient gynaecology clinic at our hospital between June 2022 and August 2022 were screened in this study. The demographic and clinical data of these women were collected. Their pelvic floor functions were evaluated via a pelvic organ prolapse (POP) quantification examination, the Pelvic Floor Distress Inventory Questionnaire-20 (PFDI-20) and the Overactive Bladder Symptom Score (OABSS).

Results

A total of 201 women were included in this study, of whom 81.09% (163/201) were Tibetan. Twenty-seven women (13.43%) were diagnosed with POP stage ≥2 and 27 women (13.43%) with an OABSS score ≥3. The median PFDI-20 total score was 4.17 (range 0-43.75). Han women (n = 38) in the TAR had much lower PFDI-20 total scores, compared with Tibetan women (n = 163) (p < 0.05). The results of the multiple linear regression models showed that the PFDI-20 scores obtained from women living in the TAR were closely related to parity, history of heavy weight lifting, age, history of instrumental deliveries, ethnicity and number of caesarean sections.

Conclusion

Pelvic floor disorder is common among parous women living in the TAR. Ethnicity, parity, history of heavy weight lifting, age, history of instrumental deliveries and number of caesarean sections are the factors closely related to the PFDI-20 scores.

A feasibility study of three-dimensional ultrasound imaging of the vagina under distension

BACKGROUND

The distension properties of the vagina are critical to its function including support of surrounding organs, childbirth, and intercourse. It could be altered by many pathophysiological processes like pregnancy, radiotherapy, and reconstruction surgery. However, there are no clinically available diagnostic tools capable of quantifying the distension properties of the vagina.

PURPOSE

A proof-of-concept study was designed to assess the feasibility of a novel three-dimensional (3D) ultrasound imaging technique that allows quantitative evaluation of the vagina under distension.

METHODS

Patients with symptomatic pelvic organ prolapse (POP) were recruited for the study. An ultrathin, oversized bag was inserted into the vagina and filled with water using a modified urodynamics system. The instilled water volume and intravaginal pressure were continuously recorded. At maximum vaginal capacity, 3D transintroital ultrasound of the distended vagina and surrounding pelvic structures was performed. Exams were performed in duplicate for each patient, two hours apart (round A and round B). Following the development of a 3D surface model of the distended vagina from each scan, several measurements were obtained, including cross-sectional area, anteroposterior (AP) length and lateral width in the plane of minimum hiatal dimensions (PMHD), AP and lateral diameter at the pubic symphysis (PS) level, maximum and minimum diameter, and maximum vertical length. To assess repeatability between measurements in two rounds, the coefficient of variation (CV) and the intraclass correlation coefficient (ICC) were calculated for each measurement. Correlations between physical measurements including the pelvic organ prolapse quantification (POP-Q) system and vaginal diameter measurements, and obtained metrics were also assessed.

RESULTS

Sixteen patients with POP (average age 69 years) completed both rounds of imaging. There was sufficient echogenicity on 3D transintroital ultrasound of the distended vaginal wall to establish boundaries for 3D surface models of the vagina. Overall, all metrics had good or excellent reliability (ICC = 0.77-0.93, p < 0.05; CV = 3%-18%) except maximum diameter, which demonstrated only moderate reliability (ICC = 0.67, p = 0.092). Strong correlations were found between physical exam measurements including D point of POP-Q, introitus diameter and lateral diameter at apex, and maximum vaginal capacity, maximum vertical length, lateral diameter at PS, minimum diameter, and distended PMHD measurements. The results demonstrated that this system could generate 3D models of the shape of the distended vagina and provide multiple metrics that could be reliably calculated from automated analyses of the models.

CONCLUSIONS

A novel system for evaluation of the distension properties of the vagina was developed and preliminary evaluation was performed. This system may represent a technique for evaluation of the biomechanical and structural properties of the vagina.

Most of the pelvic floor muscle functions in women differ in different body positions, yet others remain similar: systematic review with meta-analysis

Objectives

This systematic literature review and meta-analysis aimed to determine the effect of body position on the measurement of pelvic floor muscle (PFM) contractility and to analyze the influential factors.

Data sources

Five databases (PubMed, Web of Science, EMBASE, Cochrane Library and Scopus) were searched for relevant studies published up to 12nd October 2023.

Study selection or eligibility criteria

Included cross-sectional studies had to involve the assessment of pelvic floor muscle function in at least two positions.

Study appraisal and synthesis methods

We calculated standardized mean difference (SMD) with 95% confidence intervals (CI) to ascertain the potential effect of body position on outcomes.

