Pelvic Floor Health

The muscles of the pelvic floor play a key role in core stability, breathing and posture, as well as the support of the pelvic organs. Pelvic floor muscles work alongside other key muscles to enable proper support of the lower back, pelvis, bladder and bowel.
 
This guide was designed to help you understand more about pelvic floor muscles and the role they play in health conditions such as:

• Urinary and bowel incontinence
• Uterine, bladder and rectal prolapse
• Sexual dysfunction
• Pelvic pain
• Post-prostatectomy incontinence
• Constipation
• Overactive bladder
• Urinary hesitancy

The pelvic floor is made up of a number of layers of muscle tissue and associated ligaments that are anchored within the ‘bowl’ of the pelvis. These are connected to the pubic bone in the front, the tailbone in the back, between the sitting bones as well as to the hip muscles deep inside the pelvis. The muscular tissue and ligaments support all of the organs located in your pelvic region, including the bladder, small intestine, rectum, and, in women, the uterus and vagina.
 
The pelvic floor controls the passage of waste through the urethra and anus. Muscular bands called sphincters encircle the urethra and anus. When the pelvic floor muscles contract, the internal organs are lifted and the sphincters tighten around the openings.  The sphincter contraction also prevents leaking of urine and stool.  When the pelvic floor muscles relax, the sphincters open which enables urine and feces to be eliminated.
 
In addition to providing essential bladder and bowel control, pelvic floor muscles also contribute to sexual function.  Strong pelvic floor muscles correlate with increased sexual sensation and arousal.  Pelvic floor muscle spasm however, can result in pain during intercourse and orgasm, as well as causing constipation and bladder problems.  The ability of the pelvic floor muscles to both contract as well as relax is critical to normal bowel, bladder and sexual function.  Pelvic floor dysfunction, be it weakness, laxity or spasm, can have a significant impact on your overall health.

Pelvic floor dysfunction can be caused by:

• Diminished muscle integrity due to weakness, tearing or cutting
• Abnormal nerve function
• Torn or avulsed fascia, which leaves an otherwise functional muscle unattached to the anchoring structures

The most common causes of injury to the pelvic floor muscles, nerves and fascia are pregnancy and childbirth. During pregnancy the growing baby puts extra pressure on the mother's pelvic floor, especially if she is expecting twins, triplets or other multiples. In preparation for delivery, the mother’s body produces hormones which soften the ligaments and muscles to allow for the pelvic joints and soft tissue to widen, allowing the baby to descend through the birth canal.
 
Vaginal delivery can stretch and compress the pelvic floor structures.  Other events that can increase the risk of pelvic injury include large babies, fast labor or pushing for more than 1.5 hours. However, simply being pregnant increases the risk of pelvic floor dysfunction, as women who have caesarean sections may also have pelvic floor problems.
 
Other factors that can contribute to pelvic floor dysfunction or make symptoms more apparent are:

• Obesity
• Chronic constipation
• Straining during urination or bowel movements
• Coughing associated with chronic bronchitis, asthma, other lungs disorders and smoking
• Heavy lifting
• Nerve or internal sphincter damage caused by prostate surgery
• Low estrogen due to hysterectomy or menopause

Since pelvic heaviness, bloating and urinary or bowel elimination changes may be a sign of other more serious health conditions, such as urogynecologic or prostate cancer, always consult your primary health care provider if you experience any of these symptoms.

Since you can't see your pelvic floor structures, you might not even realize that they have become stretched, weakened or injured until you notice other changes in your body or health. There are four categories of pelvic floor issues that may develop, which are outlined below.

Urinary incontinence affects approximately 200 million people around the world – mostly women. In fact, 26% of women between the ages of 30 and 59 have problems with urine leakage [1]. Urinary urgency or urge incontinence can be caused by common triggers such as certain foods, drinks, and medications.  It can also be caused by medical issues as common as a bladder infection, or due to more serious causes such as bladder or pelvic cancer.

The symptoms of urinary incontinence can range from leaking urine when you laugh, cough, sneeze or run to having a sudden need to urinate that is so overwhelming that you don't always make it to the bathroom in time. Some people find that they dribble urine, while others feel like they never really empty their bladder.

