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Muscles of the pelvic floor

Author: Lorenzo Crumbie MBBS, BSc • Reviewer: Alexandra Osika • Last reviewed: April 10, 2020 

The pelvic floor is primarily made up of thick skeletal muscles along

with nearby ligaments and their investing fascia. It is a basin-shaped 
muscular diaphragm that helps to support the visceral contents of
the pelvis. The main focus of this article will be the pelvic floor
muscles. On that topic, there are several important questions that
need to be answered:

Which muscles make up the pelvic floor?

What arteries and nerves supply the muscles of the pelvic floor?
What causes pelvic floor dysfunction?
What is the best exercise for the pelvic floor?

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Musculus pubococcygeus
(Pubococcygeus muscle)  

Key facts about the muscles of the pelvic floor

Gross anatomy A variably thick muscular membrane called a

diaphragm
Coccygeus and levator ani muscles (iliococcygeus,
puborectalis, pubococcygeus)
Pubococcygeus can be further separated into –
puboperinealis, puboprostaticus (male), pubovaginalis
(female), puboanalis
Mnemonic:  Could I Please Peek?

Attachments Laterally – attached to the tendinous arch of

levator ani
Posterolaterally – attached to the ischial spine
Posteriorly – attached to the caudal sacrum and
coccyx
Anteriorly – attached to the posterior surface of
the pubis
Midline – fibers form a midline levator raphe

Blood supply Branches of the anterior division of the internal iliac

artery: inferior vesical, pudendal, inferior gluteal

Innervation Pudendal nerve (S2, S3)

Direct branches from S4 (nerve to levator ani)

Embryology Hypaxial division of the sacrococcygeal myotome

Function Prevents pelvic organ prolapse

Childbirth – supports and guides the presenting
fetal part
Helps maintain continence (both urinary and fecal)

Clinical significance Pelvic organ prolapse

Kegel exercises

These and other questions will be addressed as we discuss the gross anatomy and function of the muscles of the
pelvic floor. The piriformis and obturator internus muscles will not be discussed in great detail as they are primarily
muscles of the lower limb. The muscles that are up for discussion are those that form the lower limit of the true pelvis
and have attachment only to structures within the bony pelvis.

Gross anatomy

The pelvis marks an important transition point between the thoracoabdominal region and the lower limbs. Not only is
it important for walking, but it also houses organs of the urogenital and distal digestive systems and acts as a conduit
for arteries, veins, lymphatic vessels, and nerves necessary for daily functioning. The pelvis is a musculoskeletal
structure that is made up of hip and sacrococcygeal bones, along with several muscular layers. It is further divided into

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the greater (false) and lesser (true) pelvis. The false pelvis is the wide area just above the inlet between the ala of the
ilia while the true pelvis is the area between the inlet and the outlet. It has two lateral walls, a posterior wall
(sacrococcygeal bones), and a muscular floor. 

The lower part of the pelvis is sealed off by a muscular diaphragm and perineal membrane known as the pelvic floor.
There are two (males) or three (females) openings that allow passage of the outlet components of the pelvic viscera in
the pelvic floor. The muscles of the pelvic floor contribute to maintaining continence and help prevent the contents of
the pelvic cavity from falling through its outlet. 

Muscles
The muscles of the pelvic floor are collectively referred to as the levator ani and coccygeus muscles. They form a large
sheet of skeletal muscle that is thicker in some areas than in others. The muscles are attached along the inner walls of
the true pelvis to a condensed area of the obturator fascia known as the tendinous arch of levator ani muscle. They
can be subdivided based on their points of attachment as well as the pelvic organs with which they are associated.
Note that the levator ani is made up of the puborectalis, pubococcygeus, and iliococcygeus muscles. The coccygeus
(also referred to as ischiococcygeus) is not part of the levator ani. 

Muscles of the pelvic floor (diagram)

The pelvic surface of the levator ani is separated from the visceral organs by their associated fascia. The perineal
surface functions as the medial and superior walls of the ischioanal fossa and its associated anterior recess
respectively. There is loose connective tissue between the posterior border of the muscle and the coccyx. Finally, the
outlets of the visceral organs separate the medial border of the two muscles. 

