You are uniquely positioned to identify and treat pelvic floor dysfunction, and by simply asking the right questions during patient evaluations, you can uncover symptoms that may otherwise go unreported.
While there are multiple forms of pelvic floor dysfunction (PFD), stress urinary incontinence (SUI) is the most prevalent. SUI is the unintentional leaking of any amount of urine when physical stress is placed upon the bladder and pelvic floor, such as from a cough, laugh, sneeze or activities, such as running and jumping. SUI affects (a known underreported) one in four women.
In a 2018 poll, women aged 50-80 were asked about incontinence, and 43% of those women under 65 reported experiencing it daily (which increased to 51% of women over 65), but 67% didn’t report their symptoms to their doctor.1 This means two thirds of women over 50 who are unable to control their bladder don’t even mention this health problem to their doctors.
The effects of underreporting are far-reaching. Nursing homes are full of people who cannot control their bowel and bladder movements. A cross-sectional study from 2015 showed the prevalence of all types of incontinence in 16 nursing homes was 69.2%.2
Some might be too embarrassed to admit the problem. But many patients—and providers—believe nothing can be done about SUI, and I believe DCs can change that.
We ask about loss of bowel or bladder function to rule out things, such as Cauda Equina Syndrome. But if we take a moment to further ask, “Do you leak any amount of urine if you laugh, cough, jump or sneeze?” we often uncover previously undisclosed dysfunction.
What is the pelvic floor?
I began investigating pelvic floor function when I was preparing for my first pregnancy. I quickly realized just how underappreciated this crucial area of the body is and how my own doctorate education hadn’t equipped me to fully understand its functions. (I also discovered many of my male colleagues didn’t even know they had a pelvic floor, thinking this was strictly female-specific anatomy.) As neuromusculoskeletal (NMS) experts, it is our responsibility to be well-versed in all NMS tissue, including the inconveniently located regions.
The “pelvic floor” refers to a sling of multiple-layered muscles running from the pubic bone to the tailbone with holes for urine and bowel excretion as well as for sexual and reproductive function. The female pelvic floor has three holes: urethra, vagina and anus; the male pelvic floor has two: urethra and anus.
At the opposite end of the abdominal cavity is the diaphragm, which also has three holes: the caval opening, esophageal hiatus and aortic hiatus. Both the diaphragm and pelvic floor have functions in respiration and posture.3
Upon inhalation, the diaphragm descends as the lungs fill, and the pelvic floor descends as the pressure within the abdominal cavity increases. On exhale, the diaphragm ascends back up into the ribcage and the pelvic floor also rises. They work together synchronously. A 2021 RCT showed pelvic floor training improved the function of the diaphragm.4
Training the pelvic floor
Most people are familiar with Kegel exercise: sucking the pelvic floor up and in. But this exercise focuses solely on concentric contraction and is not sufficient for training the full capacity of this multi-layered sling of muscles. Since just about everyone knows what Kegels are, fixing the problem is clearly not as simple as “suck and squeeze.”
There is also a broad assumption SUI occurs because pelvic floor muscles are weak. However, pelvic floor muscle activity has been demonstrated to be greater in patients with incontinence.5
Instead of just repeatedly tightening the pelvic floor muscles, we need to focus on the synchronous nature of the diaphragm and pelvic floor and the closed abdominal canister working together to support the body’s upright posture and continence. The pressure created within the closed system is called intra-abdominal pressure (IAP) and is responsible for helping keep the body upright and bodily fluids where they belong.6
However, many people breathe inefficiently, which improperly distributes IAP, causing inappropriate activity in the muscles of the spine, abdomen and pelvic floor.7
The correction for this is to breathe with full expansion: allowing the abdomen to expand as IAP increases, the ribcage to expand 360 degrees and the pelvic floor to descend on inhale, followed by full relaxation of the abdominal wall and pelvic floor muscles on exhale.
With this breathing strategy, the connection between the diaphragm and pelvic floor is re-established and normal pelvic floor function can return. It certainly doesn’t happen overnight, but considering the average breathing rate of 12-16 breaths per minute, the opportunity for impact is huge.
Your role in treating PFD
DCs play a significant role in appropriately managing PFD. At-home and in-office exercises and manual therapies are often necessary, but one case series demonstrated adjustments alone improved nocturia (nighttime urination) in elderly patients.8
The thoracolumbar (TL) junction is a critical region in the spine to address. This is where the diaphragm attaches to the spine; appropriate spinal movement within this region directly impacts the function of soft tissues attaching thereto.
