It is not yet possible to predict & prevent pelvic floor dysfunction in 100% of cases, but scientific research has mapped out a reasonable path to put us on the right track.
To ignore it would be foolish.
Read on to learn what you never knew you needed to know about your pelvic floor.
Body awareness is everything
Your pelvic floor is an expansive group of mixed muscle and connective tissue that acts as a hammock for your organs, extending between your legs from the pubic bone to the tailbone. In pregnancy, it carries the weight of the foetus too, so the hammock sits lower under more strain.
Often women who have had babies have more low-lying pelvic anatomy that is vulnerable to strain with certain activities.
Some women who’ve never been pregnant or had a baby have low-lying pelvic anatomy, and they wouldn’t even know it.
All women should understand and apply this information, regardless of their pregnancy history.
The cause of pelvic floor dysfunction appears to be multi-factorial; genetic predisposition, vaginal trauma with child-birth, high birth-weight babies, obesity, smoking, heavy lifting (think: lifting toddlers) and high impact exercise all appear to contribute. You cannot change your genes, but you can change your lifestyle to address the modifiable risk factors.
The best way to do this is through body awareness.
Understanding what activities cause strain on your pelvic floor is probably just as important as doing a specific pelvic floor exercise program.
Be aware that when you are sitting upright or standing, your pelvic floor carries the weight of your organs. When you jump or run, the impact causes your organs to bounce on your pelvic floor. When you lift an object more than a few kilograms, your 6-pack muscles contract and cause increased pressure in your abdomen.
That extra pressure pushes down on your pelvic floor and makes it bulge.
The pressure is even greater if you are holding your breath.
Of course, tensioning your pelvic floor when you lift heavy objects or toddlers can provide some counterforce to this downwards bulging, but this is less likely to be sufficient protection if the pelvic floor is weak, lacking endurance, or it is in a stretched or strained position.
The effects of bulging, bouncing and sagging forces
It appears that over time, repetitive pelvic floor strain from bulging and bouncing predisposes women to urinary incontinence, faecal incontinence and prolapse of the bladder, bowel, vagina and/or rectum.
It is more common than you think. Some call it a silent epidemic.
1 in 2 women who have ever had a baby will experience some form of pelvic organ prolapse in their lifetime. Statistics suggest almost 1 in 3 women experience prolapse to the entrance of the vagina or beyond in their lifetime.
This is more common in peri-and post-menopausal women when ‘tissue sagging’ accelerates, but it can happen at any age.
Women who seek assessment and treatment for prolapse often describe a sensation of heaviness or dragging in their vagina (which often is not present in the morning but gets worse over the course of the day as their pelvic floor muscle endurance fatigues).
Some say they feel like they are “sitting on a lump”. However, it is important to note that 75% of women in the Mothers Outcomes after Delivery Study who had prolapse to or beyond the hymen were asymptomatic or minimally symptomatic.
This finding is consistent with observations made by Bradley & Nygaard (2005), who found that 84% of postmenopausal women with this degree of prolapse did not see or feel a vaginal bulge.
In this video, an expert panel discusses the incidence, causes and treatments of pelvic organ prolapse.
If you’d like to read more, perhaps order the following books by well esteemed Australian physiotherapists who have devoted their professional lives to pursuing better research and better treatment outcomes for women with pelvic floor dysfunction.
There is often silent strain on the toilet
Pushing on the toilet to poo causes pelvic floor strain (and hemorrhoids).
In addition to optimising your fibre and fluid intake, it is worth changing your toileting posture to mimic a squatting posture. A small footstool can make a world of difference.
By leaning forward on the toilet with your knees higher than your hips and your elbows on your knees, you can straighten your anorectal angle when you poo so you don’t have to push around a bend. Be sure to keep your chest lifted up so that you don’t lose the curve in your lumbar spine.
Finally some humour amongst all this negative news!
A unicorn can teach you how to poo correctly in this video.
This is not a product endorsement – any small stool will do the trick.
How to contract your pelvic floor muscles
Let’s first understand what a pelvic floor contraction IS NOT.
- IT IS NOT squeezing or clenching your inner thighs.
- IT IS NOT squeezing or clenching your butt cheeks.
- IT IS NOT tilting or lifting your pelvis.
IT IS involved in stopping the flow of urine midstream, but that is not the best pelvic floor contraction you could be practicing.
It is ok to try to stop the flow of urine midstream, just to get a feel for the muscles involved, but it is best not to do this regularly because it doesn’t achieve much and it can irritate your bladder.
