In this video, Charlotte Berthier, Osteopath (Rousset, France) poses a complete framework on what the perineum is, how its integrity and functionality can be compromised because of endometriosis and how the osteopath can intervene to relieve it.
The importance of the perineum
The perineum is linked to reproductive functions and forms the “foundation” of the pelvis that closes downwards. Anatomy books, due to its location, have long neglected it, yet it is essential in posture and body maintenance. If it is relaxed, very little tonic, injured, hypertonic, many inconveniences can appear. Women, due to their anatomy, pregnancy and childbirth and hormonal exposure are more at risk of experiencing these discomforts. However, men are not exempt and may also have certain problems related to injuries of these muscles.
Due to our biped nature, our standing position generates much more stress on the organs that have a natural tendency to descend, a tendency that can be exacerbated over the years, in case of weight gain, childbirth, osteopathic dysfunction, posture!
It is for this reason that the term “pelvic floor” is still widely used, obviously referring to the strength and support it must have to sustain the viscera and also to guarantee the functions of urinary and fecal continence.
The perineal space consists of a rhombus separated into two parts by the superficial transverse muscle which goes from one ischium to another:
– in front, the anterior or superficial perineum, which is not very mobile. It has a role in the external aspect of the perineum and in sexuality because it is very innervated
– the pubo-rectal muscle, belongs to the anterior and posterior perineum, goes from the pubis to the coccyx, passing through both sides of the vulvar cleft. It is the muscle of retention that allows continence. When the sphincters fail to manage it all, this allows us to save a little time before having to go to the bathroom
– the transverse muscle constitutes the horizontal diagonal and connects the two sit bones; it separates the urinary compartment from the anus and the coccyx. This small mobile muscle has a role in stabilizing the pelvis and in the perception of defecation needs
– the deep perineum covers the lateral walls of the cavities (vagina and rectum). It is made up of three muscles that converge towards the coccyx. The ilio-coccygeus lines up on the inner wall of the vagina and forms a diaphragm that will support the cervix. These muscles help to support bladder, uterus, and intestines.
The importance of good pelvic mobility
The pelvis constitutes the bony framework that surrounds the perineum. Its mobility is an important element for respecting the function of the perineum.
– the coccyx is the small end piece of the spinal column and is the anchor of various muscles of the perineum. It is articulated with the sacrum and its mobility goes from front to back. When the perineum contracts, the coccyx leans forward as when we have to relieve ourself. It can lean back as during defecation and childbirth. Its amplitude between these two movements is very important, more than 46 degrees! Bipedalism requires the coccyx to be held forward due to a permanent tone of the retention muscle
– the sacrum, triangular bone, is articulated to the coccyx but also to the two iliac bones by dimples. This joint is often the site of lower back pain, which can evoke sciatica, which is often the result of a mobility problem
If this mobility is hampered, it becomes difficult for the pelvic floor to do its job.
Thus the muscles and bone structure act in synergy! We often hear about the perineum after a first delivery, which is already a little late, as it can also be damaged by sports practices where everything is pressed (as in abdominal crunches).
As you can see, the pelvic floor is a muscular sac that has a central role: organ support, continence, sexual pleasure, etc. but it is also very important for posture.
The pelvic floor works in synergy with respiration, as with the diaphragm. In addition, osteopaths also call it “pelvic diaphragm”.
On inspiration, the rib cage fills, viscera are pushed down, the perineum relaxes and “descends” also under the impulse of the thoracic diaphragm.
On expiration, air is expelled from the rib cage, the navel re-enters thanks to the impulse of the deep abdominals and the perineum rises up.
Being aware of our perineum is the first step to mobilize it and to preserve its vital functions: continence, organ support, sexuality even outside of pregnancy to preserve the pelvis and the back.
In practice, there are simple abdominal breathing exercises in which we will involve the perineum in appropriate postures and that will constitute an adapted prevention for women.
By exhaling, the perineum tightens under the contraction while the abdominals support and raise the viscera, acting in synergy with the pelvic floor.
Simple little tips to preserve our perineum
– stop pushing down when lifting loads, keep your back straight, bend your legs and lift while exhaling and be aware of this “rise”!
– prevent and treat constipation that represents more stress on the organs and perineum
– adopt the physiological position “feet on a small stool” in the toilet, which is the position that places the rectum on a vertical axis, which considerably reduces harmful pushing efforts
– during all pushing efforts (cough, laugh, sneeze), get into the habit of exhaling while putting the belly in to raise the perineum to ensure a solid base
Then, by releasing mechanical and postural stresses on pelvis, lower back and abdomen-pelvic area, the osteopath will help to reduce perceived stress by tissues in this area.
The advantage when tissues are more flexible is that, in particular, they can accept more stresses during inflammation due to menstruation, for example.
If the structures involved are already under tension before the inflammation is at its maximum, the latter will be even more important and the pain will be more disabling.
There is a whole network of fascia and membranous folds that allow the protection, separation and nutrition of the organs in the woman’s pelvis and abdomen. All the folds and layers of this fascia form a tissue continuity between the different organs and structures of the pelvis.
As we have said, in case of endometriosis, clusters of endometrial cells that develop in various places cause inflammation and adhesions. Therefore, the osteopath will treat any junction points that cause mobility restrictions in the fascia to restore mobility and abdominal-pelvic circulation.
The osteopath will also perform tissue tests and corrections to restore the flexibility and elasticity of the organ envelopes and their junction points. For example, in the case of the uterus, it will be necessary to relax the wide ligaments and the uterosacral ligaments to regain the good mobility of the uterus in relation to the pelvis, as well as free the tissue in the pelvic girdle. In addition, visceral abdominal work will allow the elements of the digestive system to regain ease their movement as well as with respect to osteoarticular and myofascial support.
In addition to the direct mechanical impact on the state of tension of the organs of the abdominal-pelvic sphere, the osteopath helps to free the circulatory and nervous passage: the vessels (arteries, veins, lymphatic vessels) and the nerves pass through the numerous structures to achieve their goals. They bind to the bones, passing through the re-entry points between some ligaments, muscles, a lot are found inside the membranous folds made of fascias, the uterine peritoneum.
Therefore, the osteopathic work of the lumbar area, pelvis, relaxation of the abdomen and pelvic organs and fascia allows to reduce the mechanical stresses that can increase the inflammation already present due to endometriosis. It will also optimize and improve circulation and fluid exchanges (arterial and venous blood, lymph) to oxygenate the tissues and reduce stasis, but it will also normalize nerve information and prevent any further irritation of the system.
In this way, we will be able to observe a positive evolution of the following symptoms: digestive disorders, low back pain and pelvic pain, pelvic pressure and pain, dysmenorrhea, dyspareunia.
The action of the osteopath is a regulatory action, it aims to normalize and allow the different systems of the human body to balance and is based on the power of self-regulation together with other approaches also natural ones.
You will have understood that the pelvic pain present in women with this disease is mainly due to the inflammation of the organs of the pelvis and in the area colonized by endometrial cells.
I hope I was able to answer many of your questions and to shed some light on the link between osteopathy, pelvic contracture and endometriosis.
Here you will find the original video in French: