Amazing Anatomy


Blog after blog, we discuss the pelvic floor and the musculoskeletal system contained within this region of the body. In case any of you have wondered, “Hmm…what exactly does she mean when she talks about the pelvic floor?…” today is your lucky day!  Because today, dear reader, we will discuss some of basic anatomy and physiology of the area we refer to as the pelvic floor.


The pelvic floor is a truly incredible system.  Several noteworthy anatomical landmarks include:

  1. Hip bone- comprised of a left and right ilium, ischium, and pubic bone
  2. Pubic symphysis- this cartilaginous joint is located at the junction of the left and right superior rami of the pubic bones. The bladder is located behind it and the clitoris and external genitalia are located below it.  This joint acts like a cushion and serves as a shock absorber during walking. It also allows for pelvic expansion during labor and delivery.  The pubic symphysis has a small degree of superior/inferior mobility (movement up or down) as well as the ability to separate slightly, as required during pregnancy to accommodate for the growing fetus.  The space in between the two pubic bones is usually 4-5 mm, however this can increase 2-3 mm during pregnancy.  Diastasis of the symphysis pubis, also known as pubic symphysis separation, is a dysfunctional excessive widening of the pubic symphysis joint during pregnancy or after delivery.
  3. Sacrum- This bone looks like an upside down triangle and it rests at the base of the spine. It consists of five smaller sacral bones (or vertebrae) which fuse between the ages of 18 and 30.  It connects to the fifth lumbar vertebrae which sits above it, the coccyx which sits below it, and the left and right ilium bones of the hip.  Several important muscles which allow for movement of the legs, including the gluteus maximus, iliacus, and piriformis, originate from the sacrum and are attached to this bone.
  4. Coccyx- This bone, colloquially referred to as the tailbone, is a small, often overlooked anatomical landmark that sits below the lumbar spine and sacrum. Despite its tiny size, it is extremely clinically significant.  Think of it as the Grand Central Station of your pelvic floor, so to speak.  The coccyx serves as the attachment site of the gluteus maximus and levator ani muscles (which include the coccygeus, iliococcygeus, and pubococcygeus muscles) and ligaments (including the anterior, posterior, and lateral sacrococcygeal, sacrotuberous, and sacrospinous ligaments).  Injury to the coccyx can affect the aforementioned muscles and/or ligaments.  Conversely, injury to the muscles and/or ligaments can affect coccyx alignment.  Symptoms of coccyx dysfunction include coccyx pain (referred to as coccydynia), pain with defecation, pain with intercourse, pain with prolonged sitting, pain with transitional movements (such as sit to stand), coccyx pain, low back pain, and even neck pain
  5. Ischial tuberosities- these prominent bumps (or protuberances) are located on the left and right ischium bones, and they are commonly referred to as the sitz bones. Most people bear weight onto the ischial tuberosities while sitting.  The hamstrings muscles and sacrotuberous ligaments attach to the ischial tuberosities.


Four layers of muscular tissue (aka diaphragms) exist within the pelvic floor:

  1. Superficial perineal space, the area overlying the pelvic outlet, which includes the genitalia, urogenital triangle, anal triangle, perineal body
  2. Urogenital diaphragm- contains deep transverse perineal muscle and sphincter urethrae (contributes to voluntary control of voiding)
  3. Pelvic diaphragm (aka levator ani muscles)- this is the deepest layer of striated muscle. The two primary functions of this layer of muscles is to elevate the pelvic floor and to resist intra-abdominal pressure.  It consists of four muscles (one on each side), the pubococcygeus, the puborectalis (controls descent of feces, creates anorectal junction/angulation), the iliococcygeus, and the coccygeus.
  4. Smooth muscle diaphragm- this contains the internal urethral sphincter and the external urethral sphincter



In addition, there are three openings within the pelvic floor. From front to back, the three openings are:

  1. The urethra, which connects to the bladder and is involved with elimination of urine.
  2. The vagina, which connects to the uterus and is the opening through which the fetus is delivered at the end of pregnancy.
  3. The anus, which connects to the rectum and is involved with elimination of stool.

The area located between the vagina and the anus is referred to the perineal body.


Hopefully, this little anatomy lesson has given you a better frame of reference for any discussion about women’s health. Understanding one’s body and how it functions will hopefully lead to a greater appreciation of the daily miracles that occur as well as lead to quicker diagnosis and treatment of dysfunction.





Girl Power

Celebrity Zosia Mamet, of the hit HBO show "Girls" openly discusses her struggle with pelvic pain
Celebrity Zosia Mamet, of the hit HBO show “Girls,” openly discusses her struggle with pelvic pain

In the near five years that I have been exclusively practicing pelvic floor physical therapy, I have noticed an interesting phenomenon.  Namely, conversation about the pelvic floor has steadily been on the rise. We as a profession have received shout outs in popular magazines including Elle, Cosmopolitan, and Runners World. “Kegel exercises” have been referenced in popular television shows including Sex in the City and 30 Rock.


A specialty which heretofore was completely unknown to most and which was rarely discussed even with one’s own doctor has become a topic that is increasingly being raised in healthy and meaningful venues.

Doctors are generally more aware of the existence and the benefits of pelvic floor physical therapy than ever before.  While I spend a significant amount of time explaining my profession to physicians that I meet (and am happy to do so), more and more individuals within the medical community are already well informed.


Not only are doctors more educated than in years past before about the specialty, but knowledge about the topic is abounding within the general population as well.  In the past, my answer to “What do you do for a living” was often greeted with confusion and curiosity.  In fact, I have a whole shpiel prepared to help explain and educate. Recently, I have been pleasantly surprised by the reactions I receive when I proudly respond, “I am a pelvic floor physical therapist.” The general response is one of admiration and respect for the powerful and holy work I have the privilege of engaging in on a daily basis. It is refreshing and exciting to witness this major transition within both the medical and lay communities.


In fact, just last week, Zosia Mamet of the popular television show “Girls” boldly shared her own personal struggle with pelvic pain in Women’s Health Magazine (February 8, 2017, article link).  In this article, Mamet described that for six full years, she felt like she had a nasty UTI that could not be fixed.  She shared that she experienced intense urinary frequency (the sensation of increased need to void) and the sensation of “a hot poker” being inserted vaginally during intercourse.


One of the worst aspects of her experience was that she was bounced around from doctor to doctor and misdiagnosed for far too long.  In fact, she was informed that she had a sexually transmitted infection (not true!) and that she “was crazy” (also not true!) by clinicians who could not figure out what was wrong.  Fortunately, she was finally referred to pelvic floor physical therapy to address her issues.


In reality, many women can unfortunately relate to Mamet.  How courageous of her to share her story and to further raise public awareness.  However, pelvic floor physical therapy should not be deemed a luxury treatment available only to the rich and famous. Pelvic health should be an unalienable right, along with life, liberty, and the pursuit of happiness.  Revitalize Physical Therapy offer excellent care in a highly affordable manner. We will help you verify your out of network insurance benefits and can offer a sliding scale to clients in need.  Our main priority is helping you achieve your goals and health.  Please let us know how we can help you, because it would truly be an honor and privilege to do so.