Envision a layer of muscles and supporting fascia, stretching from the tailbone to the pubic bone and from one sitting bone to the other, forming a hammock-like support network for the organs above. That’s your pelvic floor.
While it might not be a pleasant topic, the pelvic floor is something so important, we actually cannot survive without it. Both men and women have these specialised muscles and fascia which act to support the pelvic organs such as the bladder, bowels and uterus (in females), and aid in the maintenance of continence, as part of the urinary and anal musculature. The pelvic floor also facilitates childbirth, helps maintain optimal intra-abdominal pressure, is the basis of our core and helps to support the entire pelvis and lower back. We really do depend on the pelvic floor for quite a lot.
For women in particular, the pelvic floor muscles provide support for the growing baby during pregnancy and assist in the birthing process. These muscles can get strained and weakened by pregnancy and childbirth which can lead to issues with continence or organ prolapse. Even without having had a pregnancy, later in life women may still experience problems related to a compromised pelvic floor due to hormonal changes.
What else can weaken these muscles in men and women alike? Straining on the toilet, chronic coughing, heavy lifting, high impact exercise, age and obesity are other factors which may contribute to pelvic floor muscle impairment. Basically, no one is immune, and that’s why it is so important to maintain your pelvic floor.
For people with symptoms of a weak pelvic floor (back pain and/or incontinence during normal activities or sports), there are a number of options to get the muscles back in shape. If you immediately think of Kegel exercises, you’re not alone, but there are actually many additional exercises that can be done. Something important to note is that these muscles must be able to contract as well as relax to function properly. While Kegels lead to a concentric contraction/shortening, the muscles must also be capable of elongating eccentrically. This means they have to stay strong while letting go to maintain control.
Basically, Kegels cause the pelvic floor muscles to tighten which is helpful but equally as important is the ability of the muscles to stretch or elongate and release. If you’re only doing Kegel exercises, you may end up with tight but weak, exhausted, and disconnected pelvic floor muscles. This situation could land you with the symptoms described above which you may not think could happen by doing exercises that are meant to help. For this reason, just as you may vary gym workouts to keep your body balanced and functioning well, the same goes for conditioning or reconditioning the muscles of the pelvic floor. Variety is fundamental to pelvic floor preservation. Think of it like cross-training.
Running is thought to cause pelvic floor muscles to become tight. This may be because those muscles form part of your core which is engaged during running. If another part of the core is weak, your pelvic floor muscles have to work even harder to compensate and support your pelvis. In time, this can cause the muscles to become tighter and eventually they may become painful and weakened because they are overworking in a contracted state. This can lead to problems such that when the bladder is put under sudden pressure, pelvic floor muscles are unable to generate enough power quickly to block off the flow of urine. If the muscles are already in a tightened state, they cannot contract further. Urinary incontinence or leaking may ensue. In this case, only working on exercises (like Kegels) to tighten the pelvic floor could actually make things worse, not better.
So what are you supposed to do and how to do it? Your doctor may refer you to see a physiotherapist for evaluation and to design a program for you to follow. This might include therapeutic Pilates exercises, posture work and some individual movements depending on your needs or goals. Women can do this before, during and after pregnancy as well as later in life. Anyone and everyone can use some work on the pelvic floor to maintain its integrity.
The recommendation from most physiotherapists is to learn how to contract as well as relax the pelvic floor muscles correctly. It might sound like an easy task but it’s actually quite tricky because these muscles are not usually even thought about until a problem arises (like the inability to control your bladder or bowels). Coordinating the movement, contraction and relaxation correctly requires a fair amount of practice. Having some guidance to do this is key.
Some of the tools used by physiotherapists include; an ultrasound, to see the underlying structures and observe the muscle movement in real time; internal exam, to diagnose the extent of the muscle issues; and a prescription for exercises, to specifically target the problem areas for each individual. For example, if you only experience incontinence while doing a specific move, like hitting a tennis ball with your forehand or going from sitting to standing in a hurry, a special set of exercises can be designed to strengthen your pelvic floor in those positions. At each session, an evaluation is done to see if progress has been made and to tailor the present session to adjust to the new condition.
