The Pelvic Floor: Health, Habits, Awareness, 2007
Deborah Bowes, DPT, GCFT
The pelvic floor is a part of your body that you rarely give thought to, that is, until you experience a problem related to it, such as incontinence or low back pain. That's true for most of the functions of your body. When things are running smoothly, many people don't give their body or their pelvic floor muscles much attention. However, it's a different story when you've been injured or ill. Your health now demands your attention. You may go to the doctor, take medicine or herbs, do special kinds of exercise or meditation, all to enlist your body's natural ability to regain and maintain a healthy state. Getting well is a process that takes both time and paying attention to the effect of the treatment or intervention. In the field of integrative and complementary medicine, there are many practices that have been shown to be effective in improving your health. The Feldenkrais Method of Somatic Education is one of these. The Feldenkrais Method uses easy to do movements with specific directed attention to learn to improve ourselves. The movement lessons are based on scientific principles of learning. The precise sequence of movements takes advantage of how the nervous system works. The changes and improvements occur on both a conscious and unconscious level.
This article discusses the function of the pelvic floor system and how it relates to health.
The pelvic floor is involved in many basic life functions as varied as digestion, elimination, reproduction, breathing, and balance. A healthy functioning pelvic floor promotes greater health in all of these areas. The pelvic floor musculature works in a coordinated system of muscles to support the hips and lower back.
Problems stemming from pelvic floor difficulties are increasing. One particular problem, incontinence, is becoming more prevalent. There are advertisements for incontinent supplies, such as, pads, diapers, and discrete undergarments on television, and in women's magazines. You can find an entire aisle of supplies in any large drugstore. I saw a television ad for diapers depicting an older attractive woman preparing to go out dancing with her husband. She was sitting at her dressing table, brushing her hair, putting on her lipstick and earrings. At the very end of the commercial the woman is dancing in the arms of her handsome husband. Then there's a quick cut to her long shapely legs... and a flashback to her sitting at the dressing table pulling her diaper up over those long legs. In a magazine targeted to young working women, I saw an ad for incontinence supplies with a thirty-something woman smiling as she balances on lily pads in a pretty pond. Seeing ads like this inspired me to bring these exercises based on the Feldenkrais Method out to the larger world.
The problem cuts across generations and genders. Incontinence affects athletes as well as those less active, mothers, and women who've never given birth, the younger and the older woman and man. For postmenopausal women, one study reports 1 out of 5 with incontinence, although it may be even higher because incontinence is a secret problem. It isn't something that's talked about. This is a shame, really, because incontinence can be eliminated in over 80% of women with exercises for the pelvic floor. Men, too, have problems with the pelvic floor. For men, low back pain, injury, or prostate issues can cause bladder trouble. All types of people, all ages can learn to help themselves by increasing the awareness of the pelvic floor and how to effectively use these internal muscles.
My study to discover the full function of the pelvic floor began because I had stress incontinence after the birth of my second child in 1985. In my search for improvement, for several years, I read whatever information I could find in books and articles, and consulted with a medical specialist and was diagnosed with a mild prolapse of the bladder. I did the recommended exercises, called Kegels, in the manner they were taught. I went outside the western medical system and looked for other approaches. I tried Chinese health exercises, such as the deer exercise, sitting cross-legged with my heel pressing on my groin moving my hands in circles around my breasts. I used an antique egg carved from marble as a vaginal weight, performing muscular contractions of the pelvic floor in different positions. These exercises helped a little, but I still leaked urine with sneezing, coughing, laughing and running. I maintained my physical fitness with yoga and Tai Chi daily, as well as caring for two young daughters and working fulltime.
By 1994, my problem with involuntary loss of urine had worsened, and it changed how I lived my life. I was 44 years old, and I wouldn't run even a few feet for the bus, or jump or dance unless I wore a very absorbent pad. Once, dancing at a party, I experienced a sudden and large leakage of urine drenching my beautiful silk pants. I hadn't felt the 'accident', only the warm wetness of the fabric on my legs. I went home immediately, grateful for a long coat and a dark night to hide my embarrassment.
