In awe of the pelvic floor
The pelvic floor is an amazing muscle. In fact, having worked with it and researched it for more than a decade I am in deed in awe of it. I hope the information here will make you a little awe struck too, so that you will be motivated to get to know your pelvic floor. My ultimate hope is that you will become empowered by your new relationship with this incredible muscle, as have many women who I have had the privilege to treat over the past years.
Women’s Health FAQ
What is the pelvic floor?
The pelvic floor is a unique muscle that has several functions. It not only assists in maintaining continence (both urinary and fecal), but also helps to support the pelvic organs: the bladder; uterus (womb); and rectum (lower bowel). It also contributes to sexual sensation. Whilst it performs these tasks silently and subconsciously, most people have the further ability to consciously switch it on and off.
Where is the female pelvic floor situated?
The pelvic floor as the name suggest, makes up the floor of the pelvis. Although we think of it as one muscle, it is in fact made up of at least six muscles, each with its own subtle function. Taken together, these muscles from a shelf that stretches from front to back and side to side of the “pudding bowl” like bony pelvis.The bladder, uterus and top half of the rectum sit on this shelf. There are openings in the pelvic floor shelf for the urethra (front passage), the vagina (birth canal) and the rectum (back passage) to pass through. Any naturally occurring gaps are filled in with soft tissue to complete the shelf.
How does it work?
The pelvic floor as described above is a shelf, but unlike a shelf that we might have on a wall, the pelvic floor is soft and can easily bulge downwards if too much weight/pressure is put on it. To combat this, the tiny muscle fibres of the pelvic floor are constantly at work, even when we are not aware of it. In a healthy pelvic floor this constant work keeps the pelvic floor “stiff”. In other words, if we could put our thumb on the pelvic floor and push down it wouldn’t have a lot of “give” in it. As we move around, the tiny fibres work even harder to maintain the stiff shelf. This is particularly important during times when the pressure coming down from above onto the pelvic floor increases sharply and suddenly i.e. when coughing, sneezing, and on high impact such as running or jumping. When sudden pressure comes down from above, the pelvic floor shelf lifts up from below so that the pelvic organs are stabilized. When the organs are stabilized there is less chance of leaking from either the bladder or bowel. The stabilizing role of the pelvic floor shelf also helps to prevent over stretching of the soft tissues.
The clever shelf of the pelvic floor also changes in length. When the muscle contracts it shortens in length and the result is a squeezing action that compresses the middle of the urethra, vagina and rectum. This action is even more pronounced when we consciously contract the pelvic floor as we would do during pelvic floor muscle training. The squeezing action whether conscious or unconscious helps to prevent leakage from the bladder or bowel. During sexual activity, conscious and unconscious action of the muscle squeezes the vagina and clitoris to enhance sexual sensation.
What happens when the pelvic floor isn’t working properly?
If the supportive and squeezing action of the pelvic floor is diminished or lost, a number of symptoms may develop. These include stress urinary leakage (leakage of urine during increases in physical stress such as when coughing or sneezing), leakage of wind or stool and diminished sexual function. Women also commonly have urge urinary incontinence. This is the overwhelming urge to rush to the bathroom that may result in leakage before there is time to reach the bathroom. There is no evidence to suggest that a weak pelvic floor causes this type of incontinence. However, using the pelvic floor consciously may help dampen the urge and therefore this type of incontinence is also treated by physiotherapists.
How does pelvic floor dysfunction happen?
The pelvic floor may be in dysfunction (not work as well as it might do) for a wide number of reasons. People most usually associate damage to the pelvic floor with childbirth because this is a time when the muscles are commonly torn or cut as the infant head passes through the vagina. However it can also be damaged over the passage of time by continual straining to open the bowels (constipation); persistent heavy lifting; high impact sporting activity, a chronic cough (smoker’s cough, emphysema, chronic bronchitis or asthma); being overweight; and ageing. Inherited collagen disorders such as hypermobility disorder may results in dysfunction throughout life.
Treatment for pelvic floor dysfunction
Worldwide research is increasingly showing that pelvic floor muscle training can be useful for pelvic floor disorders. In the UK, the National Institute for Clinical Excellence [NICE] recommends that women with stress urinary incontinence should undergo three months of supervised pelvic floor muscle training, such as that provided by specialist physiotherapists, before considering surgery. Recent research has also shown the positive effects of pelvic floor exercises in women with prolapse. Whilst there are subtle differences in training approaches depending on whether the patient has incontinence or prolapse, the basic principles for pelvic floor muscle training are the same.
What percentage of women are likely to benefit from pelvic floor training?
Studies have shown that up to 70% of women with stress urinary incontinence will be either improved or cured following intensive pelvic floor training. Women with pelvic floor prolapse are also significantly likely to report improvement in symptoms and reduced need for surgery following a well supervised training programme. However, the real answer is that all women benefit from pelvic floor exercises by helping to prevent problems at al later stage in life.
How can physiotherapy help?
Research shows that women who are taught pelvic floor exercises from a leaflet are not as successful as those who have been assessed and taught by a pelvic floor specialist such as a physiotherapist. The valuable first step in physiotherapy/pelvic floor muscle training is an assessment of the pelvic floor. This is the bedrock of any exercise programme as both you and the physiotherapist need to be confident that you can perform a conscious pelvic floor contraction correctly. A correct contraction is one that makes the pelvic floor lift up inside towards the head. An incorrect one pushes the pelvic floor downwards like a straining action. Research shows that up to 15% of women who have not delivered a baby, and up to 30% of those who have, cannot correctly lift the pelvic floor in an upward direction. My experience is that even women who can do an upward lift are not confident that they are lifting correctly when they first attend for treatment. This is why specialist assessment is so important.
What happens during a physiotherapy assessment?
Firstly the assessment will be explained to you so that you fully so that you can give your informed consent. Assessment aims to establish whether you can correctly contract the muscle; how strong or weak it is; it’s ability to contract quickly and how long the contraction can be held. It is most widely performed by a vaginal examination as the pelvic floor muscles can be felt just inside the opening to the vagina. The muscles may also be assessed using a rectal examination for those patients with faecal incontinence. At Physiolink we also use ultrasound imaging to get a visualisation of what is going on. The ultrasound probe sits on the outside of the vagina and so is less invasive than vaginal examination. Many of our patients opt for ultrasound imaging. It is particularly useful for women with pelvic pain or for younger patients who have not yet undergone their first vaginal examination. Although it doesn’t provide such detailed information, it is also possible to do the imaging through the abdomen. This does not involve removal of any underclothing. Whichever assessment method is used, the physiotherapist will ask you to consciously contract your pelvic floor. This will provide information on whether or not you are correctly performing a contraction and how the contraction might be improved by changing your technique slightly. Other important information such as strength and endurance levels will guide the physiotherapist in planning an individualised exercise programme for you.
What are the aims of pelvic floor muscle training?
The aims of training will vary based on the assessment. However in most cases, the aim will be to strengthen the pelvic floor in order to make it “stiffer” so that it can better support the pelvic organs. This stiffness will also lift the bladder to a position where it is more able to resist pressure and load. Further, the increased strength will allow the pelvic floor to squeeze the urethra closed: an action that is much the same a treading on a hosepipe. Training also aims to improve the ability to quickly contract the pelvic floor. This is useful when you need to pull up quickly when coughing or sneezing to help prevent leakage. Finally, the training aims to improve the endurance of the pelvic floor muscles so that they do not tire so readily. Your physiotherapist will discuss your individualised aims of treatment with you before moving on to the treatment programme.
What happens next?
The mainstay of treatment will be your home exercise programme. Your physiotherapist will design this based on the assessment and aims. To help get you going, bio feedback may also be used. Biofeedback allows you to see how well you are performing a contraction and how you are doing at subsequent appointments. It can take the form of seeing a read-out of squeeze pressure (manometry) or electrical activity (EMG) or direct visualization using ultrasound imaging. At Physiolink we use ultrasound visualisation. For many women the sensation to the pelvic floor is poor and they may not be able to feel that they are doing anything after a couple of contractions. Seeing the pelvic organs move during continued contractions results in increased confidence and motivation. In women who have difficulty contracting the pelvic floor, extra time will be spent on biofeedback. If further help is required, electrical stimulation can be used on a regular basis at home. Gentle electrical impulses pass through to the nerves causing the pelvic floor to contract thus providing biofeedback about a contraction. In my experience, many women gain the ability to self contract using this method.
What does an exercise programme comprise?
An exercise programme usually comprises 2-3 exercise sessions of about 5 minutes each every day. The aim is to build up in order to regularly perform a minimum of 30 contractions per day. This is what is known as the intensive stage of training. Once the treatment aims have been achieved, the intensive period gives way to the maintenance phase. This comprises the same regime on 2 or 3 days per week. Like any fitness routine this is for life. Use it or lose it!
What else might be included in a programme?
As mentioned earlier, electrical stimulation may help some women. Cones are another tool that we are frequently asked about. These offer a graduated weight training system. A plastic cone is filled with a small weight that can be gradually increased. The cone has to be held in the vagina by the pelvic floor for 20 minutes as you go about your daily home tasks. There is no evidence that cones work better than pelvic floor exercises alone. However, some women prefer to use these as they find it easier to remember to use them than doing exercises. They may also find it encouraging to see improvement over several months as they gain the ability to use greater weights.
How quickly does pelvic floor training work?
It takes a minimum of three months to start to strengthen any muscle in the body. In my experience the intensive phase of pelvic floor training can take up to a year and sometimes even more. However, women who have stress urinary incontinence often see improvement within a couple of weeks as they gain the ability to contract the pelvic floor consciously during physically stressful conditions such as coughing or sneezing. After this initial improvement, it may take some months to see further improvement. This could be potentially discouraging, but the knowledge that this plateau in progress is normal is motivation in itself to continue a training programme. Women with urge urinary incontinence often improve more quickly as progress is not as dependent on pelvic floor muscle strengthening as stress urinary incontinence.
How many treatments will I need and for how long?
Length of a treatment programme and number of sessions is very individual. At Physiolink the average number of sessions is 8 over a period of a year. Once established on a good training programme, follow up sessions are aimed at progressing the exercises and providing motivation.
Trying exercises at home
We understand that not everyone can get to see a specialist physiotherapist, and may wish to try exercises on their own. For this reason we have provided some tips on how to get started and a basic routine below.
Firstly you need to know that you are performing a contraction correctly. If you are not squeamish about trying a self examination, you can check this yourself. Imagine the outside ring of your vagina like a clock face. The pelvic floor muscles are at 5 o’clock and 7 o’clock. Lying comfortably on your back, place your fingers just inside your vagina (about 2cm) on the 5 and 7. As you squeeze and lift you should feel the muscle squeezing and lifting under and around your fingers. If your fingers are pushed out then you are not contracting correctly. You can also place a mirror between your thighs and observe what happens as you contract. You should see your vagina and/or anus moving inwards. If your vagina or anus bulges outwards as you contract you are not doing a contraction correctly. If you have any doubts, ask your practice nurse or GP to examine you to get you started.
Getting the technique right
Looking on the internet it is easy to see why women are confused by the many different instructions for a pelvic floor contraction. Some say you should squeeze around the vagina, some to pull up in front around the urethra as if to stop your self mid urine flow, and other to pull up from the back, or the whole lot to together. I was just as confused by the variation in instructions which was why I started my research to investigate how we should be maximizing the potential worth of every contraction. The research showed that using a squeeze from the back passage (as if trying to stop the escape of wind) is better than pulling up in the front as if trying to stop the flow of urine. Similarly, puling up from the front and back together is better than pulling up from the front in its own. This may sound confusing, as it is intuitive to pull up from the front where urine is likely to escape from. However, there is a big muscle that wraps around the back of the pelvic floor that we think gets largely left out when you pull up from the front on its own. The recommendation I now make is that you should try to do a pelvic floor exercise by squeezing and lifting up from the back, or from the back and front together, but try to avoid just squeezing and lifting from the front on its own.