A pelvic floor contraction involves an active squeeze and lift at the vagina and anus. This should feel like the muscles are moving in the OPPOSITE direction to how they move when pushing to poo or to give birth.
The following examples may sound silly, but give them a go and see if using imagery can generate a stronger and more localised pelvic floor contraction for you.
Try not to hold your breath while you do them.
Imagine you are busting to urinate and busting to pass wind at the same time. Squeeze and lift at the vagina and anus to try to hold on and keep control of your bladder and bowels.
Imagine the vagina and rectum are elevators in your pelvis. Squeeze to close the doors of the elevators (as much as possible – the vagina cannot seal!) and lift up, up, up to levels 1, 2 and 3 of the building.
Imagine there is a marble or a $2 coin in your underwear. Use your vagina to grip it and lift it up inside, as if to hide it. (This is imagery only, keep your coins in your purse).
Know your anatomy
The transverse abdominis is a postural stability muscle that is a “good friend” of the pelvic floor. It is positioned like a corset around your lower abdomen.
When the pelvic floor is activated, the transverse abdominis tends to tension to some extent, and vice versa. So if you notice your lower abdominal region also tensioning like a corset when you contract your pelvic floor, you are probably on the right track.
Continence and women’s health physiotherapists have undertaken advanced training in performing vaginal examinations.
When performing an assessment of your pelvic floor a physiotherapist will consider not only the contractility of the muscle group (how well you can squeeze and lift it) but also the endurance of the muscle (how long you can hold the contraction for, and how well you perform the contraction with repetition).
The physiotherapist will also assess the distensibility of your pelvic floor (how much it tends to bulge when your bear down e.g. on Valsalva). The distensibility of your pelvic floor is affected not only by the strength and endurance of your muscles but also by your tissue type (remember the pelvic floor is mixed tissue – not only muscle).
Tissue type is a hard one for you to assess yourself, but if you are prone to stretch marks you might assume you have poorer collagen composition in your connective tissue, and this makes you more vulnerable.
Other signs of poorer collagen are umbilical hernias, varicose veins, joint-hypermobility, and abdominal muscle separation with previous pregnancy.
Next Step Physio is a physio service without walls.
We hire exercise spaces in Brisbane, not private clinical rooms.
We cannot offer you a discreet and professional environment for a pelvic floor examination, but we can recommend an appropriate clinic.
Pelvic floor considerations with general exercise:
Many sports and gym workouts are good for your heart and other muscles but are harmful to your pelvic floor. Often your exercise class instructor or personal trainer is very confident that they can safely train all women throughout the lifespan.
Unfortunately, sometimes they don’t know what they don’t know, and the silent strain on your pelvic floor is often not understood by your trainer. If some of this education comes as a surprise to you, there is a good chance that your personal trainer hasn’t heard it either.
If you have a good relationship with a personal trainer, you can direct them to some online resources to make sure they understand these concepts. The link below is a good one.
Essentially, there should be additional considerations to training strength in women than in men because the structural design of our pelvic floor anatomy simply makes it more vulnerable under load.
When you choose to add extra weight/load to an exercise, it tends to be because your skeletal muscles are getting stronger and can handle that additional load. It is sensible to consider all the muscles that are going to be affected by that load, and ensure it doesn’t strain the weakest muscle group. This is essentially catering to the lowest common denominator, and when you cannot see it, it is hard to prioritise it especially when you are being supported and encouraged to increase your upper body weights.
Unfortunately, pelvic floor strain is usually silent, it rarely causes pain, and loss of urine under strain should not be the yardstick for exercise appropriateness; it is a very high threshold that might be reached well after significant bulging strain has occurred.
There are modifications that can make weight lifting safer for you. For example, a woman may choose to do her upper body strength training on her back, to offload the weight of the pelvic organs and reduce the overall abdominal pressure bearing down on the pelvic floor. Learning breath control is also important so that some abdominal pressure can be released with exhalation during the exertion phase of an exercise.
Without a vaginal examination with a physiotherapist, it is hard to know how vulnerable your pelvic anatomy is with exercise.
As a general rule:
If an exercise causes your breasts to bounce, the impact is probably causing your pelvic floor to bounce too.
If an exercise causes your belly to bulge, the abdominal pressure is probably causing your pelvic floor to bulge too.
Exercises that involve lifting both feet off the floor at the same time tend to be high impact (running, jumping) or high abdominal pressure (V sitting, two feet at “tabletop position”, Pilates 100s exercises).