Later that year, on a trip to Australia, I was introduced to the work of two colleagues, Feldenkrais Teachers, Dr. Judy Pippen and Barbara Bell, PT, who developed a program called Pelvic Power that they were teaching women throughout Australia. Their approach to pelvic floor exercises was based on the Feldenkrais Method of Somatic Education. This method, developed by Dr. Moshe Feldenkrais, promotes improvement in our movement and function through increasing our awareness of how we are moving. I am thankful for their pioneering work and my inspiration to learn more.
My study and experimentation took a new direction. I drew from my experience and knowledge as a Physical Therapist and Feldenkrais Teacher to find an effective solution, based on movement science and research to improve my own situation. I began to combine Kegel type exercises with movement rather than trying to isolate the pelvic floor. Over the next few months, I practiced several times a week. Most of the time, I exercised for twenty minutes when I was going to bed. Off and on during the day, I would include pelvic floor contractions in ordinary activities like sitting, waiting in line, walking and coughing, or carrying the laundry basket. These experiments improved both my awareness and the strength of my pelvic floor. I researched the relevant anatomy and physiology. In six months of applying my learning, my incontinence was gone. I have continued to improve even as I've aged and moved into menopause. I can jump on a trampoline at my granddaughter's birthday. I run for the bus; I dance without worry. I don't need to know where all of the toilets are. I never use a pad. I can cough and sneeze without crossing my legs. I feel stronger in my legs and hips.
The exercises I have designed are practical and will help you discover the full use of the pelvic floor. The Pelvic Health and Awareness program includes original movement lessons using awareness and imagery that are based on Feldenkrais Method. You don't have to know anything about this remarkable method of learning in order to benefit. Anyone can do the exercises, starting from where you are today. There are also short informative lectures to increase your understanding of the anatomy and physiology of the pelvic floor.
Improvement starts with awareness. The movement of the pelvic floor is subtle, and yet it is possible for everyone to feel its effect. Once you can feel the pelvic floor muscles working, you can learn greater control both in relaxing and contracting.
It took me over ten years to learn what I needed to help myself. I want to share this with all of you who have this secret difficulty. It won't take ten years. Most people will see improvement in a few weeks or even less.
Habits and the pelvic floor
You have preferences in the way you move; a habitual way of doing something. Some of these movement habits are easy to notice, such as being right handed or having a dominant eye. Some preferences are not so obvious, such as the way you walk. However, you can observe the effect of this asymmetrical habit by the uneven wear on the soles and heels of your shoes. The pelvic floor can also have habits, although the movement is subtle. For women, it's difficult to observe these habits because you don't see anything happening. It's a little easier for men, because they can sense how the direction of the genitals changes when they contract the pelvic floor in different ways. However, you may become aware of this asymmetry when you have problems with maintaining continence or balance or getting up from a chair. For both men and women, developing the ability to sense the pelvic floor will improve how you can use it.
The pelvic floor can develop a weakness in one aspect, for example, on the right side, or more to the front. This can result from having a baby, getting older, menopause, emotional or physical trauma, repeated stress, breathing difficulties, pain, or excessive exercise. If you want to improve the function of the pelvic floor, you have to learn how to contract and relax all of it, in a balanced and more equal manner. This is what makes your pelvic floor healthier and stronger, using all parts coordinated with your whole body. This program will help you to discover how to sense and contract the pelvic floor in all directions combined with easy movements of the whole self.
Awareness and Improvement
You can improve because you can learn. Learning is a fundamental human ability. Learning involves awareness. Awareness is the capacity to know what you are doing. If you can't sense it, you can't do it. If you can't do it, you can't sense it. It's a self-perpetuating cycle.
When you can 'sense' where the action happens, it is possible to improve the way you contract and relax these muscles. When you improve your sensation in the pelvic area, you can have better control, more functional strength, decreased low back pain, better balance and continence.
Most people will see improvement in a few weeks of practicing the gentle full body Awareness Through Movement lessons. The movements are scientifically designed to enlist help from the auxiliary muscles to facilitate the full function of the pelvic floor. This approach is different from traditional Kegel exercises that require you to isolate the pelvic floor muscles. The isolation approach is not functional and is often ineffective for incontinence or other pelvic difficulties, such as pain.
