The pubococcygeus is the central and most important component of the levator ani, running from the pubic bone posteriorly to insert on the coccyx and the anococcygeal raphe. In females, fibres also insert into the lateral vaginal walls (pubovaginalis) and in males into the prostate (puboprostaticus). It forms the main muscular component of the pelvic floor diaphragm and is the primary muscle targeted in pelvic floor physiotherapy exercises for continence and prolapse.
| Origin | Posterior surface of the pubic body (anterolateral), just lateral to the pubic symphysis |
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| Insertion | Anococcygeal raphe and the coccyx, with fibres also blending into the walls of the vagina, rectum, and prostate |
| Nerve Supply | Branches from S3-S4 (nerve to levator ani); Inferior rectal nerve |
| Blood Supply | Inferior vesical artery; Internal pudendal artery |
| Actions | Elevates the pelvic floor and closes the urogenital hiatus; Supports pelvic viscera against intra-abdominal pressure; Contributes to urinary and faecal continence |
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The pubococcygeus is the muscle trained in Kegel exercises (pelvic floor contractions), which strengthen the levator ani complex to improve urinary and faecal continence and support pelvic organ prolapse management. Biofeedback therapy, electrical stimulation, and physiotherapy target this muscle specifically. In childbirth, the pubococcygeus stretches dramatically over the fetal head, and avulsion from the pubic bone is a primary mechanism of levator ani injury leading to pelvic floor dysfunction. Surgical reinforcement using mesh placed below the pubococcygeus is controversial due to mesh erosion complications.
Assessed on vaginal or rectal examination as the firm muscular band that contracts when the patient is asked to squeeze or stop urination, palpable on the lateral walls of the vagina or rectum bilaterally.
Avulsion of the pubococcygeus from its pubic origin during vaginal delivery, particularly with forceps, large fetal head, or prolonged second stage, produces a pelvic floor defect on MRI that is the strongest single risk factor for subsequent pelvic organ prolapse and stress urinary incontinence.
Weakness or incoordination of the pubococcygeus from childbirth injury, ageing, obesity, or chronic straining produces stress urinary incontinence, pelvic organ prolapse, and defaecatory dysfunction, managed primarily with pelvic floor physiotherapy and Kegel exercises before surgical intervention is considered.