Summary of the pelvic floor muscles

Puborectalis Origin: Posterior surface of bodies of pubic bones

Insertion: None (forms 'puborectal sling' posterior
to rectum)
Innervation: Nerve to levator ani (S4)

Pubococcygeus Origin: Posterior surface of bodies of pubic bones

(lateral to puborectalis)
Insertion: Anococcygeal ligament, Coccyx, Perineal
body and musculature of prostate/vagina
Innervation: Nerve to levator ani (S4); branches via
inferior rectal/perineal branches of the pudendal
nerve (S2-S4)

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Iliococcygeus Origin: Tendinous arch of the internal obturator

fascia, Ischial spine
Insertion: Anococcygeal ligament, Coccyx
Innervation: Nerve to levator ani (S4)

Coccygeus (ischiococcygeus) Origin: Ischial spine

Insertion: Inferior end of sacrum, Coccyx
Innervation: Anterior rami of spinal nerves S4-S5

Coccygeus (ischiococcygeus)
The coccygeus (ischiococcygeus) muscle is sometimes considered as a part of the levator ani complex rather than as a
separate muscle. However, this muscle is actually a separate entity that is situated at the most posterosuperior
aspect of the muscle complex. 

It is a triangular sheet of muscle with its apex inserted on the tip and pelvic surface of the ischial spine and the base is
attached to the 5th sacral segment and the lateral margins of the coccyx. The remaining fibers of the muscle
converge at the midline. The muscle is anteriorly related to the pelvic surface of the sacrospinous ligament. 

Iliococcygeus

The iliococcygeus part of levator ani is

anteroinferior to coccygeus muscle and
posterosuperior to pubococcygeus. The muscle
extends laterally to the tendinous arch of the
levator ani. The posterolateral fibers have
attachments to the ischial spine (just inferior and
anterior to the coccygeus muscle attachment),
while the anterolateral fibers attach at the
obturator canal. The posterior midline fibers are Anococcygeal ligament (inferior view)
attached to the lower part of the sacrum and
coccyx. 

The majority of fibers of iliococcygeus meet with fibers of the contralateral half of the muscle to form a midline
raphe. The raphe – a groove where the two halves of the muscle unite – is continuous with the anococcygeal ligament
and provides a strong posterior attachment for the pelvic floor. 

Pubococcygeus
The pubococcygeus is the intermediate part of the levator ani muscles. The anterior fibers arise from the posterior
surface of the pubic arch and travel posteriorly in the horizontal plane. The fibers then decussate to meet with the
fibers from the contralateral side, to form a sling around the distal parts of the pelvic organs. Pubococcygeus can be
further subdivided based on the structures that the fibers are immediately associated with:

Puboperinealis - The innermost fibers travel adjacent to the urethra and its associated sphincter as it exits the
pelvic floor. In some instances, the muscle is called pubourethralis because it is associated with the proximal half of
the urethra and forms part of its sphincter complex
Puboprostaticus (males) and pubovaginalis (females) - Another group of muscle fibers passes around the inferior
part of the prostate (in males) or posterior wall of the vagina (in females). 
Puboanalis - A few fibers cross to the other side and blends with the fibers of the longitudinal rectal muscles and
fascia to form the conjoint longitudinal coat of the anal canal. 

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Puborectalis
The puborectalis passes behind the rectum along the levator raphe as a muscular sling curving around the anorectal
junction. Collectively, the subdivisions of pubococcygeus and the puborectalis muscle together are referred to as the
pubovisceralis.

Mnemonic
There is an easy way to remember the muscles of the pelvic floor. The mnemonic ' Could I Please Peek?' will help you
recall the following structures:

Coccygeus
Iliococcygeus
Pubococcygeus
Puborectalis

Then challenge yourself with our study units to see how much you remember. Repetition is the master of learning!

Muscles of the pelvic floor

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Blood supply

The anterior division of the internal iliac artery is responsible for supplying the levator ani group of muscles with
oxygenated, nutrient-rich blood. Its three terminal branches – the pudendal, inferior gluteal, and inferior vesical
arteries – access and pierce these muscles in order to supply them. Venous drainage is achieved by the similarly named
veins.

Learn more about the arterial blood supply and venous drainage of the pelvic floor and pelvis with these study units!