Results

In total, we included 11 cross-sectional studies to ascertain the potential effect of body position on outcomes. There was no statistical difference in the results of maximum voluntary contraction (MVC) of the pelvic floor muscles when assessed in between supine and standing positions (SMD -0.22; 95% CI -0.72 to 0.28; p = 0.38). The results of the meta-analysis showed significantly larger values of resting voluntary contractions (RVC) measured in the standing position compared to the supine position (SMD -1.76; 95% CI -2.55 to -0.97; p < 0.001). Moreover, pelvic floor muscle movement during pelvic floor muscle contraction in the standing position was significantly better than that measured in the supine position (SMD -0.47; 95% CI -0.73 to 0.20; P < 0.001).

Conclusion

The results of this study showed that the RVC and PFM movement varied with the position of the assessment. In contrast, MVC values are independent of the assessment position and can be selected according to clinical needs.

Systematic review registration

PROSPERO, identifier CRD42022363734, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022363734.

Transperineal pelvic floor ultrasound for assessing posterior pelvic injury and prolapse in postpartum women

OBJECTIVE

To analyze the association between transperineal pelvic floor ultrasound findings and posterior pelvic injury and prolapse in postpartum women.

METHODS

A total of 108 postpartum women received treatment from January 2020 and December 2022 were divided into 2 groups, with 53 cases in a pelvic floor disorder (PFD) group and 55 cases in the no PFD group according to whether they developed PFD after delivery. The relationship between ultrasound data and the Pelvic Floor Distress Inventory (PFDI-20) scores was analyzed by Pearson correlation. The diagnostic value of transperineal pelvic floor ultrasound for PFD was analyzed by using the receiver operating characteristic curve, and the relationship between transperineal pelvic floor ultrasound parameters and PFD was analyzed by using the RR hazard ratio.

RESULTS

The distance from the bladder neck to the posterior inferior border of the pubic symphysis, the distance from the cervix to the posterior inferior border of the pubic symphysis, and the shortening rate during retraction were shorter or lower in the PFD group than those in the no PFD group. Additionally, bladder descent, cervical subluxation, urethral rotation, anterior and posterior diameters of the static levator ani muscle (LAM), anterior and posterior diameters of the retracted LAM, anterior and posterior diameters of the LAM in the maximal Valsalva maneuver, and PFDI-20 scores in the PFD group were longer or higher than those of the no PFD group (P<0.01). Shortening rate during retraction, bladder descent, cervical subluxation, urethral rotation, and elongation at maximal Valsalva maneuver were positively correlated with the PFDI-20 score (R = 0.027, 0.053, 0.102, 0.002, 0.011, 0.123, respectively, all P<0.05).

CONCLUSIONS

The degree of bladder descent, cervical subluxation, urethral rotation, shortening rate during retraction, and elongation at maximal Valsalva maneuver are closely related to the PFD I-20 score.

Pelvic floor dysfunction: prevalence and associated factors

BACKGROUND

Pelvic floor dysfunction in women encompasses a wide range of clinical disorders: urinary incontinence, pelvic organ prolapse, fecal incontinence, and pelvic-perineal region pain syndrome. A literature review did not identify any articles addressing the prevalence of all pelvic floor dysfunctions.

OBJECTIVE

Determine the prevalence of the group of pelvic floor disorders and the factors associated with the development of these disorders in women.

MATERIAL AND METHODS

This observational study was conducted with women during 2021 and 2022 in Spain. Sociodemographic and employment data, previous medical history and health status, lifestyle and habits, obstetric history, and health problems were collected through a self-developed questionnaire. The Pelvic Floor Distress Inventory (PFDI-20) was used to assess the presence and impact of pelvic floor disorders. Pearson's Chi-Square, Odds Ratio (OR) and adjusted Odds Ratio (aOR) with their respective 95% confidence intervals (CI) were calculated.

RESULTS

One thousand four hundred forty-six women participated. Urinary incontinence occurred in 55.8% (807) of the women, fecal incontinence in 10.4% (150), symptomatic uterine prolapse in 14.0% (203), and 18.7% (271) reported pain in the pelvic area. The following were identified as factors that increase the probability of urinary incontinence: menopausal status. For fecal incontinence: having had instrumental births. Factors for pelvic organ prolapse: number of vaginal births, one, two or more. Factors for pelvic pain: the existence of fetal macrosomia.

CONCLUSIONS

The prevalence of pelvic floor dysfunction in women is high. Various sociodemographic factors such as age, having a gastrointestinal disease, having had vaginal births, and instrumental vaginal births are associated with a greater probability of having pelvic floor dysfunction. Health personnel must take these factors into account to prevent the appearance of these dysfunctions.