Exercises for your Pelvic Floor Muscles
- Get yourself comfortable. Any position that helps you to really feel the activity of your pelvic floor is good.
- Squeeze and lift the ring of muscle around your back passage (anus) as strongly as you can, as if you are trying to stop the escape of wind. Relax completely. You should feel the muscle let go as you relax. Don’t worry if your lower abdomen tightens at the same time as this is normal and is not to be discouraged. You may also feel your buttocks or thighs working. This is common and does not mean that you are doing a contraction incorrectly, but it is a waste of effort. Don’t worry about this. As you start being more confident about your exercises you will gain the ability to isolate the contraction to your pelvic floor without using your buttocks and thighs.
- Try doing the same thing but holding the contraction for a few seconds. Everyone is different and whilst some will be able to get to the count of 10 seconds, others will only manage a few seconds to start with. Try a few of these at a time several times a day to get the hang of it.Most women instinctively hold their breath when they start these exercises. To correct this, start by taking a gentle breath in. Whilst you gently breathe out, squeeze and lift the pelvic floor. Continue to breathe gently. This also takes a while to get the hang of because at first it’s difficult to maintain strong squeeze and lift whilst trying to breathe at the same time.
- Now do the same thing, but this time squeeze and lift from the front, as if trying to stop the flow of urine. You probably won’t be using this as an exercise on its own, but you need to get the feel of it so that you care able to combine it with a lift from the back.
- Finally, try a squeeze and lift from the front and back together.
- Some women find it easier to imagine that there is a zip from the back passage to the navel. Start the contraction from your pack passage and then zip forward all the way to the navel.
- Choosing whether you will go ahead contracting from the back on its own, or the back and front together is very individual. It makes sense to do back and front together so as to leave no stone unturned. However, many women find it difficult to do this, and find a back lift on its own very much easier. Our research showed that either of these cues results in a contraction that is equally as effective in supporting the bladder. Whatever, don’t worry about this issue: choose the technique that is easiest for you (even if this means pulling up from the front on its own).
- You are now ready to start the intensive phase of a training programme. This is the part of the routine that takes concentration, so it can’t be done if you are not in a position to fully concentrate i.e. whilst at your desk at work or in a busy household. Set aside dedicated times when you know you can concentrate and are not likely to be distracted. Ideally you should exercise three times per day. The aim is to build up to at least 10 contractions at each session. How quickly you build up is entirely individual, but the aim is that by the end of every session, your pelvic floor will feel tired. Some women will feel the muscle wobbling, others will just feel like they couldn’t possibly carry on and others will simply lose the sensation that anything is happening. So if you can only manage three or four squeezes of a couple of seconds each before you feel the muscle is protesting, then this is the starting point for you. To begin with, leave a good resting period between each contraction. So if you can manage a 5 second squeeze, rest for 10 seconds between squeezes. As your muscle strengthens, you will be able to reduce the length of the rest periods. A typical session to start with might be: 6 squeezes, holding each one as hard as you can for 5 seconds, with a ten second rest between each squeeze. Ultimately, it would be 10 squeezes or more of 10 seconds each with a 3-5 second rest between squeezes. Whatever you do, make sure that your pelvic floor is tired by the end of each session. Even if it only takes 3 or 4 squeezes to reach tiredness, your muscle will strengthen. As your muscle gets stronger, you will be able to hold for longer and do more squeezes.
- Switching on your pelvic floor every time you cough, sneeze or do an action that you know would normally make you leak is part of the training routine too, although you will be practicing this randomly. Pull up your pelvic floor as quickly and as strongly as you can and try to hold onto it each time you cough/sneeze/laugh etc. Using this technique, some women will immediately feel improvement in the amount urine that leaks. For others it will take longer.