Blood supply of the female pelvis Blood supply of the male pelvis
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Innervation

Branches from the sacral plexus contribute to the innervation of the levator ani group of muscles. The pudendal
nerve, which originates from the second to fourth sacral segments (S2-S4) directly innervate the pubococcygeus
muscle. Direct branches arising from the fourth sacral segment form the nerve to levator ani (S4), which also
innervates the pubococcygeus. The remaining coccygeus and iliococcygeus are innervated by direct branches from
the fourth and fifth segments (S4 and S5) of the sacral plexus.

Check out these resources to solidify your knowledge about the sacral plexus and innervation of the pelvic floor
muscles.

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Custom quiz about the pelvic

Muscles of the pelvic floor
floor muscles
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Sacral plexus Nerves of the male pelvis

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Neurovasculature of the female

Nerves of the female pelvis
perineum
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Function

The muscles of the pelvic floor are primarily supportive structures. They help keep the pelvic viscera in place and
prevent them from being pushed through the pelvis during strain. It achieves this task by being unconsciously
contracted at rest and can be consciously contracted during times of raised intra-abdominal pressure (vomiting,
sneezing, coughing, lifting a heavy object, or forced expiration). 

Contraction of the levator ani muscles also provides additional occlusion to the outlet segments of the pelvic viscera.
In other words, the muscles aid in maintaining both urinary and fecal continence until it is convenient to void. The
puborectalis muscle best demonstrates this function. Recall that it is a muscular sling U-shaped muscle that arches
around the anorectal junction. When this part of the muscle is contracted, it pulls the anorectal junction anteriorly,
forming a 90 degrees angle between the rectum and anus. Therefore fecal matter cannot flow freely from the
rectum. In order for micturition (urination) and defecation to occur, the levator ani muscles must be relaxed.

Want to learn more about the muscles of the pelvic floor? With attachments, innervations and functions
clearly detailed in handy revision tables, our trunk wall muscle chart has you covered. 

The pelvic floor muscles also provide additional support during childbirth to the presenting fetal part – the part
closest to the uterine outlet. It holds the fetus in place while the uterine cervix dilates and contracts. It also keeps the
presenting part of the fetus in the anteroposterior plane of the pelvic outlet to further support the process of
delivery.

Histologically, the majority of the pelvic floor muscles are made up of slow-twitch or type I muscle fibers. The
prevalence of type I fibers is important given the function of the pelvic floor muscles outlined above. Recall that type I
fibers are ideal for long periods of contraction, while type II fibers are needed for quick response to physiological
changes. 

Embryology

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The muscles of the pelvic floor can be contracted under voluntary control and are therefore skeletal muscles. This
means that these muscle fibers arise from the dermomyotomes of somites and undergo an epithelial to
mesenchymal transition. Multiple transformation factors promote the conversion of mesenchymal cells to myoblasts
(primitive muscle cells).

Myoblasts are characterized by longer nuclei and cell bodies in comparison to their precursor cells. Some of these
myoblasts fuse to form myotubes – multinucleated cylindrical cells. As fusion takes place, myofibrils and other
skeletal muscle organelles begin to appear in the cell cytoplasm. As the myoblasts continue to form they migrate
away from their myotomes to form non-segmented muscle groups. Those of the pelvic floor arises from the hypaxial
division of the sacrococcygeal myotomes.

 Clinical significance
The role of the pelvic floor is to provide structural support and help maintain continence. Therefore any
disorder of these muscles would result in instability of the pelvic organs (prolapse) and incontinence. Pelvic
floor disorders are more commonly encountered in females than males. This results from the fact that
most of the risk factors (obstetric causes and hormone-related ligament laxity) occur exclusively in females.
However, both males and females may experience urinary or fecal incontinence for different reasons. The
issue of organ prolapse, however, remains mostly a gynecological problem. One of the most distressing
complications of defective pelvic floor musculature is pelvic organ prolapse. 

