Monet and I attended an incredibly helpful workshop on pelvic floor health a few weeks ago sponsored by one of my faves, Kathryn over at Denver Natural Mom - follow the link to hear DNM's interview with Jen. I was floored (no pun intended) by the severity of pelvic floor issues we ladies are faced with after our babies make the tight squeeze through the birth canal, but also encouraged by the healing potential in seeking professional support. I asked Jen, the Physical Therapist who conducted this workshop, to educate our readers on pelvic floor health. Enjoy!!
Hello cord! My name is Jen Anderson PT, DPT and I am a pelvic health physical therapist in Denver, CO. I am excited to be sharing the following information with you. Many women, both those that have gone through the birth process and those that have not, are offered little education on their pelvic floor and the important role it plays. There is so much more that we can be doing for our bodies that the medical community does not make widely available. Read on to learn more and please email me if you have further questions or concerns.
What is the Pelvic Floor and What is its Role?
The pelvic floor is a very important group of muscles that forms “the floor of your core”. It consists of three layers of superficial and deep muscles that encompass and support the pelvis and its adjacent structures.Layer 1 includes superficial transverse perineal, bulbocavernosus, and ischiocavernosis. Layer 2, also known as the Urogenital Diaphragm is made up of sphincter urethra, sphincter urethrovaginalis, compressor urethra, and deep transverse perineal. This layer has a fascial connection with the transverse abdominis. Layer 3, the Pelvic Diaphragm, lifts the pelvic floor and consists of the levator ani, pubococcygeus, puborectalis, and the illiococcygeus. Layer 3 connects to a thickened band of fascia formed by the obturator internus (OI) called the arcus tendinous levator ani (ATLA), which attaches at the ischial spine and the posterior pubic symphysis. Layer 3 uses type I tonic muscle fibers for support (70%) and type 2 phasic muscle fibers for forceful contractions and closure (30%). The PF muscles and their surrounding tissues are innervated by the following nerves: Pudendal Nerve, Levator Ani Nerve, Ilioinguinal Nerve, Genitofemoral Nerve, Perineal Nerve, Inferior Rectal Nerve, Posterior Femoral Cutaneous Nerve, Coccygeal Nerve, and Sacral Nerves (1).
There are five roles of the PF muscles, which can be remembered by the “5 S’s”. Sphincter control:closes the openings of the urethra, vagina, and rectum and maintains urinary and fecal continence. Stability: assists in stability of sacroiliac joint (SIJ), pubic symphysis, sacrococcygeal, lumbopelvic and hip joint. It has a critical role in enabling effective load transfer from the lower extremities to the pelvis and spine.Sexual function: orgasm, blood flow, and mobility. Support: for the pelvic organs against gravity and intra-abdominal pressure; tone for the vaginal and rectal walls. Sump Pump: a venous and lymphatic pump for the pelvis to prevent congestion (1).
Your pelvic floor and the transverse abdominis, or deepest layer of abdominal musculature, are responsible for stabilizing your spine and pelvis and forms your stable core. I often make the analogy of comparing this to a soda can with your diaphragm as the top, your pelvic floor as the bottom, and your transverse abdominis forming the walls. If your soda can springs a leak then that is a sign of pelvic floor dysfunction.
Unfortunately, sometimes the issue is not so plain and simple.
Eight signs of pelvic floor dysfunction:
1. Leaking urine (or feces) when you exercise, laugh, cough or sneeze
2. Urgency when needing to use the toilet
3. Frequent urination (more than every 2-4 hours)
4. Difficulty emptying bladder or bowel
5. Accidentally passing wind
6. Pain in your pelvic area
7. Painful sex
8. Prolapse: this may be felt as a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging or dropping
There are several reasons why pelvic floor issues might be occurring:
• You have a weak pelvic floor
• You have an overactive, strong pelvic floor but even stronger abdominal, back and diaphragm and glottis (voicebox) muscles
• You have an overactive but weak pelvic floor
• You have a damaged pelvic floor (prolonged labor, tearing with labor)
• You have a medical condition i.e. spinal cord compression, multiple sclerosis
The Weak Pelvic Floor
Pelvic floor weakness can be caused by increased stress on the pelvic floor during childbirth and pregnancy. During pregnancy your pelvic floor will drop and tissues will lengthen to accommodate for the growing baby. Urinary frequency, urgency and occasional leakage during pregnancy is common due to these physical changes. However, once your baby is born it is not normal to continue to leak urine and to have urgency with the need to urinate. Pelvic floor weakness can also be caused by prolonged labor due to the compression on the muscle tissue and nerves that innervate the pelvic floor. Any tissue tearing that may occur during labor will also affect the strength and coordination of your pelvic floor muscles. If the pelvic floor is weak then strengthening can help. Kegals are the gold standard when it comes to strengthening the pelvic floor. Many women do not perform Kegals correctly. It is a gentle lift of the tissue between your sit bones, pubic bone, and tailbone. You should not use your buttocks, inner thighs or abdominals. It is best to be instructed to do Kegals by a pelvic health specialist, which may be a physical therapist, nurse practitioner, or occupational therapist.
