Pelvic Floor Dysfunction can be treated with acupuncture "Pelvic Floor Muscle Stimulation-Regulation” by stimulating the body's proper musculature, ligaments, innervation by promoting blood, hormonal (or endocrine) and immunological circulation in the affected area.
Pelvic Floor Dysfunction,
The Not Well Known Malady#
By Emmanuel Arroyo, Lac
21 May 2010 12:03 AM Eastern Standard Time (New York, USA)
Updated 21 Octuber 2011 12:39 PM Eastern Standard Time (New York, USA)
Third update 23 October 2011 11:57 Eastern Standard Time (New York USA)
4th update 1 November 2011 12:16 Eastern Standard Time (New York USA)
5th update 4 January 2012 10:04 Eastern Standard Time (New York USA)
Before entering into details on what is Pelvic Floor Dysfunction (PFD) it is necessary to understand its anatomy by which I mean the muscles, places where the muscles attach to or cross and the innervation (nerves that supply those muscles) in what is known as pelvic floor.
The Muscles #
The muscles involved in PFD are the following: Levator Ani, Coccygeus, Transversus perinei,Bulbospongiosus, Ischiocavernosus, Sacrococcygeus, Obturator internus and Gluteus maximus.
The Levator ani has three parts known as the pubococcygeus, iliococcygeus and puborectalis, while the Coccygeus is also known as the ischiococcygeus muscle. There are two Transversus perinei the superficial one that is known as transversus perinei superficialis and one that is deep which is called transversus perinei profundus.
Ligaments, Tendons and Bony Structures
The ligaments, tendons and bony structures closely related with PFD are Sacrotuberous ligament, Tendinous Arch of the levator ani muscle, Anococcygeal body, Perineal body, coccygeal fascia, Sacrospinous ligament and Sacrotuberous ligament (or sacrotuberal ligament) some important bony structures are the pubis and pubic symphisis, Coccyx, Sacrum, Ischial spine, Ischium and Ischial tuberosity.
An Illustration is Worth Thousand of Words#
Connecting the Dots
The pelvis is divided into 3 sections or openings: superior, middle and inferior openings or circumference. The superior opening is demarcated by the pectineal line which could be said is a “extension” of upper border of the pubic symphisis toward the sacrum (the promontory which is level with the sacrum prominence, right on top of S1). The middle opening is found right on the center of the pubis symphysis running towards the ischial spine and to the sacrum (S2,S3,S4 and part of coccyx). The inferior opening is composed of the lower border of pubic symphisis, lower borders of the ishchiopubic ramus and the coccyx. Last the pelvic floor is contained in its place by the perineum which in turn is divided into 2 triangles: anterior traingle that contains genitourinary structures and the posterior triangle which has the orifice of anus. The triangles are separated by an imaginary line that runs from ischial tuberosity to ischial tuberosity crossing the peroneal body.
Now that we have a few illustrations of the pelvis we can start putting together the muscles and some ligaments. Let start with the coccygeal fascia; the coccygeal fascia is a bundle of cartilaginous tissue that wraps on the coccyx (tail bone) from here anococcygeal body emerge and attach to the anus (Du 1# if you are an acupuncturist); from the anus to the scrotum or vagina we have the perineal body (Ren 1). Before I proceed to explain more I will make a parenthesis and explain that there are two pubis one at the left and one at the right and that portion right between both is called the symphisis. The symphisis (Ren 2) serves as point of origin of two muscles the ischiocavernosus and bulbospongiosus. Right on the pubic symphisis (Ren 2) is a tendon that holds structures into the pubic symphisis. Both bulbospongiosus and ischiocavernosus are located in the inferior opening. The ischiocavernosus is more close to what is called Kidney 11 in acupuncture and needling should be done deeper than regular japanese style acupuncture. Other muscles that are within the inferior opening are superficial and deep transverse perineal muscles. The superficial transverse perineal muscle attaches to the tendon located on what is called in acupuncture Ren 2 (pubis symphisis). The deep transverse perineal muscle is found around the ischiopubic ramus aiming to the pubis and peroneal body and grapping around the urogenital openings of the anterior triangle and on top of the bulbospongiosus. The majority of the muscles that attach to the coccyx can be seen as part of the inferior opening of the pelvis while those that are attaching on to the sacrum would belong to the middle opening.
