Back pain? Don't neglect your perineum

Low back pain is a common complaint affecting millions of people worldwide, significantly impacting their quality of life. Often, the search for solutions focuses on the lumbar region itself, but a holistic approach, such as an osteopathic consultation, may well reveal the often overlooked importance of the perineum. The perineum is the anatomical region between the external genitalia and the anus. This region, often associated with pregnancy and childbirth (although let's not forget that men have a perineum too), plays a much wider role in the stability of the lower back and the prevention of lower back pain.

Low back pain, or pain in the lumbar region, is a common condition that can have a variety of causes. The pain associated with low back pain can spread to the buttocks, the back of the thighs and even behind the knees. There are two main categories of lower back pain:

• Specific low back pain is the result of conditions such as scoliosis, ankylosing spondylitis, etc. 
• Low back pain "on its own" or common is not linked to a specific medical cause. There are 3 types of common low back pain:
  1.    Chronic low back pain, present for more than 3 months;
  2.    Acute low back pain, lasting less than 6 weeks, with a sub-acute phase lasting up to 12 weeks;
  3.    Recurrent low-back pain, characterized by acute episodes recurring at variable intervals over several months to years.

The impact of pain on daily life, and consequently on the management of low back pain, varies considerably from one patient to another.

Although often misunderstood, the perineum is an anatomical region encompassing a collection of muscles, ligaments and connective tissue between the pubis (front pelvic bone) and the coccyx (lower end of the spine). Its function extends far beyond the sphere of pregnancy and childbirth. It provides support for the pelvic organs, controls urinary and fecal functions, participates in sexual function, etc. In the context of low-back pain, the perineum also plays a key role in spinal stability and the prevention of muscular imbalances, as a weakened perineum can lead to muscular imbalances that exacerbate low-back pain. Ignoring this area could deprive those suffering from low-back pain of potential solutions.

The perineum is made up of several muscles, the 3 main ones being :

• The anus elevator muscle is located in the anterior part of the perineum, extending between the pubis and coccyx. This muscle supports the pelvic organs, participates in urinary and fecal control, and maintains the stability of the spine.
• The ischiococcygeus is located in the medial part of the perineum and extends between the ischial bone and the coccyx. It also helps support the pelvic organs.
• The superficial transverse perineum is located in the posterior part of the perineum and extends between the ischiae. This muscle plays a role in supporting the pelvic organs and closing the anal canal.

In addition to muscles, the perineum includes the anatomical structures found in this region.

These include external genitalia such as the penis in men and the vulvar lips in women. In women, it is also associated with the urethral and vaginal orifices. The urogenital hiatus is the space between the elevator muscles of the anus and the superficial transverse muscle of the perineum, housing the urogenital structures. The posterior part of the perineum is in contact with the rectum.

Now that we have the anatomy in mind, we understand the close anatomical link between the perineum and the lumbar region. The muscles of the perineum play a crucial role in maintaining urinary and fecal continence. Dysfunction in this area can lead to additional pressure on the lumbar muscles. Pelvic floor muscles also contribute to pelvic stability. Imbalance or weakness in this region can influence posture and lumbar stability, contributing to back problems. Finally, pelvic floor muscles interact with other trunk muscles to maintain balanced posture. Problems in the perineum can disrupt this interaction and contribute to postural problems, including back pain.

If your back pain is persistent, it's essential to consult a healthcare professional. A visit to an osteopath can be a key element in the management of low-back pain, particularly when the perineum is taken into account. Using appropriate manual techniques, the osteopath aims to restore the body's overall balance by considering the relationship between the perineum, the spine and the pelvic organs. Gentle manipulations, combined with advice on appropriate exercises, offer a holistic approach to relieving and preventing back pain. By assessing the mobility of the perineum, the osteopath can identify tensions or restrictions that may be affecting the pelvic organs and lumbar region. Osteopathic treatment aims to restore natural mobility and harmony between the perineum and surrounding structures.

Perineal rehabilitation, carried out by a physiotherapist or midwife, includes specific exercises to strengthen the pelvic floor muscles. This can help improve pelvic stability and reduce tension in the back region.

In addition to osteopathic treatment, specific exercises can be recommended to strengthen the perineum. Your osteopath will also be on hand to give you personalized advice on what exercises to do. 

Different exercises are required depending on the contraction of your perineum. You may need to strengthen it in the case of hypotonia, or relax it in the case of hypertonia. 

Here are a few tips to help you work on your perineum: 

• Voluntary contraction: sitting or standing, contract your perineal muscles (as if you were trying to hold back urine) without straining your abs, glutes, etc. Try to hold the contraction for 10 seconds, then relax for the same amount of time.
• The pelvic bridge: lie on your back with your knees bent and your feet flat on the floor, then lift your hips towards the ceiling, contracting your perineum muscles.
• Diaphragmatic breathing: inhale deeply through the nose, inflating the belly and gently contracting the perineal muscles as you exhale. 

Taking the perineum into account when managing back pain offers a holistic approach that can improve quality of life. Targeted exercises and special attention to this area can help not only to relieve existing pain, but also to prevent future recurrences. Let's not forget that the health of the perineum goes beyond motherhood, and deserves regular attention to ensure the body's overall well-being.