Pelvic floor dysfunction is not something we think about in our late teens, or even our twenties. The first time most young women hear about incontinence or prolapse is in relation to a much older female, perhaps their elderly grandmother or even their mother, but she’s in her fifties and has had three kids so it must be normal, right? Wrong. So what and where is the pelvic floor and what are some of the things that can go wrong with it? And what should women know in preparation for having their first baby, or subsequent babies, or if they have incontinence or a feeling of heaviness in the vagina? Read on.
Female Pelvic Floor Anatomy
The Pelvic Floor is a large group of muscles that have many functions. These functions include supporting the pelvic organs (such as your bladder, ovaries and uterus) to prevent prolapse; sensory function during intercourse; maintaining urinary and faecal continence (the ability to consciously decide when to open your bladder or bowel, and not having leakage in between toilet stops); working with the diaphragm, abdominal wall and spinal extensor muscles in a postural and stability role; and withstanding increases in intra-abdominal pressure (such as when sneezing, coughing, laughing and lifting) so that our organs don’t ‘fall down’ through the vaginal cavity with a little extra pressure.The pelvic floor is quite a large group of muscles that covers the entire area that would touch a bike seat if you were cycling, excluding the buttocks and inner thighs.
The bladder is a muscular storage tank for urine. The urine flows outside the body through a tube called the urethra. Closure of the urethra keeps the urine in the bladder. This is achieved through the combined action of the voluntary and involuntary muscles and the vascular (blood) system. The striated urethral sphincter muscle is circular and wraps around the smooth muscle of the urethral wall. The urethra requires a supportive pelvic floor to contract against in order to fully function and prevent urinary leakage. Stress Urinary Incontinence (SUI, the leakage caused by sneezing, coughing, running, jumping, etc) is caused by problems with the muscles surrounding the urethra, as well as those supporting it. Pelvic floor muscle retraining is the first line of treatment to improve continence in people with an underactive pelvic floor. If your pelvic floor is overactive (too tight) and/or painful, other strategies and exercises have to be learned and this will require specialist intervention from a Women’s, Men’s and Pelvic Health Physiotherapist.
Supportive Muscular System
DeLancery and Norton described the interaction between the pelvic floor muscles and the supporting ligaments and fascia as the ‘boat in a dry dock’ theory. The ship represents the pelvic organs (bladder, uterus, rectum, ovaries), the ropes are the ligaments and fascia (connective tissues) that connect the organs to the pelvis, and the water is the pelvic floor muscles. When the pelvic floor muscles function normally, the organs are well supported, and the ligaments and fascia are under normal tension. When the pelvic floor muscles are weak or damaged, the pelvic organs are held in place by the ligaments and fascia alone. If the pelvic floor muscles are not rehabilitated, the connective tissues will become stretched and damaged.
Pelvic floor dysfunction may lead to the following conditions:
· Urinary incontinence (stress, urge and mixed incontinence) – see https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/musculoskeletal/pelvic-floor-muscle-training-urinary-incontinence for detailed information from the Royal Australian College of GPs, which indiciates physiotherapists with an interest in pelvic floor as a first line of treatment
· Faecal incontinence
· Pelvic organ prolapse - see https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/musculoskeletal/pelvic-floor-muscle-training for detailed information
· Sensory and emptying abnormalities of the lower urinary tract
· Defecatory dysfunction (difficulty with bowel movements, or inadequate emptying)
· Sexual dysfunction
· Chronic pain syndromes
· Overactive pelvic floor (often occurs with endometriosis)
These conditions are not limited to older women. In fact, young women sometimes experience incontinence or prolapse as a result or childbirth or participating in high level impact sports, such as gymnastics, athletics and dancing. Even teenagers can experience these symptoms. If you feel that something isn’t right down below, your first port of call should be a specialist Men’s, Women’s and Pelvic Health Physiotherapist (see https://choose.physio/findaphysio and search for Women’s Health Physiotherapist). They will be able to conduct a thorough assessment and establish a specific exercise program to help you improve your symptoms and manage your condition. As long as you don’t have a tight, overactive pelvic floor (if you are not sure, have a check with a physio first), the following exercises may be useful to help you strengthen your pelvic floor. Keep in mind that they are best practiced in consultation with your physiotherapist to ensure you are activating the correct muscles and not causing further damage.
Pelvic Floor Exercises
1. Sit on a chair with your back straight, shoulders back and pulled slightly together, chin slightly tucked and the back of your neck long. You can facilitate this by placing your hand on the top of your head and pushing your head up into your hand. Now move your hand to the base of your skull and gently push your head back into your hand. Now that you are in good posture, you are ready to activate your pelvic floor.
2. Focus your attention on your pelvic floor muscles – the ones that touch the seat when riding a bike. This does not include your inner thighs or the big muscles in the butt. Try to draw the pelvic floor up to close the urethra and vagina, as if stopping the flow of urine. You should also notice your lower tummy drawing in gently.
a. Breathe as you hold the contraction for 4 seconds, then relax for 4 seconds. Repeat 10 times.
b. Now hold the contraction for 10 seconds and relax for 10 seconds. Repeat 10 times.
c. Now hold for 30 – 60 seconds. Rest for the same amount of time you held the contraction.
d. Now try some quick contractions – lift, relax, lift, relax, lift, relax – 10 times in total.
e. You can try all of the above exercises (a-d) in other positions – such as on your hands and knees and in standing.