- Whenever you think about it do a few fast squeezes. Make each on as strong as you can, although you can let go again quickly. These can be done anytime. You can do a few at a time, or if you have longer than a few moments, see how many you can do before the muscle gets really tired.
- If you are sexually active, use your pelvic floor during intercourse or by using a vibrator (switched on or off). This is a great form of biofeedback as you will hopefully be able to feel what you are doing as you squeeze around the shaft. You may not be able to feel very much happening to start with, but hopefully as your muscles get stronger, a change will be felt.
- Now that you are getting in tune with your pelvic floor muscle, start using it more often. Whenever you can, squeeze and lift gently (about 30-50% effort) and hold it for as long as you can whilst you carry on your daily tasks. Many women find it useful to make a list of activities that will prompt them to do this i.e. each time they walk up or down stairs, or are on the telephone, or while they brush their teeth etc.
The maintenance phase
You should train using the intensive routine for at least 3 months or until your symptoms have gone or have improved and reached a plateau. The maintenance phase is for life. As is the case for any muscle, if you don’t use it the strength will soon be lost. To maintain the strength that you have gained, do the exercises as described in section 8 (above) on a few days per week i.e. do three sets of exercises on 2-3 days per week. Or you may prefer to do one set of exercises daily. Use the same principal of pushing the muscles to tiredness each time you exercise. Continue to switch on your pelvic floor whenever you cough or sneeze or are going about your daily activities: for life!
What else can I do to protect my pelvic floor?
Women who are overweight have a higher chance of developing stress incontinence or prolapse than those who have a healthy body mass index. If you are overweight you can help your pelvic floor by shedding some pounds. Try visiting www.nhs.uk/livewell/loseweight . Smoking over time may cause a chronic cough and so if possible try to stop smoking. For information on help for this visit www.smokefree.nhs.uk . If you have a chronic cough for any other cause make sure that your GP is aware of it so that you can receive appropriate care and ask your GP for a referral to physiotherapy. Constipation that causes straining is also potentially damaging to the pelvic floor. For information on how to manage this visit www.bladderandbowelfoundation.org. Always try to minimise the loads you are lifting by getting someone else to help and always lift correctly. For information on how to lift correctly visit www.backcare.org.uk . Finally wear soft soled shoes whenever possible, and particularly during physical activity that involves high impact, in order to reduce pressure through the pelvic floor.
I have urge incontinence. How can physiotherapy help this?
We don’t know why urgency occurs although a new school of thought is that it is caused by bacterial infection that goes undetected on routine urine tests in up to 50% of women. Currently treatment options with respect to a safe antibiotic to treat this are limited. Other theories are that it is due to reduced support to the bladder or it can be a force of habit i.e. behavior that has become automatic through repetition. There is no evidence that pelvic floor training on its own improves urge incontinence. However, in combination with behavioural techniques i.e. helping you to change behaviour/habits around the issue, physiotherapists have become very involved with its management. Physiotherapy will involve you keeping a bladder diary to measure how much you drink and how much urine you pass over few days. Un-useful patterns often emerge that your physiotherapist will be able to help you with. Very often, the fear of leaking results in women going to the bathroom frequently to make sure they have an empty bladder. This results in the bladder getting used to accepting smaller amounts of urine and signaling urgently that it is full when in fact there is only a small amount in it. Typically in this situation, the bladder diary would reveal lots of small voids of perhaps only 100-150mls. The aim of what we call “bladder training” is to get you to regain control over your bladder rather than your bladder having control over you. You will get your bladder used to holding increasing amounts of urine by strategies and tips that your physiotherapist will provide to help put off the urge. In this way you should gradually be able to hold on for longer and get used to holding larger volumes of urine whilst experiencing fewer urges.
Tips to dampen urinary urgency
You can try some simple behavioral strategies without expert help. It is best to start the strategies when you are at home as more leakage can occur in the initial stages, when you are trying to hold on for longer. Do not be disheartened if you have more leakage in the initial stages as this is to be expected. It is possible to calm down an urge by taking control of the situation and there are several things that will help. Next time you have the urge, try the following steps:
- Try not to panic and tell yourself that you are in control of your bladder and your bladder is not in control of you.
