Pelvic Floor facts and stats
Along with supporting the internal organs, the pelvic floor has the important function of managing the passage of fluids/materials out of the body. You will see in the picture to the right that there are three main passageways exiting the body through the pelvic floor. The pelvic floor has the very important job of keeping these exits closed, but an equally important job of RELAXING and allowing these passageways to open when required. Pelvic floor dysfunction is usually thought of as weak pelvic floor (leaking urine, having to go NOW, having to go all the time), but it is just as often an issue of a tight/tense/overactive pelvic floor (not fully emptying the bladder, constipation issues, painful sex, etc).
This muscle group obviously goes through a lot of stress and strain during the baby-growing and baby delivering stages, but is the pregnancy at fault or is it the “straw that breaks the camels back” so to speak? I often wonder if the way we are rehabilitated post-birth and the habits we adopt throughout our lives are more of an issue than the actual birthing process. Because our bodies are meant to do this crazy child producing thing, right?
One study found that 25% of women struggle with continence immediately post-birth, but 49% of women report continence issues 7 years post birth[vi]. To quote Physiotherapist Diane Lee:
“It is apparent that for some women, something happens during pregnancy and delivery that impacts the function of the abdominal canister either immediately, or over time”[vii]
For me it was definitely over time. I was very happy with my pelvic floor function at 6 weeks postpartum, but it was a different story after a year of carrying a child that continued to gain weight and get more difficult to hold. I’m sure that a combination of funky postures and carrying positions, not allowing enough time to work on myself, and "hormonal stuff" with pregnancy and breastfeeding all played a part, but my pelvic floor was getting weaker by the month.
This led me into this line of researching and questioning…if it’s not actually the birth that directly affects the pelvic floor what is it? And what can we do to fix it and/or prevent it from happening?
Well that’s easy, Kegel of course! Come on everyone knows that!
What is a Kegel and do they work?
Dr. Arnold Kegel came up with a way to exercise the pelvic floor in the 1940s in hopes of giving women a non-surgical way to improve pelvic floor function. A kegel is basically just a pelvic floor contraction (think lift and close), which many describe as the “stop urinating mid-stream” contraction (if you want a great visual check out this video). Kegels are meant to be a type of resistance exercise where you learn to contract and relax the muscle group, increasing the ability to control the muscle group (better motor patterns) and eventually increasing the strength and tone of the muscle. Theoretically this should lead to better bladder/bowel control and prevent Pelvic Organ Prolapse (POP), which is where your organs basically drop into the pelvis due to weakness of the muscle, ligaments and connective tissue. Pelvic Floor Muscle Training (PFMT) is still seen as the first-line defense against Urinary Incontinence and is the primary tool used to treat the condition.
I would always recommend that women see a professional when starting a pelvic floor exercise program, as a recent study showed that almost 60% of women with incontinence and/or prolapse were actually doing their pelvic floor exercise wrong[viii]; which at best would be a waste of time, and at worst could be detrimental by creating bad habits and bearing down (weakening) the pelvic floor. If you are unsure about your ability to properly contract your pelvic floor or just want to double check that you are doing it correctly, please go and see a physiotherapist trained in Real Time Ultrasound (Women’s Health Physiotherapists are fantastic). I think a pelvic floor check-up with your physiotherapist 6-10 weeks postpartum should be a mandatory part of postnatal care...so let’s spread the word!
So do Kegels work?
A big review study in 2015 looked at all the studies using PFMT and whether they made a difference in continence rates if used preventatively (during pregnancy) or as treatment (after birth)[ix]. Depending on the situation, the person and the program, yes, these exercises seem to make a difference. In a supervised program lasting at least 8 weeks with “strength training principles”, these exercises are shown to have a preventative effect and can be an effective treatment for incontinence[ix].
Now looking critically at many of these studies I notice two things; the first is that the majority of people do not exercise their pelvic floor exercises under these research conditions (supervised, lasting at least 8 weeks, etc). The second is that most studies are looking at short term effect of PFMT. Yes these people get better after doing the exercises, but what happens when we stop doing our kegels because we feel better? The problem most often comes back. This is where most health professionals tell you it’s a “use it or lose it” muscle and you need to keep up your kegel training. But I think this is where we have stopped looking at the bigger picture.
Don’t get me wrong, I think kegels can be a great starting point for a rehabilitation program, I do them and recommend them to most clients. So please don't give up your kegels yet, especially if they were prescribed to you for continence and/or back pain. But pelvic floor exercise alone just doesn’t cut it when rehabilitating such an integral part of the body.
1. We need to look at the bigger picture of the whole person:
A person with a pelvic floor problem does not just have a pelvic floor problem! Remember the "foot bone is connected to the..." song?
If a client came in to see me with knee pain I might start by asking them to squeeze their quad muscles to make sure they have the motor pattern to actively contract the muscle group. But then I would look at their pelvic stability (core), femur rotation (glutes), and foot mobility among other things, and put it all together in functional exercises. I would also look for patterns, habits, and tightness in the body that may have caused the knee pain in the first place.