Pelvic floor weakness may also be caused by posture and bad habits. Sitting in a flexed or stooped posture increases the intra-abdominal pressure onto the pelvic floor and leads to repetitive strain on these tissues. In the same manner, holding your breath while you lift objects will also increase intra-abdominal pressure and increase stress on the pelvic floor. It is very important to breathe out and gently pull your pelvic floor up and in while lifting or performing “work”. “Work” may consist of picking up your child, getting up from a chair, or picking up an object from the floor. Making this a habit will help to protect your pelvic floor against further strain, strengthen your pelvic floor, and prevent incontinence with activity. Remember, incontinence is not a normal part of aging.
The Overactive, Tight Pelvic Floor
Many people with pelvic pain have pelvic floor dysfunction, but specifically hypertonic muscles, or muscles that are too tight. Oftentimes muscles that are tight, become short, and also become weak. These muscles must be able to contract to maintain continence, but also need to be able to relax to allow for urination, bowel movements, and sexual intercourse. Hypertonic muscles may cause urinary frequency, urgency, stopping and starting of the urine stream, painful urination or incomplete emptying of the bladder. Tight pelvic floor muscles can also contribute to constipation, pain during intercourse, and to low back, hip and pelvic pain. It is important for people who have unresolved low back and hip problems who also have pelvic floor problems (incontinence, prolapse, urinary or bowel urgency and frequency,constipation or painful Intercourse), to seek out a pelvic floor assessment since their pelvic floor problems may well be the reason that their low back and hip pain is not getting better. Pelvic floor tightness can be diagnosed by a pelvic health specialist using internal and external “hands-on” or manual techniques to evaluate the function of these muscles. They will assess your ability to contract and relax these muscles, and feel for tight bands or trigger Points in the muscles. When your pelvic floor muscles are tight and weak, the tension is treated before the weakness. The pelvic health specialist will treat the trigger points presents in the pelvic floor as well as tight musculature in the low back, abdomen, and thighs. Once the muscles have reached a normal resting tone, and are able to relax fully, their strength is reassessed and pelvic floor strengthening exercises are prescribed if appropriate.
Pelvic Floor, Pregnancy, and Postpartum
During pregnancy major physiological changes occur. For example, the uterus, once a pelvic organ, expands from the size of pear into the abdominal cavity and reaches the bottom of the sternum. The uterus expands its capacity from 10 mL to 5000mL. That’s a huge change! It is normal for urinary frequency and urgency to increase during pregnancy as well as needing to go to the bathroom more during the night. It is also normal for the abdominals to stretch, and sometimes rectus diastasis may occur. A Rectus Diastasis is a separation in the rectus abdominis, also known as the "6-pack" muscle. Sometimes it will spontaneously correct following birth, but it does not always. If you lift your head while lying on your back and the center of your belly protrudes out, you may have a rectus diastasis. This is important to address as it is affecting the structure of your “soda can” and your core stability.
During pregnancy, performing regular Kegals may decrease urinary leakage and decrease low back, SI joint or pelvic pain. At 36 weeks, you may be advised by your pelvic health therapist to focus on pelvic floor bulges, or reverse Kegals to help with the delivery of your baby. It may also be helpful to start perineal massage to start stretching and relaxing the tissue to possibly prevent any tissue tearing during delivery. If you have an episiotomy or experience tearing during vaginal birth than a pelvic health therapist can also help with mobilizing the scar tissue that may make wearing jeans, having intercourse, or having a bowel movement uncomfortable. A pelvic health therapist can also help address a c-section scar in the same manner.
The important thing to know is that urinary leakage, urinary urgency, pain with intercourse or a Rectus Diastasis should not be considered “normal” following the birth of your child. While these issues are common, they should not be allowed to persist as they will cause greater health issues and affect quality of life in the future. Pelvic floor dysfunction and rectus diastasis can be corrected with education, exercise, manual techniques, and proper body mechanics.
Listed below are resources where you may find more information on pelvic floor health or search for a Pelvic Health Therapist close to you. If you are experiencing any pelvic floor dysfunction please seek out treatment. Many Pelvic Health Specialists are caring individuals with extensive educational backgrounds that can help you with the problems you are experiencing without invasive procedures.
Pelvic Floor Resources
I just discovered this website and I love it. It covers so many important topics in depth. Head here if you want to educate yourself more about pelvic health diagnoses and treatment options.
Want to find a Pelvic Health Therapist?
• APTA Women’s Health Section
• Herman & Wallace
1. Pelvic Floor Function, Dysfunction and Treatment- Advanced PF3. Herman & Wallace Inc. Pelvic
Rehabilitation Institute. 2010-2013