What is your pelvic floor?
Your pelvic floor is a hammock-shaped complex of muscles, a bit like a trampoline, that can change shape depending on how much pressure is on it.
“It spans from the coccyx at the base of the spine to the pubic bone at the front, filling the bottom of the pelvis,” says pelvic floor physiotherapist Katie Mann.
These muscles have three important functions.
“The first is for support,” says Mann. “It has to hold up the pelvic organs – such as the uterus, bladder and bowel – as you walk around. The second is a sphincter effect, helping to keep the bladder and bowel closed until you choose to go to the loo. The third is for sex – if it’s too weak, that can lead to a loss of sensation and poor orgasmic response.”
What happens when you have a weak pelvic floor?
Many things might cross your mind during a workout. Do these leggings pass the squat test? Why isn’t there a clock in here? Whether lunges might cause you to wet yourself, however, isn’t a welcome thought. Yet, for Katy, 34, it’s a real anxiety.
“It was after starting a fitness kick that I realised I had a problem,” she recalls. “We were asked to do this deep sideways lunge in a class and I leaked. I carried on, but there was this constant fear of ‘what if?’ It got worse over time.”
A study from the Medical University of Vienna revealed there’s more shame and embarrassment around pelvic floor issues, such as incontinence, than there is around other tricky-to-talkabout conditions. No wonder it’s seriously damaging our collective mental health: research shows as many as 30 per cent of women with incontinence will also be depressed, with the condition doubling the risk of postnatal depression.
But, campaigns such as #pelvicroar and World Continence Week are breaking the silence.
“There are so many pelvic floor issues people are facing because for so long we’ve swept [the topic] under the rug,” says Heba Shaheed, a pelvic and female health expert, who shares advice on her Insta @thepelvicexpert. “They feel alone, so it’s about moving away from that loneliness.”
The more we talk about it, she adds, the faster support can be found.
“Some people don’t realise they have certain issues. Then they read a blog article ... and message me saying, ‘this has changed my life. All along I had a prolapse and [I got help] and now I can exercise and do things like I used to daily.’” In short, sharing really is caring.
What causes weak pelvic floor muscles?
A 2016 study by Loyola University Medical Center in the US found high rates of stress incontinence among female triathletes, with 37.4 per cent of those surveyed affected. Meanwhile, 2014 research by the team found female runners were similarly afflicted. The sheer impact of pounding the pavement can slacken the pelvic floor muscles over time, while the motion also raises intra-abdominal pressure (the pressure inside your torso) which weighs down on your pelvic floor.
“If a woman comes to me with leakage while running, we look at it holistically,” says Shaheed. “It might be related to the way her foot moves, and that then translates up into the pelvic floor. We have to look up and down the chain. The best thing is to get checked out early by a pelvic floor physiotherapist, who can assess what’s happening and then give the right treatment.”
Also, have a fitness professional check your workout form. Easy!
The force of the contractions in your diaphragm and the muscles between your ribs increases the pressure inside your chest, which pushes down on the pelvic floor, and if the muscles aren’t strong and taut enough, urine can escape from the bladder.
“Coughing and sneezing are two of the largest forces on your pelvic floor and bladder,” says Shaheed. “If you’ve worked on your pelvic floor, when you do get [coughing or sneezing] attacks, you may be able to safeguard yourself. It’s all about prevention.”
Pregnancy and birth
A baby’s position in the body means it’s essentially sitting on your pelvic floor. This weight, as well as that of the placenta and amniotic fluid, means pressure will build.
“There can be a perception that having a C-section will protect the pelvic floor, but it’s only partial protection,” says Dr Dudley Robinson, a consultant urogynaecologist. Interventions during birth, such as having a forceps delivery, increase the risk of weakening your pelvic floor.
Shaheed says, “I’d love every pregnant woman to see a pelvic floor physio around 20 and 32 weeks to do prep work. And postpartum at eight weeks, so [any issues after birth] can be picked up straight away.”
A pregnancy pilates and yoga class can also be great for strengthening the body.
This isn’t to say that you need to swerve the squat rack; just be mindful of your pelvic floor by focusing on form. In fact, while studies have shown that most exercise raises intra-abdominal pressure, the level of this increase can vary between individuals, suggesting that how you lift can make a big difference. A physio can help you with functional exercises, to make sure you’re doing things like lunges and squats correctly, advises Shaheed. A basic rule: don’t hold your breath, as this adds pressure, but activate and hold your pelvic floor during the move.
Being constipated is a risk factor for a weakened pelvic floor, as straining also puts a lot of pressure on these muscles, explains Mann. Accordingly, piles could suggest you need to show your pelvic floor some love, as they can be a result of constipation. As for clearing that blockage, drinking more water and eating more fibre-rich fruit and veg should do the trick. And prioritise sorting out any gut issues, urges Shaheed.
Candles on the cake
Like any muscle, the pelvic floor weakens as you age. Plus, the drop in oestrogen during perimenopause and after menopause means incontinence becomes more common then.
“Being strong in your 30s and 40s is important to give you that baseline,” says Shaheed. “But, it’s never too late – we see 80-year-olds [with pelvic floor issues] and, with a specialised program, most will see vast improvement.”
An unhealthy weight
Carrying excess kilos can increase the internal pressure on your pelvic floor.
“Not only can achieving a healthy weight reduce your risk of developing incontinence, there’s evidence it can improve existing weakness by lightening the load on the pelvic floor,” says Robinson.
So, it’s not that slimming down will gift you a watertight pelvic floor – more that you’re giving your muscles less work to do. Equally, carrying too little body fat can pose issues, too.
How to do Kegel exercises for a strong pelvic floor
Do your Kegels right with pelvic floor physiotherapist Katie Mann’s six-step guide to pelvic floor exercises.
1. Contract the back passage as if stopping wind, while at the same time squeezing at the front as if trying to stop the flow of urine.
2. Engage the correct muscles. Make sure your buttocks aren’t contracting – an easy mistake. It’s not the bottom you sit on that you’re trying to contract, it’s the area around your anus and vagina.
3. Try to breathe normally and don’t let your thighs squeeze together. Your legs should be relaxed and any movement should be internal.
4. The action needs to feel like a lifting sensation between your belly and groin. Don’t worry if your lower stomach contracts – that supports the action of the pelvic floor.
5. Ideally, do your exercises three times a day. Try 10 long squeezes, holding for 10 seconds, followed by 10 quick squeezes. Let the muscles relax after each contraction.
6. Find a way to fit it into your regular routine. Try when you’re on the bus or at your desk. An alarm to remind you to do them can help. So get busy and reap the benefits!
Still suffering? See a pelvic floor physiotherapist
More than a fifth of active women between 18 and 40 report urinary incontinence, found an International Journal of Sports Medicine study. The good news? A specialist physio can help work out what’s happening and, from there, effective treatments are available. These range from pelvic floor exercises to a vaginal pessary in the case of, say, a prolapse (when a pelvic organ collapses into the pelvis).
“Pessaries help to lift the organs back into a more desirable position,” Shaheed says.
And if these don’t work?
“The recommendation is to try 12 months of conservative treatment – pelvic floor physiotherapy – before you look at a surgical option,” she says, adding that some surgeries have higher success rates than others. Issues aren’t just caused by weak pelvic floors, either. A hypertonic one is where the muscles are too tight or incapable of relaxing, and causes issues like pain during sex and problems with tampons. Exact causes are unknown, but stress is thought to play a role. A specialist physio can help you out.