Endometriosis is a disease characterized by endometrial-like tissue found outside the uterus. This tissue will bleed every month causing inflammation and adhesions to form.

For most individuals with endometriosis the initial symptoms is painful periods. And even though there is no correlation to the amount of adhesions and the intensity of pain they can both cause pelvic floor problems.

An adhesion is a band of scar tissue that connects two structures/surfaces of the body that are usually separate. Adhesions can do the following:

• limit organ and muscle mobility

• constrict blood/lymph flow

• strangle nerves

When adhesions limit organ and muscle mobility, the tissue cannot lengthen or contract. The tissue may become twisted or result in a torsion. Even though endometrial tissue has been found on every organ in the body, the most common organs it find adhesions are the other pelvic organs including the reproductive organs (uterus, ovaries, fallopian tubes, cervix, vagina), bladder, colon and intestines. This can lead to any number of pelvic floor issues depending on the organs or muscles involved including:

• constipation and bloating

• bladder urgency, frequency or pain

• mechanical infertility or difficulty sustaining a pregnancy

• painful sex/intimacy, pelvic girdle pain, low back pain, hip pain

When adhesions constrict blood or lymph flow, this has more of a wide spread impact. For example, when blood flow is stagnate this blocks the nutrients, hormones and oxygen that need to get to the tissues and the removal of chronic inflammation, hormones from natural processes and toxins from environmental exposure. This is similar for the lymph system that is part of our immune system and helps maintain fluid balance in our body by collecting excess fluid and particulates from tissues, cleaning out pathogens and transporting the fluid back to the blood stream. If either flow is blocked by adhesions it can result in bloating and pelvic congestion.

When adhesions strangle or restrict nerves it can cause pain, change in sensation or dysfunction down the chain of innervation. Since it is more common to have adhesions in the abdominal cavity and pelvic bowl the nerves that exit the lumbar and sacral spine are most impacted. These nerves innervate the low back, pelvis, and legs. A great phrase to remember is “S2, 3, 4 keep pee and poop off the floor,” meaning these nerve roots that feed to the nerves that innervate the organs and muscles of the bladder and bowels come from the sacrum. So just like a herniated disc or muscle tension pinching a nerve, adhesions can do the same. When this happens you may have:

• pain that follows a particular pattern or movement, picture pain in the vulva and groin like you had just sat on a saddle

• tingling, numbness, hypersensitivity along a particular pattern called a dermatome

• muscle function changes like weakness along a particular pattern called a myotome, leading to bladder and bowel control issues

All of these side effects of adhesions can lead to pain. But endometriosis can lead to pain regardless of the amount of adhesions. Studies have shown that the type of pain individuals experience with endometriosis is visceral (organ) and somatic (sensory nerves in skin, bones, joints, connective tissue and muscles). Both forms of pain can be felt in the pelvic floor because both types of tissue are housed within the pelvis.

But there is another way pain can impact the pelvic floor. Through a process of protective, leading to a pain cycle that can change how your nervous system responds to the initial pain. To keep it simple, think of when you touch something hot, your body pulls your hand away quickly. This action sends a message to your muscles to tense or contract. Then after the initial stimulus your nervous system and body calm down. However, if you do it many more times or the fear of doing it again is very strong, your nervous system may stay on high alert, to protect you from getting burned.

This is the same protective mechanism that happens with pain from endometriosis. And since most of the pain is abdominal or pelvic in origin, those are the muscles that will contract, tense and protect or guard. Unfortunately, your body has no way of differentiating between an actual threat or a perceived one, meaning this guarding can linger. Especially if the pain lasts longer than 3 months (becomes chronic) and your nervous system stays on high alert for the pain. So any movement, posture, activity, etc that was painful will be viewed as a threat.

In regards to the pelvic floor this can show up as:

• painful sex, intimacy or orgasm (dyspareunia)

• painful bowel movements

• pelvic girdle pain, low back pain, hip pain

• painful use of internal period products

• pain with sitting or wearing tight clothing

• bladder pain or pain with urination

Since the pelvic floor and abdominal muscles tense up, it can also impact bladder urgency and control, gut motility, posture, breathing and more.

As you can see, endometriosis can have wide spread implications on the pelvic floor. And these can last even after excision surgery or adhesions have been removed. This is why it’s important to address not only the underlying cause of endometriosis, but also the physical impacts it has on the body.

If you have endometriosis and want to see how your pelvic floor is impacted, download my pelvic floor self assessment to begin.