Evaluation of sexual dysfunction in females with neck and upper back myofascial pain syndrome: a cross-sectional study

Myofascial pain syndrome (MPS) is a prevalent chronic musculoskeletal pain disorder that is frequently encountered in clinical practice and can cause sexual dysfunction in women. While there have been studies examining sexual function in various painful rheumatic conditions, particularly fibromyalgia, no studies have been conducted specifically on primary MPS. In this context, we aimed to investigate the frequency of sexual intercourse and the factors associated with it in women diagnosed with MPS. The study was designed as a cross-sectional study at a tertiary rehabilitation center between May 2022 and April 2023. Forty-five consecutive sexually active women (mean age: 38.1 ± 6.8 years) diagnosed with primary MPS were included in the study. They were compared to 45 healthy women of similar ages. The participants were interviewed regarding their weekly frequency of sexual intercourse and the importance of sexual life. Also, the Beck Depression Inventory (BDI) and the Visual Analog Scale (VAS) were assessed. The importance of sexual life score (p = 0.008), BDI (p < 0.001), VAS pain (p < 0.001), and VAS fatigue (p < 0.001) values were found to be lower in the patient group compared to the control group. The frequency of sexual intercourse was lower in the patient group, although this difference did not reach statistical significance (p = 0.083). In patients with a higher BDI score (≥ 17), the number of sexual intercourse was lower (p = 0.044), and the severity of fatigue was higher (p = 0.013). Significant associations were observed in MPS patients between the weekly frequency of sexual intercourse and VAS pain, VAS fatigue, BDI, and the importance of the sexual life score. A positive correlation was observed between the number of weekly sexual intercourses and the importance of the sexual life score (r = 0.577, p < 0.001), and negative correlations were found between BDI (r = - 0.478, p < 0.001), VAS pain (r = - 0.409, p < 0.001), and VAS fatigue (r = - 0.439, p < 0.001). Patients with MPS should be assessed for depressive mood and fatigue, as these factors may contribute to sexual dysfunction. These results may also emphasize the importance of adopting a multidisciplinary approach in the management of MPS patients with concurrent sexual dysfunction. Clinicaltrials.gov identifier: NCT05727566.

Modified lumbo-pelvic exercise to alleviate mild stress urinary incontinence in middle-aged females

Urinary incontinence is one of the common clinical problems of females passing middle age. Traditional pelvic floor muscle training to alleviate urinary incontinence is too dull and unpleasant. Therefore, we were motivated to purpose a modified lumbo-pelvic exercise training incorporating simplified dancing components with pelvic floor muscle training. The objective of this study was to evaluate the 16-week modified lumbo-pelvic exercise program that incorporated dance and abdominal drawing-in maneuvers. Middle-aged females were randomly assigned into the experimental (n = 13) and control (n = 11) groups. Compared to the control group, the exercise group significantly reduced body fat, visceral fat index, waistline, waist-hip ratio, perceived incontinence score, frequency of urine leakage, and pad testing index (p < 0.05). In addition, there were significant improvements in pelvic floor function, vital capacity, and muscle activity of the right rectus abdominis (p < 0.05). This indicated that the modified lumbo-pelvic exercise program can promote benefits of physical training and alleviate urinary incontinence in middle-aged females.

Rumba Dance Combined with Breathing Training as an Exercise Intervention in the Management of Stress Urinary Incontinence in Postmenopausal Women: A Randomized Controlled Trial

Purpose: Stress urinary incontinence (SUI) refers to involuntary leakage from the urethra, synchronous with exertion/effort, sneezing or coughing, which has a negative effect on quality of life. Studies have shown that mild-to-moderate physical activities reduce the risk of SUI by multiple mechanisms. The objective of this study was to determine whether the Rumba dance combined with breathing training (RDBT) can reduce the severity of incontinence and improve the quality of life of patients with SUI. Methods: A randomized clinical trial was conducted with women who were sedentary, were postmenopausal, reported mild-to-moderate SUI on a 1-h pad test, were not already engaged in Rumba dance and did not receive estrogen replacement therapy. The patients were randomly assigned to the RDBT group (n = 13) or the control group (n = 11). The intervention included 90 min of RDBT three times per week for 16 weeks, and the vaginal resting pressure (VRP), pelvic floor muscle (PFM) strength and endurance, 1-h pad test, International Consultation on Incontinence Questionnaire—Urinary Incontinence Short Form (ICIQ—UI SF), and the Incontinence Quality of Life Questionnaire (I—QOL) were measured or completed at baseline and 16 weeks. None of the participants reported adverse events. Results: The mean (±SD) age of the participants was 55.75 ± 5.58 years. After 16 weeks, in the RDBT group, the urine leakage on the 1-h pad test was significantly decreased −2.91 ± 0.49 from the baseline (p = 0.000). The VRP increased from 76.00 ± 16.23 cmH2O to 95.09 ± 18.90 cmH2O (p = 0.000), the PFM endurance of class I (−3.15 ± 1.99% vs. −0.46 ± 0.97%, p = 0.000) and class II (−0.69 ± 0.95% vs. −0.23 ± 0.44%, p = 0.065) increased, and the grades of PFM strength of class I and class II were significantly enhanced (p < 0.01). Finally, the severity of self-reported incontinence (ICIQ—UI SF) significantly decreased from 6.12 ± 2.15 to 3.81 ± 1.68 (p = 0.000), and quality of life (I—QOL) improved from 75.73 ± 11.93 to 83.48 ± 7.88 (p = 0.005). Conclusion: A 16-week RDBT program can increase PFM strength and endurance to reduce the severity of incontinence symptoms and improve the quality of life in patients with SUI, demonstrating the feasibility of recruiting and retaining postmenopausal women with SUI into a RDBT therapeutic program.