That is the norm for knee rehab. Why is it not the norm for pelvic rehab? Pelvic floor strength is great, but without the strength and alignment of the muscles holding the pelvis and sacrum in place, how can you expect it to stick? We need to start looking outside of the box and treat the pelvic floor as part of a functional WHOLE body.
2. Different people have different issues with the pelvic floor:
Remember that many people have a weak pelvic floor because their pelvic floor is too tight, tense or overactive. Some hold stress and tension in their pelvic floor like others hold tension in their neck and shoulders. For these people a kegel may actually exacerbate the problem, and yet everyone is told to Kegel?!
3. We need to look at how our pelvic floor got so weak in the first place:
For some, it may be labour and childbirth that created a weakened pelvic floor, but I don’t think the babies should get all the blame. Remember the research shows that often the pelvic floor function gets worse with time. And women with no children still have a high percentage of pelvic floor issues. In Part II we will look at a study of tribal women that average 4.3 vaginal deliveries each and maintain very strong, functional pelvic floor muscles. Lifestyle plays a big factor in the health of any muscle group, and exploring the parts of our lifestyle that are not conducive to maintaining strength and function may be the key to real pelvic floor health. Leading me to my next point…
4. What are you up to the rest of the day? It’s like an hour of exercise at the end of the work day to make up for 10 hours of sitting. It’s just not cutting it. At best the kegel happens 3 sets of 10 reps, maybe 10 mintues of your entire day. What happens the other 23 hours and 50 minutes of your day…do you have bad habits (like sitting on your tailbone) that are reeking havoc with your pelvic floor and is there a way to get more strength naturally throughout the day?
5. Kegels are boring (that’s right I said it). This is probably why adherence rates to pelvic floor programs are so low.
6. Is it natural for the human body to have to “kegel”? How have we got to the point that we need to squeeze a muscle (that should be working all of the time) to keep it working? Where are we going wrong? Are these rates similar across cultures and lifestyles? And if we were able to look back at our hunter-gather ancestors would we see the same issues?
But I would say most of us are still falling through the cracks of the healthcare system, we are doing “OK” so we are told to do our kegels, go home doing them wrong, get bored so we stop doing them, our kids get heavier and life gets busier and all of sudden we have issues that were never there before.
So I say it’s time for a change. Let’s explore why our pelvic floors aren’t doing their job from a whole body, holistic perspective that takes the “whole you” into account. Please stay tuned for Part II where we look at the effects of lifestyle and “natural movement” on Pelvic floor health, and I will suggest 10 tips for whole-body pelvic floor awesomeness.
For regular updates check out my facebook page, or sign up here to get Part II and future blog posts emailed direct to your inbox. And please get in touch to tell me about your pelvic floor and kegel experiences!
[i] Smith MD1, Coppieters MW, Hodges PW. (2007). Postural activity of the pelvic floor muscles is delayed during rapid arm movements in women with stress urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct, 18(8), 901-11.
[ii] Eliasson K., Elfving B., Nordgren B., Mattsson E. (2007). Urinary incontinence in women with low back pain. Man Ther, 13(3):206-12
[iii] Smith M.D., Coppieters M.W., Hodges P.W. (2008) Is balance different in women with and without stress urinary incontinence? Neurourol Urodyn, 27(1), 71-8
[iv] Bardino M., Di Martino M., Ricci E., Parazzini F. (2015). Frequency and Determinants of Urinary Incontinence in Adolescent and Young Nulliparous Women. J Pediatr Adolesc Gynecol, pii: S1083-3188(15)00004-2. doi: 10.1016/j.jpag.2015.01.003. [Epub ahead of print]
[v] Chan S.S. Cheung R.Y., Yiu K.W., Lee L.L., Leung T.Y., Chung T.K. (2014). Pelvic floor biometry during a first singleton pregnancy and the relationship with symptoms of pelvic floor disorders: a prospective observational study. BJOG, 121(1): 121-9.
[vi] Wilson, P.D., Herbison, P., Glazener, C., McGee, M., MacArthur, C. (2002). Obstetric practice and urinary incontinence 5-7 years after delivery. ICS Proceedings of the Neurourology and Urodynamics, 21(4), 284-300.
[viI] Lee D.G., Lee L.J., McLaughlin L. (2008). Stability, continence and breathing: the role of fascia following pregnancy and delivery. J Bodyw Mov Ther, 12(4), 333-48
[viiI] Thompson J.A., O’Sullivan PB. (2003) Levator plate movement during voluntary pelvic floor muscle contraction in subjects with incontinence and prolapse: a cross-sectional study and review. Int Urogynecol J Pelvic Floor Dysfunct. 2003;14:84-88.
[ix] Mørkved S., Bø K. (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence: a systematic review. Br J Sports Med, 48(4), 299-310