The Pelvic Floor Muscles a Guide for Women

Introduction

Up to a third of all women experience a problem with their pelvic floor muscles at some time during their life. The most common problems are leaking with activity, sneezing or coughing (stress urinary incontinence) and pelvic organ prolapse (a feeling of something coming down in the vagina).

All the bladder, bowel and sexual functions require good pelvic fl oor muscles. Effective pelvic fl oor muscles in pregnancy will reduce the All the bladder, bowel and sexual functions require good pelvic fl oor muscles. Effective pelvic fl oor muscles in pregnancy will reduce the risk of postnatal stress urinary incontinence (SUI).

he pelvic floor muscles lie across the base of your pelvis to help keep the pelvic The pelvic fl oor muscles lie across the base of your pelvis to help keep the pelvic organs  - bladder, uterus, vagina (if previous hysterectomy) and organs  - bladder, uterus, vagina bowel - in the correct position.  The muscles are held in place by ligaments that support the organs especially when there is an increase of pressure in the abdomen that occurs with lifting, bending, carrying and straining. This is called intra-abdominal pressure and when it increases the pelvic fl oor and abdominal muscles brace so that the internal organs such as the uterus and bladder are not pushed downwards.

The pelvic floor muscles work to help keep the bladder and bowel openings closed to prevent unwanted leakage (incontinence) and they relax to allow easy bladder and bowel emptying.  Good pelvic fl oor muscles can help with sex by improving the vaginal sensation and your ability to squeeze during penetration.

Your pelvic floor muscles are important in posture and with the abdominal muscles help to support your spine.

Not all women with symptoms have weak pelvic floor muscles, but sometimes they need to learn to use their pelvic fl oor muscles in the right way and at the right time. Pelvic fl oor muscles should be kept strong and active just like any other muscle in your body.

Why do problems occur with the pelvic floor muscles?

Causes

The pelvic floor muscles can be weak, overstretched, slow to work, too tight or torn just like the other muscles of your body.

Pregnancy and childbirth can cause  problems for the pelvic floor muscles especially if you have had an assisted vaginal birth, an episiotomy or significant tear or a very large baby. It is important to do your pelvic floor exercises regularly during pregnancy to reduce the risk of of future problems with incontinence.

Chronic Constipation - having to strain to empty your bowels on a regular basis can cause overstretching and weakness. Difficulties with emptying may be due to poor relaxation of the pelvic floor muscles. Heavy or repeated lifting - causes increases in abdominal pressure which may put your pelvic floor muscles under strain.

High impact exercise - heavy weights-based and very vigorous gym activities with jumping can overload your pelvic floor muscles - patricularly if you have not increased your exercise programme carefully over time.  

Being very overweight - may increase the pressure on the pelvic floor muscles.

Chronic Respiratory Conditions - prolonged bouts of coughing to clear your lungs may put pressure on your pelvic floor muscles

Smoking - might cause a regular cough which may put pressure on the pelvic floor muscles.

Menopause - vaginal changes after the menopause may make your pelvic floor problems worse.

Other conditions which affect the muscles may have an effect on the pelvic floor muscles e.g. neurological conditions and diabetes.

Symptoms

You may have more than one of the following symptoms:

Bladder:

• Stress Urinary incontinence - leakage with coughing, sneezing and activity which may include sexual intercourse
• Urgency - a sudden need to go to the toilet that may include leakage
• Frequency - going to the toilet too often
• Nocturia - getting up at night to go to the toilet

Bowel:

• Anal incontinence - leakage with activity or urge
• difficulty    getting    clean    after    bowel    movements
• leakage    of    wind

Vaginal:

• a    feeling of  something coming down,  or  heaviness (pelvic organ    prolapse)
• pain which can be felt vaginally, abdominally or  in  the pelvic area
• lack of sensation during sex

Finding your pelvic floor Finding your pelvic floor muscles

It is important to get working in the right way.  In a comfortable lying or sitting position It is important to get the right muscles working in the right way.  In a comfortable lying or sitting position imagine that you are trying to stop yourself from passing wind and urine at the same time; imagine that you are trying to stop yourself from passing wind drawing the pelvic floor muscles upwards and forwards from the back passage towards the bladder. You may feel a lifting up and tightening as your muscles contract. Try not to hold your breath; breathe in through your nose, drawing air to the bottom of your lungs and letting your tummy relax, then breathe out through your mouth. You could also try counting out loud to encourage normal breathing.

Your lower tummy may tighten, which is normal, but keep your buttocks and legs relaxed. Let your pelvic floor muscles relax fully after every contraction.

There are 3 main ways to check if you are contracting your pelvic fl oor muscles correctly:

1. using a mirror, the area between your vagina and back passage (perineum) should move up and inwards away from the mirror when you contract your pelvic fl oor muscles. If you see any bulging - STOP, you may make your pelvic f l oor muscle problem worse. You should try to get help from a specialist physiotherapist (p6)

2. feel inside your vagina with your thumb or index finger. Tighten your pelvic floor muscles. You should feel the muscles tightening around your thumb or finger 

3. if you are sexually active, and having penetrative sex, you could try to squeeze your muscles during sex. Ask if your partner can feel the squeeze

If you experience pain when exercising the pelvic floor muscles, or if you have abdominal or pelvic pain after doing the exercises, you should seek specialist advice from a physiotherapist experienced in treating women with pelvic floor problems (see p6).