The bulbospongiosus goes around the scrotum and base of the penis (or vagina in case of women) to connect with perineal body (Ren 1) and from here it travels around the anus connecting with annococcygeal body (Du1), this portion that wraps around the anus is called sphincter ani externus (there are three one which is superficial and seats on two, one is deeper and one right between the superficial and deep). Forming a horizontal line is the tranversus perinei superficialis which seats between the end part of the bulbospongiosus and ani sphincter (Ren 1 area) and attaches to the ischium tuberosity (sitting bone which is UB 36). This group of muscles form a cross like shape figuratively speaking. Departing from the Ischial tuberosity (UB 36) area is the ischeocavernosus muscle which passes by the pubis (ST 30, LR 12, SP 12 area leveled with the lower border of the pubic symphisis) to finally end on the symphisis (Ren 2, KI 11 area).
The levator ani muscle is kind of an umbrella name which is called differently depending where it is located. The lower portion of this muscle is named pubococcygeus while the upper portion is known as Illiococcygeal muscle (belongs to middle and inferior opening). The portion of the pubococcygeus that connects with the perineal body (Ren 1 area) and is right in front of the anus is known as prostate levator muscle (in women it is called pubovaginalis muscle and acts as a sphincter). The posterior portion of the pubococcygeus is referred as the puborectalis and is where the rectum rests. Let me summarize, this muscle has more or less a U shape, the part that goes close to the prostate is called prostate levator and the portion going around the rectum is called puborectalis.
The illiococcygeus muscle connects with the tendinous arch of the levator ani (the tendinous arch goes from the ischial spine to the pubis (KI 11 area) and attaches to the fascia# of the obturator internus) and another portion of the muscle goes to the coccyx (can be accessed with UB 35). This muscle is located in both middle and inferior openings of the pelvis.
The coccygeus muscle ( UB 35 area) attaches along the sacrospinal ligament (lateral to UB 33,34 area or S3, S4 area) and to the coccyx, this muscle runs next to illiococcygeus. This muscles belongs to the middle opening of the pelvis.
The Obturator internus (inferior to GB 30 or Piriformis muscle leveled with S3, S4, and close to the ischial tuberosity or UB 36) passes between the sacrospinal and sacrotuberous ligament covering the obturator foramen and exiting through the lesser sciatic foramen (right below the illiococcygeus).
Gluteus Maximus (a muscle that forms part of the buttocks) has a portion that attaches to the coccyx.
If you need a visual help on where the muscles are located the following link will take you to a nice picture with almost all the muscles. Here is another one that shows where are the bulbospongiosus and ischiocavernosus.
Innervation
The nerves that supply the pelvic area are: Hypogastric nerve which is divided into superior and inferior hypogastric, these are found right between the foramina of the sacrum and run from the 4th lumbar vertebrae to the area of the coccyx. The hypogastric nerve starts on T10 to L2. The inferior hypogastric innervates the viscera in the pelvic cavity with branches on the side of the rectum (in both male and female) and vagina in women. From L1 nerve root we have different nerves emerging: iliohypogastric, genitofemoral and from the latter we have 2 branches: the genitofemoral femoral and genitofemoral genital. The genitofemoral nerve supplies the inguinal canal, the cremaster muscle and the skin of the scrotum in male, in female it innervates the mons pubis and the labia majora. The iliohypogastric nerve in a very general way we could say that supplies the psoas, quadratus lumborum, transversus and olbique internus abdominis muscles; The femoral nerve that branches from L2, L3 and L4 nerve (L4 nerve is the lumboscaral trunk) and the femoral cutaneous which branches off L2 nerve. The femoral nerve supplies the iliopsoas emerges in the inguinal ligament and then supplies the anterior and posterior thigh. There is a posterior femoral cutaneous nerve that branches off S1, S2, and S3. From S4 nerve we have a branch called the levator ani nerve. The obturator nerve branches from L2, L3 and the lumbosacral trunk (L4). The pudendal nerve branches from S2, S3 and S4. The last nerve that is on the pelvic area is the sciatic nerve which branches from S2, S3 and S4. The significance of nerve innervation is clear: Acupuncture points on L2, L3, L4, S1, S2, S3 and S4 are important points in neurofunctional acupuncture. Such points are the “Huo tuoa jia ji”, UB 31, 32, 33, 34, GB 30 (to access part of the pudendal and other sacral branches), and UB 36. ST 30 regulates the obturator nerve and other nerves innervating the cremaster in male and labia majora in women; the obturator nerve goes down the psoas and emerges through the obturator foramen to then go down the thigh touching the obturator externus, pectineus and adductor muscle group and other muscles of the medial thigh (LR 12 is a point that access nerves emerging from the ilipsoas and going medially on the thigh). Trigger points on these two muscles elicits diffuse pain into the pelvic area.