Examples of beneficial exercises:
Alternate arm and leg lift (on all fours)
Leg lift sitting on an exercise ball
Bridge exercise with feet on ball
Pelvic tilts (similar to cat/cow poses) while seated on an exercise ball
Standing balance work on Bosu ball or balance disc
During these moves, see if you can get your pelvic floor to relax on the inhale. A secret to getting a good muscle contraction is to achieve full relaxation first because if the muscle is already tight, there is no room for it to contract.
Think about connecting and controlling your pelvic floor. Putting your mind to it helps.
Considering these exercises, it’s easy to see the pelvic floor is more of a whole body issue than an isolated one. With some effort, you can improve and preserve your pelvic floor.
If you’re not successful with physiotherapy, pilates or other exercises to alleviate the problems you may be experiencing, there are some alternatives to consider but sometimes the next option is surgery.
A word of caution about training your pelvic floor, according to one physio with a very informative website: Don’t pee and blow your nose at the same time. We’ve all done it! It saves time when you’re a mum, right? Well, there’s a little problem with that particular time-saving tidbit. If you’re blowing your nose (an action which naturally tightens the pelvic floor and core muscles) while simultaneously relaxing your pelvic floor to let out urine, you’re actually retraining your pelvic floor not to respond correctly. Not a good idea.
ANSWERS FROM A PHYSIOTHERAPIST
Playtimes asks Kate Smith, a woman's health physiotherapist at Thrive Health HK, a few questions about maintaining the pelvic floor.
1. How common are pelvic floor issues in your practice?
Very! All of my pre- and post-natal clients experience a degree of pelvic floor dysfunction at some stage. I also see many women who aren't pre/post-natal who experience stress or urge incontinence, or have issues with pelvic pain.
2. What type of symptoms do they typically present with?
Incontinence, urinary urgency or frequency, trouble holding in wind, dragging/feeling of heaviness vaginally, lower back pain, painful sex.
3. How do you go about designing a rehab program? What would be some typical exercises?
I prescribe pelvic floor rehab programs based on what I find on assessment- it is individual to each person. An internal pelvic floor exam assesses the position of pelvic organs, as well as the ability of the different muscles to both contract and relax. I assess the strength, endurance, speed and co-ordination of these muscles and give an individualised exercise program to suit the client's ability and goals. I also assess the joints and muscles around the pelvis, lower back, hips and the abdominal wall.
4. Approx how many sessions over what period of time is sufficient to see some recovery?
This is quite individual, depending on the dysfunction and the goal of the client. It depends on their starting point, and what they want to achieve (for example, being continent while sneezing vs heavy weight lifting). Many clients will see a benefit from having one assessment and learning the correct techniques. Like any other muscle group in our body though, it will take weeks of training to see muscle adaptation.
5. Once therapeutic sessions are done and symptoms improved, do patients typically come back for maintenance work?
If there is a big change, for example subsequent pregnancy/birth or an increase/change of activity such as a return to high impact activity, then clients tend to benefit from reassessment.
6. What other issues are related to pelvic floor weakness?
The pelvic floor forms part of our core, so any issues with your lower back, abdominal wall (including diastasis recti), and pelvis or thoracic issues can be related to pelvic floor problems.
7. Do you see women with these problems who’ve never had children?
Yes! Although pregnancy and birth are the most common, any kind of activity that increases intra- abdominal pressure puts stress on the pelvic floor. This can include chronic respiratory issues, persistent vomiting, or high impact exercise.
8. Even if the pelvic floor is ok now, when might issues crop up...hormone influences etc?
The effects of ageing and your estrogen level can affect your pelvic floor function. You may notice changes if you're not having a period, if you're exclusively breast feeding, or when you're going through menopause.
9. Are most cases resolved with physio?
There is very strong evidence for pelvic floor muscle training as a Physiotherapy intervention. Clinically I would say that symptoms can always be improved.
10. What guidelines should women follow post-partum in terms of what to do and when?
A great resource for education and postpartum advice is the pelvic floor first website, where you can find a timeline to follow.