Many people with urinary incontinence tend to suffer in silence because they are too afraid or embarrassed to talk to their doctor. Many women with this problem also wrongly assume that the loss of bladder control is a normal part of aging or motherhood because it is so common. More than half of first-time moms and one in three women who have already had a baby experience some urinary leakage [2]. If urinary incontinence is affecting your daily life, you should definitely talk to a medical professional.
 
Your family doctor, nurse practitioner, urologist or gynecologist can do a number of tests to determine what type of incontinence you have and what might be causing it. This may include keeping a bladder diary for several days and having a urinalysis and/or blood tests.

Further specialized testing may be needed to provide more detailed information.

Three common techniques that are commonly used to help improve bladder control are:

Exercises – Many people simply need to strengthen and re-educate their pelvic floor muscles to dramatically improve their symptoms. Gaining greater control over the muscles deep in your lower abdominals can also help improve pelvic floor muscle function. Rigid contractions of both the abdominal and pelvic floor muscles can actually make leaking or pain worse.

Biofeedback – Although many people have heard of Kegel exercises, more than half are not able to contract the right muscles based on verbal or written instructions [3]. Biofeedback can be used in combination with an exercise program to help make sure you are targeting the proper muscle groups. Biofeedback provides you information by a computer screen or a sound that tells you when you are contracting the correct muscles. This enables you to learn how to control the muscles during functional activities in sitting, standing and lying down. It also lets you know if you are fully allowing the muscles to relax. This is a crucial function especially with clients with pelvic pain.

Muscle Stimulation – Sometimes pelvic floor muscles are so weak that doing exercises (even with biofeedback) isn't enough. The muscles need to be physically reminded how to work properly. Pelvic floor muscle electrical stimulation can assist your muscles to remember how to contract.

Behavioral modifications are lifestyle and dietary changes that can significantly reduce your symptoms and improve your overall health. Combining behavioral modifications with pelvic floor strengthening techniques will improve the effectiveness of your program.

Bladder Training – People with incontinence often get into the habit of going to the bathroom too often. There are a number of techniques you can use to gradually increase the amount of time between bathroom trips, including learning how to control the urge to urinate and learning how to empty your bladder more completely. Monitoring what and how much you drink, losing weight and doing regular exercise may also help reduce or eliminate your symptoms.

Relaxation Techniques – Stress, anxiety and tension only make bladder problems worse. Breathing, postural and relaxation techniques can help put you back in control.

Many people with urinary incontinence tend to suffer in silence because they are too afraid or embarrassed to talk to their doctor. Many women with this problem also wrongly assume that the loss of bladder control is a normal part of aging or motherhood because it is so common. More than half of first-time moms and one in three women who have already had a baby experience some urinary leakage [2].  If urinary incontinence is affecting your daily life, you should definitely talk to a medical professional.
 
Your family doctor, nurse practitioner, urologist or gynecologist can do a number of tests to determine what type of incontinence you have and what might be causing it. This may include keeping a bladder diary for several days and having a urinalysis and/or blood tests.

Further specialized testing may be needed to provide more detailed information.

Muller N. What Americans understand and how they are affected by bladder control problems: highlights of recent nationwide consumer research. Urologic Nursing. 2005:25(2):109-115.

Ege E, Akin B, Altuntuğ K, Benli S, Arioz A. Prevalence of urinary incontinence in the 12-month postpartum period and related risk factors in Turkey. Urol Int. 2008;80(4):355-61.

Bump RC, Hurt WG, Fantl JA, Wyman JF. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991;165:322-27.

Barber MD, Visco AG, Wyman JF, Fantl JA, Bump RC. Sexual function in women with urinary incontinence and pelvic organ prolapse. Obstet Gynecol. 2002;99(2),281-289.

Dorey G, Speakman M, Feneley R, Swinkels A, Dunn C, Ewings P. Randomised controlled trial of pelvic floor muscle exercises and manometric biofeedback for erectile dysfunction. Br J Gen Pract.