Improving your pelvic floor muscles  

Pelvic floor muscle exercises (sometimes called Kegels) should include long, held squeezes as well as short, quick squeezes; ensuring that you let the muscle ‘go’ or ‘relax’ after each squeeze. You should work the muscles until they tire and do the exercises regularly to help the muscles become stronger and more effective.

Long squeezes

• Tighten    your    pelvic    floor    muscles,        hold    them    tight,    then    release    and    let    them    fully relax. How long can you hold the squeeze
• Repeat    the    squeeze    and    hold    until    the    pelvic    floor    muscles    tire.    How    many    times can you repeat the squeezes?

Short squeezes

• Quickly    tighten    your    pelvic    floor    muscles,    then    immediately    let    them    go    again.    How many times can you do this quick squeeze before the muscles get tired?
• Always    let    the    muscles    fully    relax    after    each    squeeze

Aim to be able to do 10 long squeezes, holding each squeeze for 10 seconds, followed by 10 short squeezes.

You may need to start with ‘little and often’ if you find that you can only hold the squeeze for a short time, or only do a few before the muscles tire.

You should do your pelvic floor muscle exercises at least 3 times each day. You may find it easier to start your programme when you are sitting or lying down.

Build up your exercise routine gradually over the weeks and months. You should notice an improvement in 3 - 5 months and then keep practising your pelvic floor muscle exercises once a day to maintain the improvement.

As your muscles improve, aim to do your exercises in other positions  such as standing up. Eventually you can practise using these muscles whilst doing activities such as walking and bending. 

Remembering to exercise

It is easy to forget to do your pelvic floor muscle exercises, particularly when your symptoms start to improve. Try to make them part of a daily routine, doing them at the same time as another activity you already do regularly e.g. brushing your teeth. Try the following suggestions:

• put a reminder on your phone
• try one of  the pelvic floor exerciser apps available    
• after emptying your bladder, whilst  sitting on the toilet (but don’t practise by   stopping your urine flow)
• take a moment to do them when you go to the gym    
• during a regular journey in the car,  bus or train

Ideally you will be able to improve your pelvic floor muscles with these exercises. Some women like to use gadgets to help them remember. There are many available to buy, but they don’t always suit everyone. It is best to seek advice from a specialist physiotherapist about what might help if you are finding it difficult to do these exercises.

Other ways to help

All these suggestions are based on best available current evidence.

• Lifting - always try to avoid unnecessary strain on your pelvic floor muscles. If you have to lift in your job or daily routine, get advice about safe lifting and equipment to help.
• The Knack - tighten your pelvic floor muscles before any activity which involves a rise in intra-abdominal pressure - coughing, sneezing, lifting, carrying, bending - even laughing sometimes!
• Constipation - See a specialist physiotherapist (p6) or ask  your doctor if you have difficulty emptying your bowels regularly or always have to strain.
• Bladder problems - don’t reduce your fluid intake to try and reduce frequency; it may make your urine stronger which might cause more irritation of the bladder. Avoid fizzy and caffeinated drinks. To help with the urgency of needing to go to the toilet, sit down if you can, use your pelvic floor muscles to help the bladder relax and wait until the strong urge passes.
• Toileting position - using a step or stool under your feet while on the toilet helps create a squatting position which will reduce pressure into your rectum when passing a stool. This will reduce pressure on the ligaments and muscles in this area. It is also important to ensure you always sit and relax on the toilet and not get in a habit of hovering as this does not allow your pelvic floor to relax completely while you empty your bladder. 
• Relaxation  - it is just as important to have pelvic floor muscles that can relax as it is for them to be strong. Increased stress can cause changes to your posture and breathing and this can put more tension in all our muscles, our pelvic f loor included. Practising some mindfulness techniques can help to improving our breathing techniques as well as relax our muscles. There are many apps available online that can help with this. You can also find out more about simple relaxation    methods    in    our    booklet    on    the    ‘Mitchell    Method    of    Relaxation’.    
• Exercise - if you find that you have stress urinary incontinence with exercise, try a low impact activity such as pilates/walking/swimming. You might need to avoid very high impact exercises which involve jumping, heavy weights or prolonged increases in intra-abdominal pressure e.g. double leg lifts.
• Menopause changes - a mixture of pelvic floor muscle training and using a local vaginal hormonal treatment has been shown to be safe and effective.
• Weight - if you are overweight, try to lose weight as this may help your symptoms. Seek help from your doctor if you have tried but not succeeded with weight loss.
• Smoking - try to give up if you can. Your doctor might be able to refer you to a smoking cessation group.

Getting help

If your ability to follow advice in this booklet is affected by any health problems, or if you have any diffculty with the exercises in this booklet and find that f ind that your symptoms are not improving; ask your GP to be referred to a physiotherapist with experience in treating women with pelvic floor muscle problems. In some regions you maybe able to refer yourself to an NHS women’s health/pelvic floor specialist physiotherapist.