For runners, the first clinical guidelines have recently been released for return to running postpartum. This is evidence based and advises to wait at least 3-6months before returning to running. It can be accessed for free here.
A few considerations outlined by an OB/GYN, including when to seek surgical intervention:
1. Any recommendations during pregnancy to help keep the pelvic floor in shape and avoid issues later?
Pelvic floor weakness contributes to urinary incontinence and even flatual incontinence. Being pregnant and having a vaginal delivery may lead to its weakening.
The best way to prevent or treat incontinence secondary to the weakness is by strengthening the muscles through exercise. Pelvic floor exercises should be done throughout and after pregnancy. A physiotherapist is best equipped to guide you and it is worth noting that pelvic floor strengthening (aka Kegels) is not appropriate for everyone and may in some cases make symptoms worse, especially if done incorrectly. Women who already suffer from pelvic floor weakness prior to pregnancy may benefit from seeing a physiotherapist early on to ensure adequate and appropriate pelvic floor exercise.
2. What are the guidelines postpartum in terms of how best to preserve the integrity of the pelvic floor - anything to avoid, anything to specifically do, timeframes for these activities?
Childbirth is different for every woman and no delivery is the same. That said, for most new mums the best time to start your pelvic floor exercises is as soon post-partum as you feel comfortable or your OBGYN allows. Gentle pelvic floor squeezes in the first few days after birth can help the healing process, reducing swelling and improve circulation, as well as helping with that all important continence control.
After delivery, the best thing to do is start doing the exercises on a regular basis and throughout your day alongside another regular activity, such as eating or going to the toilet, so that you remember to do it.
Note that many women will experience incontinence in the first few days after birth. However if this is continuing longer than a couple of weeks, it is recommended you consult your OBGYN or GP and ask to be referred to a pelvic floor physiotherapist. A pelvic floor physiotherapist can advise how to safely perform or modify activities that may impact pelvic floor healing.
You may need to avoid the following to prevent further weakening of the pelvic floor:
lifting heavy objects or exercise that involves this
constipation or straining
excessive weight gain
certain abdominal exercises
3. If your patients have issues such as incontinence, at what stage would they require intervention? What is the first line of therapy?
Patients should seek treatment as soon as symptoms arise and the first line of therapy is physiotherapy with a pelvic floor physiotherapist. There is strong evidence that pelvic floor strengthening is effective in the treatment and management of urinary incontinence and prolapse.
It’s important to understand the initial severity as a baseline for future comparison so an evaluation will be performed. Many women find it embarrassing to talk about and may not seek help until the symptoms start affecting their daily activities.
In some countries every woman who gives birth gets a full post-natal pelvic floor and abdominal check-up/rehabilitation program. This helps to identify those at risk of developing pelvic floor issues before they happen.
4. At what point is surgery recommended?
Surgery becomes a point of discussion when therapeutic exercises fail to address the incontinence and it progressively worsens. Surgery is definitely considered a last option. Women usually opt for surgery if the symptoms are severe or if they have other associated conditions related to pelvic floor weakness, such as uterine prolapse.
5. Are all of the above commonly discussed with your patients or only when a problem arises?
We usually delve into the details when symptoms start to arise. Not all women will suffer from urinary incontinence in their pregnancy, but weakness will occur for all women during pregnancy. We recommend all women to do pelvic floor exercise in pregnancy and work closely with midwives and physiotherapists.
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Bio feedback sessions
One method of getting help with the pelvic floor, which is not dissimilar to physio, is with manual or electro-stimulation and bio feedback with a vaginal probe. Muscle activity can be monitored and directed under the guidance of a midwife. The aim is to relieve leaking or prolapse as well as generally rehabilitate the pelvic floor and abdominal muscles. This work is best done five to six weeks postpartum and before returning to normal exercise.
With 10 sessions post-partum, the ability to gain control over your pelvic floor muscle function is restored. In the case of C-Section, five sessions would suffice.
With thanks to Dr Lucy Lord, Dr Christina Hui and Hazel Walpole at Central Health and Dr Zara Chan of OT&P.
This article appeared in Playtimes Winter Issue 2019 and was updated in January 2020.