The Pelvic Floor – don’t suffer in silence!

Recent statistics indicate that 1 in 2 women suffer from some form of urinary incontinence related to pelvic floor dysfunction and these numbers are continuing to increase (Wu et al 2009) Women should not be embarrassed about seeking help for this irritating and often debilitating problem.

Unsurprisingly one of the main risk factors for developing dysfunction with the pelvic floor is during and post pregnancy.  Having recently given birth in France myself I have seen first hand how important the problem is considered here. Midwives routinely perform an internal pelvic floor examination at the 6 week check post partum and at the first sign of symptoms women are referred onto a physiotherapist for pelvic floor rehabilitation exercises, involving up to 10 sessions of muscle retraining with biofeedback.

The difference in the way that healthcare is structured in the UK means that often only those with severe symptoms of pelvic floor dysfunction or an obvious prolapse end up being referred by their midwife for more specialist treatment. Many others will just be advised to continue pelvic floor exercises (known as “Kegels” in the USA) on their own at home indefinitely, never really sure if they are doing them right. Many women just put up with continuing symptoms, imagining that the weakness is to be expected.

Symptoms of Pelvic Floor dysfunction

  • Urinary incontinence
  • Pelvic organ prolapse-which may present as backache, perineal pain, incontinence or heaviness and bulging in the vaginal area.
  • Sensory and emptying abnormalities of the bladder
  • Faecal incontinence
  • Pain or reduced sensation during sex
  • Chronic pain syndromes

Often these problems have a knock on effect. Some women are too embarrassed to go back to exercising after pregnancy because they are afraid of accidental leakage. Becoming less physically active can eventually lead to further weakness of the pelvic floor as well as contributing to other problems such as chronic back pain and obesity,

To understand why pelvic floor dysfunction is such a common problem, we need to understand a little about the anatomy of the area and potential risk factors for injury.

Anatomy of the pelvic floor

The pelvic floor is made up of the right and left levator ani muscles, which lie horizontally in the floor of the pelvis and the coccygeus muscle which is situated behind. The muscles and fascia here make up a complex multi-layered hammock that supports the bladder, rectum, uterus and other internal organs. Bands of the muscles surround the vagina, anus and urethra (the tube carrying urine from your bladder).

Given this anatomy it is not surprising that the pelvic floor is most commonly damaged during pregnancy and childbirth. However there are some additional factors, which can increase the risk of dysfunction.

Risk Factors for Pelvic Floor dysfunction

  • The extra weight of the baby and uterus during pregnancy itself
  • Vaginal birth : certain factors during the birth itself may increase your risk of damaging the pelvic floor.
  • continuous fetal moitoring, epidural analgesia -as these may both lead onto other interventions such as vacuum extraction or forceps delivery or episiotomy:
    • lying on the back
    • episiotomy
    • assisted vaginal birth
    • caregiver-directed pushing
    • fundal pressure
  • Post gynaecological surgery, e.g. hysterectomy
  • Obesity -BMI>25
  • Illnesses which lead to chronic coughing-such as sneezing, asthma, hayfever
  • Smoking

 

If you are suffering from symptoms of pelvic floor dysfunction, there is no need to suffer in silence. If you are suffering whilst pregnant, you can discuss how to reduce some of the risk factors above with your midwife. Post partum your physiotherapist can advise you on the rehabilitation options available,

Rehabilitation Options for the Pelvic Floor

Pelvic Floor Exercises (Kegel Exercises)

You can feel your pelvic floor muscles if you try to stop the flow of urine when you go to the toilet. Traditionally women are often advised to do these exercises during and after pregnancy and it is thought that contracting the muscles regularly can reduce urinary incontinence and improve sensitivity during sex.

The best way to start is sitting comfortably on a chair with your knees slightly apart (to relax your inner thigh muscles). Next try to contract the muscles, which you would use to stop yourself peeing if you were on the toilet.  The NICE guidelines for incontinence recommend that you perform at least 8 contractions, 3 times a day.  You may need to build up the repetitions gradually adding more squeezes each week and holding the squeezes for up to 10 seconds.