Functional Pelvic Floor Exercises
This is where we learn to activate our pelvic floor while we are doing other movements. This is an important step in the rehabilitation process but is often overlooked. Pelvic floor activations can be consciously added to any movement, but here are a few examples:
1. Sit to stand- lift your pelvic floor up then try to hold the contraction as you stand and then sit down again.
2. “The Knack” – activate your pelvic floor prior to coughing or sneezing. This will not only protect your pelvic floor, but will also allow you to do a stronger cough or sneeze.
3. Squats- lift the pelvic floor, perform the squat (with your feet shoulder-width apart, pretend to sit back in a chair, keeping your knee caps behind your toes and in line with your middle toes). Return to standing while maintaining your pelvic floor contraction.
4. Other exercises that are specific to your exercise regime, urge triggers or daily routine
Safe Abdominal Exercises
Everyone wants to know what abdominal exercises are safe for them to perform. This differs depending on stage of pregnancy, time since childbirth, your pelvic floor presentation and the ability of the pelvic floor. As a guide:
1. No abdominal ‘strengthening’ exercises, such as crunches, sit ups, push ups or planks, should be done after 16 weeks of pregnancy. Doing these exercises puts unnecessary strain on the pelvic floor and worsens the diastasis (separation of the abdominal muscles necessary for the uterus to grow).
2. Crunches, sit ups, push ups and planks must be avoided until the diastasis is less than 2cm wide, the connective tissue is strong, and the pelvic floor is functioning well. This means that there is no leaking of urine, faeces, or flatulence AT ALL, in any situation.
3. Crunches, sit ups, push ups and planks must also be avoided in women with pelvic floor dysfunction. They massively increase the intraabdominal pressure, putting unnecessary force down through the pelvic floor, further weakening this already delicate area.
So, what can you do?
If your physiotherapist deems it safe, then the following exercises can be performed:
1. Low tummy (transversus abdominus) and pelvic floor draw-ins on hands and knees
2. Lower abdominal pelvic tilting in reclined sitting on a theraball - tummy in, pelvic floor lifted
Returning to Exercise After Baby
Pelvic Floor First have written comprehensive guidelines on the return to sport and exercise post-baby, and I will link to them here http://www.pelvicfloorfirst.org.au/pages/returning-to-sport-or-exercise-after-the-birth.html. It is important to begin doing pelvic floor contractions from day 1 post vaginal birth or caesarean section. I want to stress the importance of having a pelvic floor assessment with a Women’s, Men’s and Pelvic Health Physiotherapist at 6 weeks post-partum and again prior to running or doing any form of high impact exercise, which shouldn’t happen before 12-16 weeks, or even longer in some women. They can check that your muscles are functioning well prior to you adding exercises which put extra stress down on the pelvic floor. You may find that high impact exercises feel fine at the time, but you may pay for it months or years down the track if you find yourself suffering symptoms of prolapse.
Pelvic Floor Care
To look after your pelvic floor, please remember the following:
1. “The Knack” refers to us actively lifting our pelvic floor prior to coughing or sneezing. Practice this so that it becomes automatic. This technique prevents unwanted pressure forcing down on the pelvic floor when the intraabdominal pressure is raised quickly, such as during coughing or sneezing. This is particularly important for allergy sufferers during the Canberra Spring!
2. Correctly exercise your pelvic floor everyday – it is like cleaning your teeth. If you stop exercising it, your muscles will become weak and you will start noticing your symptoms again.
3. Eat a healthy diet high in vegetables and good fibre in an effort to maintain a healthy weight and reduce constipation. Constipation puts unnecessary stress on the pelvic floor and leads to muscle weakness. A dietitian can be helpful here.
4. Refrain from smoking – smoking is associated with overactive bladder, and smokers are more likely to have a chronic cough, which can lead to stress urinary incontinence.
5. Always use the correct toileting position – feet supported on a step or stool so that your knees are above your hips, lean forward so you elbows are on your knees, relax the tummy and pelvic floor and don’t strain
6. Share your knowledge with others to help us tackle pelvic floor dysfunction in the wider community! Men, women and athletic teenagers (usually girls) can all develop pelvic floor dysfunction and pain for many reasons. Symptoms can be improved if only people knew where to look for treatment options.
What is Low Pressure Fitness?
Low Pressure Fitness is an alternative approach to exercising the pelvic floor that uses a particular breath holding approach to passively lift the pelvic floor. This is done via a suction effect of the diaphragm. The goal is to improve resting tone of the pelvic floor muscles, rather than strengthen them. Everything we do in life increases intraabdominal pressure and stresses the pelvic floor – walking, standing from a sitting position, running, coughing etc. This is the only type of exercise that reduces intraabdominal pressure and doesn’t put more strain down on the pelvic floor. So, as you can imagine, it can be a great adjunct to complete pelvic floor rehabilitation. Please note that the best evidence is still for traditional pelvic floor exercises, but there is a growing body of people who have gained a reduction in their pelvic floor symptoms by adding this type of training into their regime. LPF is a whole-body approach to pelvic floor retraining. It uses certain body positions combined with the breathing technique to activate specific myofascial chains (which are connections between the muscles, fascia and other connective tissues in the body) which help to activate the pelvic floor and increase its tone. This also helps to draw the diastasis together, improve posture, reduce low back pain and improve the body’s overall functionality.
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