A pelvic floor assessment will help to identify if your anatomy and tissue type can tolerate these activities, and from there you can make an informed choice about your exercise routine.
You can learn more about how to recognise exercises that are not safe for the pelvic floor from the following links:
Pelvic floor considerations for pregnant women:
True core stability exercises engage the pelvic floor and transverse abdominis to stabilise your spine, ribs and pelvis in their ideal position while you perform an activity. These exercises train your muscles to cope with the increasing strain on the body in pregnancy, and they ought to set you up for a better postnatal recovery.
When 6-pack exercises are labelled “core exercises” it is particularly confusing and misleading for pregnant women because 6-pack exercises add little value to core stability in pregnancy. They also tend to strain your pelvic floor and may bring about more substantial tearing of the connective tissue that holds your 6-pack together.
This is called a rectus diastasis.
recuts diastasis resized
You can learn about it here:
Cardiovascular exercise helps to combat fatigue in pregnancy, and to build your endurance for labour. Maternal exhaustion is one of the primary reasons that episiotomies and vacuum extractions are performed in labour.
In a healthy pregnancy, moderate intensity, low impact cardiovascular exercise on most days of the week is ideal. In fact, research suggests it reduces the likelihood of unplanned C-sections by 20%, and reduces the risk of high birth-weight babies by 31%, without increasing the risk of low birth weight babies. Read about it here.
If you are pregnant you can learn to apply biomechanical knowledge to identify the exercises you should be avoiding from this video
To reduce the likelihood and extent of trauma to the pelvic floor muscles you may consider perineal massage in pregnancy.
For some women, knowledge is frightening. For others, knowledge is power.
If you wish to read scientific literature about childbirth, these are quite comprehensive:
Pelvic floor considerations for postnatal women:
In the first weeks after childbirth women are tied up in a world of magic and mayhem.
Unfortunately, tissue healing waits for nobody, and most women miss the opportunity to positively influence their pelvic floor healing. In fact, most women compromise the tissue repair by doing activities that strain the pelvic floor muscles in the healing phase.
The standard soft tissue injury management protocol of R.I.C.E in the first 72 hours applies to the pelvic floor too.
R I C E
Be aware that when you are sitting, standing or laying semi-reclined, your pelvic floor is still working to support the weight of your organs. Working an injured muscle is not ideal.
To rest the pelvic floor, take the weight of the organs off it by laying on your back or on your side as much as possible. Avoid elevating the head of a hospital bed when resting.
It is good for your circulation to get up and walk around. Just prioritise rest and use your rest time wisely; on your back or on your side.
Applying an ice pack to injured tissue after birth reduces both pain and swelling. A suitable ice pack can be made by filling a condom with water and freezing it. Wrap it in a clean cloth before placing it in your underwear between your perineum and sanitary pad.
Icing for 15 minutes at a time every 1-2 hours is ideal particularly in the first 24 hours, but you may benefit from continuing for 72 hours post birth.
There isn’t a lot of research on compressing the perineum postnatally.
It isn’t an easy area to bandage!
Clinical observations on maternity wards have lead clinicians to recommend compression to the perineum to reduce swelling and pain.
Supportive elasticised undergarments appear to help.
With reinforcements in the perineum, SRC Recovery Shorts are worth considering, particularly if you have severe swelling, pain in sitting or if you have varicose veins in the vulva.
If you had a swollen ankle, a physiotherapist would advise you to elevate it higher than your heart. Elevating a swollen vagina is not practical, but you can encourage swelling resolution by at least putting it on the same level as the heart, by following the advice set out above in the Rest section.
Unless you have been given specific advice about postnatal pelvic floor exercise by your obstetrician or physiotherapist on the maternity ward, perhaps treat the E in the R.I.C.E acronym as Exercise instead.
Start with just gentle pelvic floor contractions to encourage circulation and to prevent pain inhibition of the muscles, then when tenderness resolves, follow the action plan set out at the end of this document.
If you’re pregnant or postnatal, you can learn more about tissue healing timeframes, and the fine balance between postnatal rest and exercise from this blog post.
Be aware that just carrying the weight of your baby on your pelvic floor in pregnancy has put it under some strain and it is likely sitting in a more lengthened position due to this strain. Your lifetime risk of prolapse is lower than a woman who has had a vaginal birth, but it is not zero.