Spinal manipulation of pregnant patients specifically has been shown to cause pelvic floor relaxation.9 This research highlights the impact not only of adjustments on pelvic floor tissues, but on the hormonal impact of adjusting, as the same results were not seen in the nonpregnant women.
There are benefits to internal pelvic floor work, but not all states permit internal work in the chiropractic scope. (It is within my scope in North Carolina; however, I address PFD externally and refer to a trusted pelvic PT as needed for internal work.)
Patients can perform internal work at home with a pelvic wand to mobilize tight tissues to their own comfort level and tolerance.
In-office myofascial techniques addressing the obturator internus can be incredibly beneficial because this unique muscle functions internal and external to the pelvis. The tendon can be accessed at the posterior hip, similar to working with a patient’s piriformis or gluteal muscles. (See Figure 1.)
Home exercise
An effective dynamic neuromuscular stabilization exercise for improving pelvic floor dysfunction is high bear.
Patients begin on hands and knees and then tuck the toes under and elevate the knees slightly off the floor. They then further lift the pelvis so that it ends up higher than their shoulders, but their knees remain slightly flexed to avoid flexion of the lumbar spine.
Encourage patients to maintain that position for one to three breaths (as described earlier to full expansion), then slowly return to hands and knees and repeat for five repetitions, twice daily.
At no point in the exercise should a patient be drawing the abdomen or pelvic floor inward: This exercise instead works on the eccentric activation of the entire abdominal cavity, including the pelvic floor.
Final thoughts: Paving the way
You are uniquely positioned to improve pelvic floor function in your patients: Begin by asking the right questions. Follow up with education, adjustments and home exercises, and we can turn the tide on the endemic of pelvic floor dysfunction.
Lindsay S. Mumma, DC, DNSP, is the owner of Triangle Chiropractic and Rehab, a multidisciplinary practice she opened in 2012. She teaches internationally for Motion Palpation Institute and moveMentors. Her practice focuses on rehabilitative chiropractic care across the lifespan and with a specific focus on prenatal and postpartum health. She was the first certified DNS Practitioner in North Carolina. She is a wife, mother to two boys, speaker, life enthusiast and author of the best-selling book “Your Pelvic Floor Sucks” and the Top 50 in Health Substack Newsletter. She can be found at lindsaymumma.com.
References
Preidt R. Poll: Women Don’t Talk to Docs About Incontinence. WebMD. Published November 1, 2018. https://www.webmd.com/urinary-incontinence-oab/news/20181101/poll-women-dont-talk-to-docs-about-incontinence. Accessed October 21, 2022.
Mandl M, et al. Incontinence care in nursing homes: A cross-sectional study. J Adv Nurs. 2015;71(9):2142-2152. https://pubmed.ncbi.nlm.nih.gov/25892454/ . Accessed September 16, 2025.
Hodges P, et al. Postural and respiratory functions of the pelvic floor muscles. Neurourol Urodyn. 2007;26(3):362-371. https://doi.org/10.1002/nau.20232. Accessed September 16, 2025.
Hwang UJ, et al. Effect of pelvic floor electrical stimulation on diaphragm excursion and rib cage movement during tidal and forceful breathing and coughing in women with stress urinary incontinence: A randomized controlled trial. Medicine (Baltimore). 20218;100(1):e24158. https://pubmed.ncbi.nlm.nih.gov/33429797/. Accessed September 16, 2025.
Smith MD, et al. Postural response of the pelvic floor and abdominal muscles in women with and without incontinence. Neurourol Urodyn. 2007;26(3):377-385. https://doi.org/10.1002/nau.20336. Accessed September 16, 2025.
Novak J, et al. Postural and respiratory function of the abdominal muscles: A pilot study to measure abdominal wall activity using belt sensors. Isokinetics and Exercise Science. 2021;29(2):175–184. https://journals.sagepub.com/doi/full/10.3233/IES-203212. Accessed September 16, 2025.
Novak J, et al. The significance of intra-abdominal pressure on postural stabilization: A low back pain case report. Slovak Journal of Sport Science. 2022;7(2):3-18. https://www.researchgate.net/publication/357893423. Accessed September 16, 2025.
Zhang J, et al. A case series of reduced urinary incontinence in elderly patients following chiropractic manipulation. J Chiropr Med. 2006;5(3):88-91. https://pubmed.ncbi.nlm.nih.gov/19674678/. Accessed September 16, 2025.
Haavik H, et al. Effect of spinal manipulation on pelvic floor functional changes in pregnant and nonpregnant women: A preliminary study. J Manipulative Physiol Ther. 2016;39(5):339-347. Accessed September 16, 2025.