What is incontinence?
Incontinence is defined as any involuntary loss of urine. If you leak when you don't want to, you have urinary incontinence. Incontinence can be a problem for women and men of all ages. Incontinence is separated into three categories.
The first type is called stress incontinence. Stress incontinence is the leaking of any amount of urine when there is physical stress on the pelvic floor. Some of the movements that increase the stress or pressure on the pelvic floor include coughing, sneezing, laughing, jumping, running, bending over, and lifting something heavy. The pelvic floor should contract to counteract this stress and keep the sphincters solidly closed and the organs supported.
The second kind of incontinence is called urge incontinence. This is not only a physical problem; it becomes a thinking problem, too. It is the powerful urge to urinate when you are on the way to the toilet. Often it is difficult to hold the urine and the whole bladder empties before reaching the toilet. This is also called 'key in the door incontinence'. Your urge to void increases as you get your keys out to open the door to you house and it seems you can't control it.
The third type is called mixed incontinence. This is having a combination of stress and urge incontinence. It's quite common to have both types of symptoms.
The treatments for incontinence include exercise, surgery and medication. Treatment with exercise is successful and the safest approach. There are no side effects and one study showed that women improved their continence by 89% with pelvic floor exercise. Exercise can also help with a prolapsed organ, for example, when the uterus or bladder or rectum is coming down or pressing into the vagina. Surgery for incontinence, on the other hand, is 50% effective as it usually only tightens the ligaments. In some cases surgery may be necessary. But after surgery, you will need to exercise to improve the awareness and control of the muscles. The muscles will help keep the internal organs (bladder, uterus, and rectum) in the correct position.
History of Kegel exercises
Dr. Kegel taught that women would benefit from strengthening the pelvic floor muscles. He thought women were given a disservice by their health care providers and did not need to suffer from prolapse and incontinence. He stressed the need to exercise the pelvic floor, but he never said how to do the exercises.
Traditional exercises, such as Kegels teach isolating the pelvic floor muscles to strengthen them. However this approach is often ineffective in helping with stress or urge incontinence or other pelvic difficulties. Recent research demonstrates that the pelvic floor muscles do not work alone. They are helped, or facilitated, by the muscles of the lower abdomen, inner thighs, hips and buttocks. These muscles are called auxiliary or synergistic muscles of the pelvic floor. The appropriate involvement of the whole body will help you to develop the full function of the pelvic floor.
Many people teach that the way to do the exercises is to practice stopping the urine stream. However, this isn't a good way to strengthen the pelvic floor because it disrupts the balance between the pelvic floor and the bladder. This exercise is only useful as a kind of diagnostic tool. If you try to do it and can't stop the stream, then you need to recover the strength of the pelvic floor.
The Pelvic Health and Awareness exercises are designed so that you can learn to sense and contract the pelvic floor from four directions, right, left, front and back.
These four directions can be defined by the particular parts of the bones of the pelvis. The pubic bone marks the front of the pelvic floor, the tailbone marks the back, the sitz bones, or ischial tuberosities of the pelvis mark the right and left sides.
Anatomy and physiology
You can understand how the pelvic floor functions by learning a little of the basic anatomy and physiology of this area.
We'll first start with the anatomy. The pelvic floor lies like a flexible, supportive hammock within the lower part of the pelvis. Imagine the shape of the pelvis like a bowl with the 'hammock' of pelvic floor muscles covering the bottom of the bowl. In women, there are three openings in this layer, and in men, there are two. The pelvic floor is made of muscles, ligaments, and other connective tissue. This supportive system of soft tissues is attached in different places to the bones of the pelvis that give it its curvy shape, including the sacrum.
The pelvic floor is a dynamic system, that means, a healthy pelvic floor responds to meet the changing needs of your body. Depending on what you are doing and feeling, the tension in this area can vary. It can be contracted and tight to relaxed and flexible, and all the different levels in between those two extremes. Muscles, connective tissue, and ligaments all working together to maintain the strength of the pelvic floor.