Pelvic organ prolapse

Pelvic organ prolapse is essentially herniation of pelvic viscera through its associated opening. For example,
uterine prolapse through the vaginal vault, or rectal prolapse through the anus. The disorder is associated
with weakening of the pelvic floor. This weakness can be induced by over-distension of the muscle over
time. The risk factors for developing pelvic floor dysfunction and subsequently pelvic organ prolapse can be
non-obstetric (chronic coughing, obesity, smoking, ethnicity, age, history of connective tissue disorder) or
obstetric (multiparity, prolonged labor, precipitous labor, operative vaginal delivery). An occupational history
suggestive of long term heavy lifting may also increase the risk of developing pelvic floor weakness and
subsequent organ prolapse. 

Women who experience pelvic organ prolapse may experience feeling a mass protruding from the vaginal
opening. They may have an anterior wall prolapse associated with a prolapsed bladder (cystocele), which
will cause symptoms of urinary retention. They may also have a posterior wall prolapse associated with a
bulging of rectal wall (rectocele), which leads to constipation. Others may experience uterine prolapse
where the cervix is extending through the vaginal opening. Even women who have had their uterus
removed (hysterectomy) may have prolapse of a poorly suspended vaginal vault. 

Both men and women may experience rectal prolapse. This is a debilitating condition where either part of
the rectal mucosa or the entire rectum can descend through the anus. It is also more prevalent in women
than in men. Most of the predisposing risk factors for pelvic organ prolapse also increase the chances of
developing rectal prolapse. 

Kegel exercises

The weakening of the pelvic floor muscles can lead to incontinence as well as a pelvic organ or rectal
prolapse. There are some exercises that can help improve problems with urine leakage or bowel control.
Women are often told during pregnancy or after childbirth to perform Kegel exercises, also known as pelvic
floor exercises, to try and prevent urinary incontinence and to help women who have difficulty achieving
orgasm following pregnancy.

Kegel exercise instructions 

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The goal of Kegel exercises is to isolate and train the muscles of the pelvic floor. A good way to isolate these
muscles is to attempt stopping the process of urination midstream. The muscles that are activated during
this process are the pelvic floor muscles. These are also the muscles used to prevent passing gas (flatus). 

Before beginning the exercise, first empty your bladder. Next, lie on your back and tighten the pelvic floor
muscles identified earlier. Now hold the contraction for 5 seconds, then relax for 5 seconds. Repeat this
process 4 to 5 times, up to 3 times a day. Once you’ve become comfortable holding contraction for 5
seconds, increase the holding time to 10 seconds for each contraction and relaxation. 

Avoid activating the abdominal, thigh, or buttocks muscles during this process and ensure you’re breathing
freely. Take note not to use Kegel exercises to start and stop your urine stream on a regular basis.
Performing these exercises while emptying your bladder can actually weaken the muscles, which can result
in incomplete bladder emptying and resultant urinary tract infections.

Muscles of the pelvic floor: want to learn more about it?

Our engaging videos, interactive quizzes, in-depth articles and HD atlas are here to get you top
results faster.

What do you prefer to learn with?

VIDEOS QUIZZES BOTH

“I would honestly say that Kenhub cut my

study time in half.” – Read more.

Kim Bengochea, Regis University, Denver

References:

Iglesia, C., & Smithling, K. (2017). Pelvic Organ Prolapse. Am Fam Physician, 96(3), 179-185. Retrieved from
https://www.aafp.org/afp/2017/0801/p179.pdf
Moore, K., Agur, A., & Dalley, A. (2006). Clinically Oriented Anatomy (5th ed.). Philadelphia:
LippincottWilliams&Wilkins.
Moore, K., Persaud, T., & Torchia, M. (2013). The Developing Human (9th ed.). Philadelphia, PA: Elsevier-
Saunders.
Netter, F. (2014). Atlas of Human Anatomy (6th ed.). Philadelphia: Elsevier Saunders. 

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4/13/2020 Muscles of the pelvic floor: Anatomy and function | Kenhub

Rakinic, J., & Poritz, L. (2018). Rectal Prolapse: Background, Anatomy, Pathophysiology. Retrieved from
https://emedicine.medscape.com/article/2026460-overview#a7
Standring, S., & Gray, H. (2008). Gray's Anatomy (40th ed.). Edinburgh: Churchill Livingstone/Elsevier.

Illustrators:         

Muscles of the pelvic floor (diagram) - Liene Znotina

Anococcygeal ligament (inferior view) - Liene Znotina

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Muscles of the pelvic floor

Neurovasculature of the female perineum

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