Asymmetries of the Muscle Mechanical Properties of the Pelvic Floor in Nulliparous and Multiparous Women, and Men: A Cross-Sectional Study

This study aimed to identify if the muscle mechanical properties (MMPs) of both sides of pelvic floor muscles (PFMs) are symmetrical in different populations of both sexes. Between-sides comparisons of MMPs of PFMs, assessed with manual myotonometry, were performed in three groups, with 31 subjects each, composed of healthy nulliparous women (without any type of delivery or pregnancy), multiparous women (with at least two vaginal deliveries), and healthy adult men. Intra-group correlations between MMPs and age, body mass index (BMI), or clinical state of pelvic floor were also obtained. The nulliparous women and the men showed no between-sides differences in any MMP of PFMs. However, the multiparous women showed that the right side displayed less frequency (−0.65 Hz, 95% CI = −1.01, −0.20) and decrement (0.5, 95% CI = 0.11, 0.01), and more relaxation (1.00 ms, 95% CI = 0.47, 1.54) and creep (0.07 De, 95% CI = 0.03, 0.11), than the left side. Further, MMPs were related to age, sex, and BMI, also depending on the population, with the multiparous women being the only group with some between-sides asymmetries, which in this case were positive and of fair intensity for the left side of the PFMs, between BMI, and frequency and stiffness (rho Spearman coefficient: 0.365 and 0.366, respectively). The symmetry of MMPs of the PFMs could depend on the subject’s condition. Multiparous women show a higher tendency to asymmetries than nulliparous women and men, which should be considered in research and clinical settings.

Differential Sensitization of Muscle versus Fascia in Individuals with Low Back Pain

Muscles and the deep fascia surrounding them have been suggested to play an important role in various musculoskeletal pain conditions including low back pain. Both have been shown to host rich nociceptive innervation and to undergo changes in individuals with chronic pain. However, evidence for the respective contribution of muscle and fascia sensitization in humans with myofascial pain syndrome is lacking. Here, we studied the sensitization of muscle and fascia in individuals with myofascial low back pain. Twenty individuals with acute (5) and chronic (15) myofascial low back pain of the quadratus lumborum muscle and a matched control group of twenty healthy individuals were recruited and clinically evaluated. All participants underwent ultrasound-guided needling of their subcutaneous tissue, deep fascia and quadratus lumborum muscle. Reported pain intensity and episodes of muscle twitching were recorded and analyzed. Among pain patients, both muscles and deep fascia demonstrated pain hypersensitivity, but muscles were significantly more sensitized than the deep fascia. No difference between acute- or chronic-pain patients was observed. Results of this study suggest that while both deep fascia and muscle show pain sensitization in both early and chronic stages of low back pain, muscles are more sensitized than fascia.

Breathing, (S)Training and the Pelvic Floor—A Basic Concept

Background: The current scientific literature is inconsistent regarding the potential beneficial or deleterious effects of high-intensity physical activities on the pelvic floor (PF) in women. So far, it has not been established with certainty whether disparate breathing mechanisms may exert short- or long-term influence on the PF function in this context, although based on the established physiological interrelationship of breathing with PF activation, this seems plausible. Objective: To propose a basic concept of the influence of different breathing patterns on the PF during strenuous physical efforts. Methodical approaches: Review of the recent literature, basic knowledge of classical western medicine regarding the principles of muscle physiology and the biomechanics of breathing, additional schematic illustrations, and magnetic resonance imaging (MRI) data corroborate the proposed concept and exemplify the consequences of strenuous efforts on the PF in relation to respective breathing phases. Conclusion: The pelvic floor muscles (PFMs) physiologically act as expiratory muscles in synergy with the anterolateral abdominal muscles, contracting during expiration and relaxing during inspiration. Obviously, a strenuous physical effort requires an expiratory motor synergy with the PFM and abdominal muscles in a co-contracted status to train the PFM and protect the PF against high intra-abdominal pressure (IAP). Holding breath in an inspiratory pattern during exertion stresses the PF because the high IAP impinges on the relaxed, hence insufficiently protected, PFMs. It seems conceivable that such disadvantageous breathing, if performed regularly and repeatedly, may ultimately cause PF dysfunction. At any rate, future research needs to take into account the respective breathing cycles during measurements and interventions addressing PFM function.