However some research has found that these types of pelvic floor exercises are commonly performed incorrectly. In fact one study suggested that only 50% of women could actually contract their pelvic floor after brief instruction and half of these were doing it in a way, which might actually promote future incontinence (Bump et al 1991).

The Association of Chartered Physiotherapists in Women’s Health explain that even if you have strong pelvic floor muscles, you may not be using them at the right time or in the right way to prevent leakage.

Supervised Biofeedback

For reasons like this it can be helpful to perform the exercises, with a biofeedback device, inserted internally, which can record how you are contracting the pelvic floor muscles. This is usually done under the guidance of specialist women’s health physiotherapists. Your GP or current physiotherapist can advise you where you can find one of these specialists or you can consult the website for Chartered Physiotherapists in Women’s Health pogp.csp.org.uk.

A Cochrane review in 2011 found that women who received biofeedback were significantly more likely to report an improvement in their urinary incontinence than women who performed pelvic floor muscle retraining without (Herderschee et al 2011).  NICE guidelines reports that electrical stimulation and biofeedback for the pelvic floor are useful to aid motivation and adherence to therapy.

Pilates

If you are already familiar with Pilates, you will know that it involves some concentration on recruitment of the pelvic floor muscles as part of setting your centre, alongside your lower abdominal muscles.

Interestingly some studies have found that Pilates itself can be as effective as specific pelvic floor muscle training. One 12 week programme found that a group who performed Pilates twice a week not only had all the same benefits in improving their pelvic floor strength as a group performing pelvic floor muscle retraining with biofeedback, but the Pilates group actually had additional benefits related to the global nature of the exercise (Culligan et al 2010).

Many women may prefer this less invasive method of retraining their pelvic floor. However it is important to note that there are certain Pilates exercises which may need to be avoided or modified in women with pelvic floor dysfunction. These are exercises, which are associated with pelvic floor overload, increased tension or over-activity in the pelvic floor. The most common exercises, which need to be modified or avoided in these cases are

 

  • The hundred
  • Scissors
  • Dead bugs
  • Chest lift holding
  • Roll ups/rolling back
  • Plank
  • Push up.

 

If you are suffering from pelvic floor dysfunction and want to use Pilates as rehabilitation it is important that your teacher understands the nature of your condition and modifies the programme accordingly in order to avoid exacerbating the problem.

Surgery

If you have explored exercise rehabilitation fully and it fails to ameliorate symptoms of stress incontinence then surgical repair may be necessary. There are various procedures available, which you can discuss with your consultant. One method uses mesh tape to create a sling under the neck of the bladder. The sling supports the urethra and helps to keep it closed, particularly when you cough or sneeze.

Surgery is usually not recommended until after you have finished your family as further pregnancies and childbirth could disrupt the effects of the surgery.

By Nikki Richards MPHTY(Sports)BSc(hons) Physio MCSP

References

Wu JM, Hundley AF, Fulton  FG, Myers ER (2009). Forecasting the prevalence of pelvic floor disorders in U.S. women: 2010 to 2050. Obstet Gynecol, Dec 114(6) 127-83.

www.nhs.uk

www.nice.org.uk/guidance/cg171

http://pogp.csp.org.uk/publications/promoting-continence-physiotherapy

Bump RC1Hurt WGFantl JAWyman JF (1991). Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991 Aug;165(2):322-7; discussion 327-9.

Herderschee R1Hay-Smith EJHerbison GPRoovers JPHeineman MJ (2011).Feedback or biofeedback to augment pelvic floor muscle training for urinary incontinence in women. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD009252. doi: 10.1002/14651858.CD009252.

Culligan, PJ, Scherer, J, Dyer, K, Priestley, JL, Guingon-White G, Delvecchio, D, Vangeli, M (2010) A randomized clinical trial comparing pelvic floor muscle training to a Pilates exercise program for improving pelvic muscle strength. International Urogynecology Journal, 21 (4), 401-408.