The overlap between back pain and pelvic floor dysfunction

A mature woman sitting on a couch, holding a hand on her lower back and grimacing in pain.

Aching back? You’re certainly not alone: an estimated 80% of Americans will cope with lower back pain at some point in their lives, according to the National Institutes of Health. If you’re in midlife or beyond, you might think the problem is due to arthritis or a spinal disc issue.

But a Harvard expert says it’s wise to consider another possible culprit — pelvic floor dysfunction.

In women, this term means that the muscles that support the bladder, uterus, and bowel don’t work correctly. These muscles serve as a core support system for the pelvis, tightening and relaxing to control urination, bowel movements, and sexual function. Sometimes, though, the muscles are too weak, too tight, or uncoordinated, leading to problems such as leaking urine or stool, constipation, pelvic floor pain or pressure, or uncomfortable sex.

Perhaps surprisingly, pelvic floor dysfunction can also lead to something else: lower back pain.

“We do know that pelvic floor dysfunction and back pain — especially when someone has urinary incontinence — are commonly seen together,” says Arianna Mitropoulos, a physical therapist and clinical specialist in pelvic health at Harvard-affiliated Brigham and Women’s Hospital. “Most people don’t associate the core with the pelvic floor, even some clinicians.”

How pelvic floor dysfunction and back pain are connected

When you think of the body’s core, your mind may automatically jump to the abdominal and back muscles that gird our trunk. That’s partly correct. The pelvic floor also plays a key role, working in tandem with the abdominal and back muscles to stabilize the spine. “The pelvic floor is essentially the bottom of the core,” Mitropoulos says.

Since your pelvic floor and diaphragm — the dome-shaped breathing muscle at the base of the lungs — are intricately connected, pelvic floor dysfunction can also change how that muscle works, leading to an aching back. “If the pressure in your trunk changes, it affects your posture,” Mitropoulos explains.

Additionally, overly tense pelvic floor muscles can also cause referred pain — that is, pain felt in a part of the body different from its source — in the lower back. “Tight muscles tend to be weak because they’re already in a contracted state,” she says. “All those muscles connect to the tailbone, which is inherently linked to the spine.”

Why risk increases at midlife and beyond

For a variety of reasons, the odds of developing pelvic floor–related back pain go up for women as we get older. As estrogen levels decline, so does muscle mass — a development called sarcopenia, which happens in both sexes but ramps up for women as menopause approaches. “Everyone will go through it to some degree, but we can see very noticeable effects in the pelvic floor,” Mitropoulos says.

Childbirth-related pelvic floor damage can also reveal itself decades later as muscles, ligaments, and other tissues sag, fueling back pain. “The more babies you had, the more likely this will happen,” she says.

Pelvic floor pain versus lower back pain: overlapping signs

When should you suspect your back pain stems from pelvic floor problems? If conventional approaches such as regular stretching or physical therapy don’t make a dent, that’s a major clue.

Lower back pain and pelvic floor pain or dysfunction may also produce overlapping symptoms such as

urinary leakage or urgency
a feeling of heaviness in the pelvis or bulging in the vagina
constipation or bowel control issues
painful sex or urination
pain with prolonged sitting or standing.

“If you have back pain that’s correlated with your bladder, bowel, or sexual function, you should immediately think it’s related to the pelvic floor,” Mitropoulos says.

Strategies to strengthen the pelvic floor

The pelvic floor may be hidden, but ways to keep it strong are clear, says Arianna Mitropoulos, a physical therapist and clinical specialist in pelvic health at Brigham and Women’s Hospital. She suggests these approaches:

Exercise. Aerobic activities such as brisk walking, biking, or swimming offer many benefits, but they don’t strengthen the core. Make sure you add core exercises such as planks along with other strength training to your regimen. “We want you to do something that actually pulls on your bones — that’s great for the core and functional for your pelvic floor,” she says.

Pilates is one of the most popular ways to strengthen the core, but “it’s easy to turn most exercises into a core exercise, if it’s done the right way,” Mitropoulos says. “Core work doesn’t necessarily mean you need to be on your back doing crunches. You can be exercising your core in any position.”

Pelvic floor physical therapy (PT). This specialized type of PT optimizes bowel, bladder, and sexual function and addresses pelvic or abdominal pain. “If there’s weakness, we do strengthening exercises, and if there’s tightness, we get the pelvic floor to release,” she says.

Diaphragmatic breathing. Also called belly breathing, this technique helps you breathe more deeply, relaxing the body. To do it, breathe in slowly through your nose and breathe out slowly through pursed lips. Repeat for several breaths, keeping your chest as still as possible while your belly moves. You can do it on your back while in bed, in a chair, or standing. “Especially if you have pain in these positions, it’s really good training for the pelvic floor,” Mitropoulos says. “We want you to have that level of control with your abdominal muscles.”