- Squeeze and lift your pelvic floor and hold on as detailed in the exercises listed earlier (practicing pelvic floor exercises as described above will help with this).
- If you are able to sit down, cross your legs and point your toes up and down. If you are unable to sit down you may try standing or rising up and down on tip toes, crossing your legs and rubbing the backs of your thighs. (These actions are believed to set off reflexes that calm activity of the bladder).
- Try to distract yourself. Perhaps count backwards in threes, or try reading. Or doing the crossword. Everyone will have different strategies to help distract them. You will need to try different ones out and decide which is best for you.
- Once the urge has passed, re start whatever it was you were doing before the urge started. If the urge returns again, sit down and start puting off the urge again. Keep doing this until the urge has completely gone or until you are in control and can walk slowly and calmly to the bathroom.
By calming the urge using these techniques you will gradually be able to increase the time it takes you to get to the toilet and also the length of time between visits to the bathroom. Commonly women get caught short as they arrive home and try to get the key in the door. The fact that they know they are only yards from the bathroom sets the bladder off into waves of urgency that are quite inappropriate. This habit can often be broken with simple training. If you are struggling to get on top of this on your own, ask your GP to refer you for expert help.
Frequently asked questions
Q: Can you tell me over the phone whether physiotherapy will help me?
A: The only valid way to be able to tell you whether you will benefit is to have an assessment so telephone calls are not usually very helpful. However it is likely that if you have urinary or faecal incontinence, urgency/frequency, prolapse, chronic pelvic pain or are awaiting or have just had pelvic surgery, that you will benefit from physiotherapy. The best thing to do is book an assessment. Alternately you may wish to book a telephone consultation which although cannot provide physical assessment, may help you develop your management pathway.
Q: I have a pelvic floor problem and was given a leaflet about pelvic floor exercises by my doctor. They don’t seem to be helping. Could physiotherapy help me?
A: Yes, patients usually do better with face to face training than with a leaflet. The most common outcome following an assessment is increased confidence and reassurance, as your physiotherapist will be able to answer questions that you may have.
Q: How many sessions will I need?
A: This is very much based on your condition and assessment findings after which the frequency of follow up is discussed and agreed. Some patients are limited by distance, work or family commitments etc and may opt to attend every other month, whilst others may opt to start on a weekly or fortnightly basis for a few sessions and then reduce to monthly. Some patients may attend for as long as two years but may have 6 month follow up in the latter half of their programme. Regardless, your programme will always be tailored around your individual set of circumstances.
Q: If I am given a pelvic floor exercise programme how often do I need to do it?
A: Usually the programme is performed three times per day although many patients decide to do them more often. Each session only takes about five minutes at a time. Once you have fitted them into your routine you should not find them too onerous. Once the exercise routine is well established you will be taught how to use your pelvic floor during every day life as well as just during prescribed exercise sessions.
Q: How soon will I see improvement?
A: Often improvement may be seen within the first two weeks, followed by a plateau in improvement whilst the muscle strengthens. This is potentially discouraging, but the knowledge that this plateau in progress is normal is motivation in itself to continue a training programme. It takes at least three months to see decent improvement and so patience is required.
Q: How long do I have to do the exercises for?
A: Pelvic floor exercises are for life. It is a case of “use it or lose it”. However, after an intensive period of exercising over several months, you will be able to reduce the frequency of exercises to maintain the strength you have gained.
Q: I am having prolapse surgery next month. Should I start pelvic floor exercises now?
A: Yes. There is some evidence to suggest that getting going prior to your surgery will help you in the long run.
Q: Should all women be doing pelvic floor exercises?
A: Yes. Pelvic floor exercises are involved in many pelvic functions and are implicated in core stability and back pain. They should be exercised just as any other muscle is throughout your lifetime.
I do hope this information has inspired you to start exercising. If it has, please tell all your friends, young or old, to get exercising and using this amazing muscle!