Recall the pelvic floor as a hammock analogy; imagine adding more and more weight to a hammock for 40 weeks. When you remove the weight, the fibres of the hammock will have stretched and the hammock would likely sit a little lower than before.
Low lying pelvic anatomy is associated with incontinence and prolapse.
It is still worthwhile commencing a pelvic floor exercise program post-C-section, and it will also assist with regaining control of your lower abdominal region, thanks to the pelvic floor and deep transverse abdominis activating together as friends.
Pelvic floor considerations during & post menopause:
Gravity is unkind to women as we age.
Muscle tone reduces with menopause and the pelvic floor muscles are no exception. Urinary incontinence shouldn’t be accepted as an unavoidable part of ageing. It should always be investigated and pro-actively managed.
Thanks to modern medicine, we now live 5 decades post-menopause.
The downside is that it gives our muscles and organs a long time to slowly migrate south. If the pelvic floor is lengthened and sitting too low to support the vagina and rectum, they are more vulnerable to prolapse under the weight of your pelvic organs.
Unfortunately, pelvic floor weakness is not the only priority in your age bracket. Bone density begins depleting around age 25, but it accelerates significantly post-menopause. Building bone density is not an easy thing to do, and is often a futile goal. The goal is to do everything you can to maintain your bone density and slow down the rate of depletion. This includes adequate calcium intake, regular impact and resistance exercises, and possibly pharmaceutical treatment if indicated by a bone mineral density test.
The bad news is the very exercises that maintain bone density (impact & resistance) can potentially damage your pelvic floor. Don’t give up!
Before including impact in your workout, post-menopausal women ought to have a pelvic floor assessment to identify if their pelvic floor can withstand impact. By modifying exercise positions, and mastering breath control, most resistance exercises can be made ‘pelvic floor safe’.
You will need to learn to workout smarter, not harder.
A physiotherapist with a special interest in women’s health can develop a strategic routine for your exercise and quality of life goals.
An action plan for women:
Every woman’s pelvic floor action plan should involve both training, protection and communication.
Train your pelvic floor with a daily endurance program.
If you haven’t had an individualised program prescribed, start by squeezing & lifting the pelvic floor muscles for a few seconds, repeating up to 10 times in a row.
Take a couple of relaxed breaths between each contraction.
After your have done a set of endurance holds, follow it with a few strong and quick contractions of your pelvic floor to work on the strength muscle fibres. Over several weeks, or even months, add more seconds to your holds, and more quick contractions at the end.
Aim to achieve at least 10 quality endurance contractions, holding each contraction for 10 seconds, and follow this with 10 strong & fast contractions.
Train to develop good breath control with exercise. We like to use pilates and yoga-based exercises for this training.
Consider a regular exercise classes with a physiotherapist that introduces progressively challenging ‘true core’ exercises.
Protect your pelvic floor by squeezing and lifting it to create a counter force to the downwards bulging pressure every time you
- cough, sneeze, laugh, vomit or blow your nose
- lift anything more than a few kilograms, especially if straining to lift.
- stand up (especially from a couch , car seat or low chair)
- get into bed or get out of bed (which should always be through side-lying to reduce the pressure in your abdomen).
Practice healthy bowel habits. Keep up your fibre and fluid intake and use the correct position on the toilet when you poo.
Talk to your mothers, sisters & daughters about pelvic floor dysfunction. You might identify a genetic predisposition that can help you make decisions about lifestyle & exercise modifications.
Talk to your personal trainer or sports coach about what you’ve learned and never be afraid to ask for a pelvic-floor safe modification of your exercise.
Talk to your partner about any pelvic floor concerns, especially if you’ve decided you need to reduce the amount of heavy lifting you do to protect your pelvic floor from the strain.
Talk to your GP about any sensations or symptoms of pain, heaviness, bulging, weakness or incontinence, and follow through with scheduling an appointment with a continence & women’s health physiotherapist.
The information published here applies to the vast majority of women, but one e-brochure does not fit all.
Occasionally a woman will have an overactive pelvic floor that is too tight and spasms. These women often have pain with pelvic floor activation and sex. If you think this may apply to you, request a professional pelvic floor assessment by a continence and women’s health physiotherapist.
Women with neurological conditions affecting skeletal muscle, such as Multiple Sclerosis or Cerebral Palsy may have very different pelvic floor endurance and tone, and this really would require an individual assessment.
Now you know what you never knew you needed to know about the pelvic floor.
What are you going to do about it?
Skill up and spread the word!