Significance of Muscle Attachments
A person with PFD might experience pain in the following areas: scrotum, vagina, anus, sacrum (ischiocavernosus, bulbospongiosus, perineal body, anococcygeal body, transversus perinei, coccygeus); lateral hip, and posterior thigh pain (gluteus maximus, obturator internus) or might exhibit incontinence, constipation, painful bowel movement or dribbling urine (bulbospongiosus, transversus perinei, perineal body, ani sphincter, puborectalis, prostate levator); painful intercourse, some erectile dysfunction, hemorrhoids or even prolapse could be seen (bulbospongiosus, pubovaginalis,
It has been observed the presence of trigger points even on adipose tissue. Acupuncture points associated with the musculature of the pelvic floor are: Ren 1, Ren 2, DU 1, UB 31, 32, 33, 34, 35 and 36 and LR 12.
Acupuncture Points from a TCM Perspective
Some
acupuncture points such as ST 30 (Qichong or Rushing Qi) and meeting
point of the Chong mai (Sea of blood meridian) make ample sense
considering that anyone experiencing spasm on the pelvic floor need to
have better blood perfusion in the musculature. Usually people
complaining of spasm have a TCM diagnosis of blood deficiency. Other
points such as KI 11, LR 12 and SP 12 could be incorporated. SP 12 is
Chongmen or rushing gate and it is the meeting point of the spleen,
liver and yin wei mai. KI 11 is a meeting point for Chong mai. SP 10 is a
possible good point considering that its name Xuehai means sea of
blood. LR 5 is the luo of the liver meridian and this one goes to the
genitals. Extraordinary meridians such as Du mai and Chong mai make lot
of sense to incorporate considering that both go along the spinal cord
and emerge on the pelvic area.
If
you are familiarized with Richard Te Fu Tang balancing system of mirror
and image then you will know that points on the elbows/knees or close
to the elbows/knees could be used. If you are familiarized with Dr Yun
Tao Ma homeostatic points you can use he sea points because all those
points travel up to the pelvic cavity and lumbar area. Another point
that he uses is the HA 14 (homeostatic acupuncture point known as
superior cluneal) which is the most tender spot on top of the iliac
crest. If you want to incorporate myofascial release or trigger point
technique then you have to use mainly points on the sacrum and ischial
tuberosity area, the patient will feel heaviness an indication of knots
or trigger points. The best treatment is alternation of front and back
acupuncture.
Causes of PFD
Some of the causes attributed to PFD are prostate, vaginal, urinary problems, and scar tissue from surgical intervention among others.
Prevalence
PFD has a higher incidence among women and it is a condition that sometimes passes undiagnosed or confused with other syndromes.
Acupuncture and PFD
If
you are not an acupuncturist you probably have noticed at this point
that I have mentioned some acupuncture points. This has been purposely
done in order to show that the areas where the muscle(s) attach are
linked with some acupuncture points and if you are an acupuncturist you
probably have learned which local points to use in order to regulate
nerves and nearby musculature.Needle insertion with a 1.5” to 3" needle pierces the illiococcygeus, pubococcygeus and puborectalis which comprises the levator ani but remember that this muscle passes next to the prostate (levator prostate muscle) hence we are stimulating all these muscles. The acupuncture points are UB 32, UB 33, and UB 34; these points also regulate the pudendal nerve hence indirectly regulating the nerves that supply the penis and muscles that are around and next to it. Needling the left UB 36 acupoint with a 3 inches needle (or smaller depending on the patients size and anatomy) in diagonal oblique insertion aiming the right S2 and S3 but deeper pierces the following muscles gluteus maximus, coccygeus and levator ani. In order to stimulate bulbospongiosus and ischiocavernosus muscles we need to insert a 3 inches needle (or smaller depending on patient’s anatomy and size) from ST 30 towards Ren 2 by doing this we are piercing both muscles. I use electricity in all these points and patients report the following: a massage like sensation on the anus, perineum, and scrotum with some sensation at the base of the penis. The purpose is to stimulate the nerves and force the muscles to relax so we can improve blood perfusion in the pelvic floor and eventually regulate the proper neuro-muscular structures. For a clearer idea on the needling technique please follow the proper links for a video clip.
We have to bear in mind that points according to TCM (traditional chinese medicine ) diagnosis should be used. Points to drain dampness, clear heat, tonify kidney or spleen qi or yang, move Qi or blood are necessary. It is also important to remember the extraordinary meridians Dai Mai, Du Mai, Chong and Ren Mai to access those deep muscles that compose the pelvic floor.
The majority of the patients that I treat with this “Pelvic Floor Muscle Stimulation-Regulation” approach are patients reporting erectile dysfunction but I have found that stimulation of the pelvic floor muscles increases blood perfusion, enhances nerve impulse conductance with some patients seen results the same day and other after 15 treatments.