The pelvic floor muscles work in different ways for different activities. They support the hips and legs in actions such as balancing, walking, dancing, and horseback riding. They help maintain continence and control of the bowels and urine by contracting when you don't want to eliminate and relaxing when the time is right. In order for a baby to be born, the mother's pelvic floor relaxes and even stretches. The pelvic floor muscles support the internal organs and are obviously involved with sexual health and function.
The function of the pelvic floor is coordinated with other muscles in your body. They usually don't act in isolation, although they can work by themselves. The pelvic floor works like other voluntary muscles in your body. They can be under your control. You can learn to contract and relax the pelvic floor. They also respond in another way, more automatically somewhat like the diaphragm muscle involved in breathing. In fact, there's a close relationship between the movement of the pelvic floor and the movement of the diaphragm. When you are simply resting and breathing, the diaphragm moves gently up and down, as does the pelvic floor when responding to the breath. It's possible to alter your breathing and control the movement of the diaphragm. You do this by breathing more slowly and deeply or speeding it up. Your breathing can also change automatically, becoming faster, slower, more shallow or deep, responding to your emotions, exercise needs, stress or type of activity. The Awareness through Movement exercises in this program use breathing to improve the function of the pelvic floor.
Another special working relationship is with the muscles of the inner thigh, the buttocks, those in the lower abdomen, and those that rotate the hip outward. These muscles are called auxiliary muscles. They coordinate to help your pelvic floor work more effectively. The Awareness through Movement exercises in this program also use these helper muscles to improve the function of the pelvic floor.
Learn how to what? Sit and relax
Most likely you think you know all about going to the toilet, after all, you've been using it for practically your whole life. As a toddler, you probably were taught where and when to urinate but not how to urinate. We've all been toilet trained, and we often have developed habits of using the toilet that weaken the pelvic floor daily. Some of the habits may have come from way back in childhood, or during your teenage days dealing with the schools' toilets, or later as you began working and maybe didn't have access to privacy or the time needed to take care of your elimination needs.
For example, women often learn to urinate very quickly, actively pushing the urine out. However, actively pushing like this eventually disrupts the normal function of the bladder. No pushing is needed, urination can occur through the work of the bladder alone. You can think of the bladder as a muscle with a space inside, something like a muscular balloon, that gradually fills with urine and then when full enough, contracts to empty itself. You don't have to push down to start the flow of urine. If the bladder has enough urine in it, the bladder will contract. You only have to allow the pelvic floor to relax. The pelvic floor relaxes when the bladder contracts. This relaxation is important to allow the bladder to do its job.
The bladder and pelvic floor have a special reciprocal relationship. The pelvic floor relaxes when the bladder contracts. The bladder relaxes when you contract the pelvic floor. Understanding this relationship is essential for improving your pelvic floor. This relationship is a physiological reflex between the muscles and nerves of the pelvic floor and the bladder (which is a muscle). One contracts, the other relaxes. Understanding and using this reflex is fundamental to staying dry and improving pelvic health.
You can use this reflex to change your habits. If you have 'key in the door' incontinence, use this reflex to retrain your bladder. Make it relax until you are in the right place to go. Each time you get the urge, stop where you are, breathe and contract the pelvic floor several times to relax the bladder. You may have to stand or sit still to do this. You can also use this technique to retrain your bladder so that you don't get up so often in the night or go too frequently during the day. Of course, if you are urinating a large volume, then you have to go, but if there is only a small amount of urine, you can try to decrease the sensitivity of your bladder and the frequency of voiding. (NOTE: This technique of bladder retraining is not recommended if you have interstitial cystitis and some other pelvic pain conditions.) If you listen to the sound of the urine stream and count the seconds, you can get feedback on how much urine was in your bladder. If the sound lasts only 2-5 seconds, perhaps you didn't have to go. Of course this is not a rule, just a guideline. The length of time you urinate also depends on how fast the stream is going, and this is a function of the bladder. You can notice your own rhythms, when your bladder is up and running and other times when it seems a little slow and sleepy.
It is important for women to sit and relax to urinate. Men may also find this helpful to improve bladder function. The relaxation spreads to the muscles of the pelvic floor. This will allow the bladder to contract normally. The urine only travels a short distance through the urethra so there is no need to push, not even at the end of the stream. Let the sensation of the contraction happen and wait a second for complete emptying. You may even experience the sensation of allowing urination to occur in this way as pleasant. Maybe, you could have a little pleasure each time.
Many women don't like to sit on public toilet seats. They stand in a high squat over the toilet. This position makes it hard to relax the pelvic floor. It can interfere with the bladder emptying through its own work because your pelvic floor is contracting in the high squat position. The tendency to push is strong. I have had women in my workshops tell me that they are able to urinate in the high squat and not push. It's possible to do so yet they are still interfering with that special relationship and many have developed incontinence. The low squat, like when we are lucky enough to urinate outdoors in the woods or 'primitive' squatting toilets in some countries, is better for your muscles.
The low squat easily relaxes the pelvic floor. That's why birthing this way is easier. For most people, squatting just doesn't work at home, yet some do find a way and use a frame around the toilet in order to safely put their feet on the toilet seat and squat. You can also have the benefits of the squat by having your knees higher than your hips and your feet firmly supported when you are sitting on the toilet. If your toilet is too high there are simple foot supports you can make or buy. (www.healthstep.com)
The idea is similar for the bowels. The intestines and colon have a movement rhythm of their own. The movement of these organs is called peristalsis. For easier elimination, you can let the peristalsis of the intestines and the contractions of the rectum do some or most of the elimination. Peristalsis moves the faecal matter through the intestinal tract to the rectum. The contractions of the rectum change its angle a little so that it's a bit more vertical and this small positional change makes an easier exit for the waste. You can sense the contractions of the intestinal tract and rectum. The sensation of fullness in the rectum or anus is from the movement of the bowel and rectum.
Constipation can be a result of inhibiting the urge to have a bowel movement over many years. There are many different reasons that people 'learn' to be constipated. If you have a long history of constipation, it will take some time for you to begin to be sensitive to these sensations. Many medications can also interfere with normal function of the bowel. Try to find a schedule where you can follow this sensation and seize the moment for this elimination. It's often an hour or so after a meal, of after drinking caffeine, or smoking a cigarette. (When I worked in the rehabilitation hospital in the 80's, patients would be given strong coffee or in some instances, or allowed a morning cigarette to stimulate a bowel movement. However, I'm not recommending taking up smoking!) There is also a rhythm to when your bowels are ready to empty. It can be in the morning after breakfast or after a later meal. Learn to sense your pattern and then make time for it in your life. When you start to sense the pressure and need to empty the bowels, sit on the toilet, relax, and let the organs do their job. If you have weakness of the pelvic floor, you can support the area and help the rectum to be more vertical by pressing on the small area between the vagina or scrotum and rectum with your hand. This place is called the perineal body.
Learning to empty both the bowels and bladder by letting the organs do the work is one of the best changes you can make to stop weakening your pelvic floor.
Another habit to observe if you have stress or urge incontinence, is urinating 'just in case'. It's called 'JIC' by therapists and doctors who treat incontinence. It's when you urinate frequently, when you're near a toilet, just in case you might need to later. Sometimes people have developed a habit of urinating hourly or more. Urinating hourly, if you don't have some medical reason for it, only makes your bladder too sensitive to smaller amounts of urine. And because there isn't enough urine in the bladder to stimulate it to empty, you might be straining or pushing to get the flow of urine started.
During the day, if you drink 6-8 glasses of water, you'll probably urinate every 3-5 hours. More than 9 times per day, may be too much. In the night-time, going to the toilet 0-2 times is considered 'normal'. If you go more than this, try to relax your bladder by contracting the pelvic floor several times and then see if you can go back to sleep. It seems to take 3-4 nights to change those unnecessary trips to the toilet.
In summary, you can discover and improve the use of the pelvic floor through the Pelvic Health and Awareness exercises that use full body movements with contractions of the muscles of the pelvis. You can stop weakening the pelvic floor by relaxing the muscles during elimination to allow the organs to do their job.
Deborah J. Bowes, 2007