If you are not an acupuncturist what I just said on the previous paragraph is simply this: Yes PFD can be treated with acupuncture by stimulating the body's proper musculature, ligaments, innervation by promoting blood, hormonal (or endocrine) and immunological circulation in the affected area.
The treatment here mentioned is a combination of TCM diagnosis with electro-neurofunctional acupuncture which is the combination of trigger points, neuromuscular approach, and nerve root origin and branching.
Feedback
On August 31 I received an email from an acupuncturist in Seattle and this is what the acupuncturist has to say:
“I saw your blog on Ani Levator pain [Pelvic Floor Dysfunction] and was hoping you could offer me some advice.
I'm an acupuncturist/East Asian medicine Practitioner in Seattle and I have a patient with this condition. I have been doing all the needles [local points] recommended on your blog post, with very good success, however, the pain always creeps back after about a week.”
I replied back with an answer explaining what the protocol consists of... I explained the importance of following Acupuncture’s meridian philosophy, taking under consideration internal pathways and extra ordinary meridians plus the concept of neurofunctional acupuncture and on 26 September 2011 I got a response:
“[the patient] is doing better...we have been doing front and back treatments 2x/week, and I have been trying to switch up the points as you had recommended, as well as adding the scalp points, and also the anus points to the ear.
He had been taking 1-2 ibuproferin in the morning as a preventative, but when i saw [the patient] last week he hadn't had any [ibupofren] for 2-3 days and the pain was just a dull ache, rather than so severe he couldn't sit, so I think we are getting over the worst of it.”
The pelvic floor treatment that I am proposing here is based on neurology and anatomical knowledge enhanced with acupuncture philosophy of meridians’ external and internal pathways. The response to the treatment is quick, secure and safe. If you are an acupuncturist and need some help, I would be more than happy to explain the full protocol. If you are having total success using my technique I would love to hear from you.
How long before total resolution? That seems to be the question of everyone... When some one has any kind of pain (low back, knee, elbow, etc) what I tell the patient is to wait after the first treatment is done. When the first treatment is performed the percentage of improvement within the first week of treatment will determine how many treatments. A patient reporting a 50% improvement usually needs 2 treatments and a maximum of 4. Someone reporting 25% improvement usually needs 4 treatments, at least that has been my experience treating any kind of pain.
About the Author
Emmanuel Arroyo is a New York licensed acupuncturist who ocassionally writes blogs and specializes in pain management, male health, and gastrointestinal issues. Recently he has incorporated chakra balancing and essential oils; currently is researching depression and how it can be treated using acupuncture, essential oils, diet modification and chakra balancing. Works as a teacher for acupuncture students and soon will start reading and researching fybromialgia and how to treat it using acupuncture, essential oils, supplements and diet modification.He can be reached at 917-324-1140 or via email dr.agujas@gmail.com
Disclaimer:
This is for educational purposes, you should always consult a professional. Acupuncture could cause minor bleeding on the site of insertion, some patients might experience light headedness, dizziness or faint hence it is advised to eat at least one hour before treatment. Some patients that easily bruise might get bruises that last 2 to 3 days up to a week in some cases. Electro acupuncture usually is performed in a range of 10 to 30 mins. My technique is a combination of the trigger point or myofascial release and neuromuscular treatments which are safe and have been in used by prominent acupuncturists (MD's and Neurologists) within the field. Deep trigger points might require longer needles depending on the area and anatomically allowable.
Bibliography:
A Manual of Acupuncture. Peter Deadman & Mazin Al-Khajafi with Kevin Baker. Journal of Chinese Publications. 2001
Myofascial Pain and Dysfunction, The Trigger Point Manual Volume 2. Janet G. Travell MD and David G. Simons MD. Lippincott Williams & Wilkins. 1993. Page 111-131.
The Female Pelvis, Anatomy and Exercises. Bladine Calais-Germain. Eastland Press. Seattle. 2003
Hypogastric nerve from Wikipedia. 30 June 2011, accessed on 4 January 2012
http://en.wikipedia.org/wiki/
Inferior Hypogastric Nerve. Wikipedia. 3 May 2011, accessed 4 January 2012 http://en.wikipedia.org/wiki/
Iliohypogastric Nerve. Wikipedia. 10 December 2010 accessed 4 January 2012 http://en.wikipedia.org/wiki/
Femoral Nerve. Wikipedia. 4 Diciembre 2011 accessed 4 January 2012 http://en.wikipedia.org/wiki/
Obturator Nerve. Wikipedia. 13 December 2011 accessed 4 January 2012 http://en.wikipedia.org/wiki/
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