Pelvic Floor Exercises
During pregnancy the pelvic floor must support the weight of the growing baby. Without exercise the muscles weaken causing incontinence. Pelvic floor exercises also help you learn how to push effectively, relaxing the pelvic floor to allow the baby to pass through.
During menopause, the drop in estrogen decreases the strength of the pelvic floor muscles. If your muscles were weak before starting menopause, you may find yourself suddenly dealing with incontinence. In fact, as many as 40% of post-menopausal women deal with incontinence. But this condition is treatable without medications. Even if your pelvic floor is already weak enough to cause urine leakage, you can strengthen it to regain control.
The first line of care for stress incontinence is pelvic floor contraction exercises. When women are taught to properly perform pelvic floor exercises, the cure rate is as high as 70%. Once a woman has improved her pelvic floor strength, completing the exercises one to two days per week is effective to maintain the improvement. It is difficult to determine the exact number of contractions necessary for improvement or maintenance because studies use different protocols.
How Does the Pelvic Floor Work?
The pelvic floor is a framework of muscles, fascia and ligaments working together to support the contents of your abdomen. This looks like a hammock spread across the bottom opening of your pelvis. Two sphincters (openings) in the muscle open and close to allow the passage of waste products. In women, a third sphincter allows access to the uterus.
While this framework appears to be a distinct muscle unit, recent research demonstrates the pelvic floor is connected to the rest of the musclular framework in the pelvic region. When contracting the pelvic floor, it is impossible to achieve the maximum contraction without also having some contraction in the abdomen and glueteal muscles. While previous research has shown that actively contracting abdominal muscles while doing pelvic floor exercises does not improve thier effectiveness, it is important to remember the pelvic floor is connected to the rest of the body. In fact, women with low back pain are at higher risk for developing stress incontinence. To have a healthy pelvic floor, you must ensure health of the entire pelvic region.
This framework has two seperate jobs. The first job is to provide the support for the pelvic floor. The second job is to hold the pelvic structures in place. Despite the two jobs, the pelvic floor is one connected unit.
Researchers are able to measure two seperate types of strength on the pelvic floor. The first type is the support strength - how well does the pelvic floor support the pelvic organs. The second type is the muscle contraction strength - how well do the muscles close the sphinctors to prevent leakage of urine or feces. It is the muscle contraction strength that weakens during pregnancy and remains weaker after a vaginal delivery. While the supportive strength decreases gradually during pregnancy, it also gradually improves after the baby is born.
In one study of the pelvic floor 76% of women experience urinary incontinence during pregnancy. All cases were due to stress incontinence - the type that improves with pelvic floor exercises.
When you tighten the pelvic floor muscles, you close the sphincters preventing the flow of urine - this is the muscle contraction strength. This is why many women find it easy to learn how to locate the muscle by trying to stop the flow of urine while peeing. In contrast, relaxing the muscle opens the sphincters, allowing passage of urine, feces or a baby as need be. Exercising the pelvic floor can help you gain control of the relaxation as well as strengthening the muscle. This can help improve pregnancy related incontinence and prepare you to push effectively.
How to do it
Pelvic floor exercises are a series of muscle contractions that will take you several weeks to master. Build slowly, allowing yourself at least a week to strengthen and gain control of the muscle before moving on to the next step.
Remember, there is no research on the number of contractions necessary for improvement or maintenence of pelvic floor strength. If you are not currently experiencing pregnancy related stress incontinence, research suggests practicing these exercises one to two times per week may be enough to maintain your current strength.
To begin, try to isolate the pelvic floor by contracting it as if you were trying to stop the flow of urine. Do not worry at first about letting go of the contraction, just let it relax on its own.
The second step is to learn how to let go of the contraction.
Then begin building the strength of the muscle by holding the contraction for 1 second, then 2 seconds and eventually up to 3 seconds.
When you are strong enough to hold the contraction for 3 seconds, increase your control of the muscle by contracting a little, then a little more, then all the way. Learn to contract the muscle in increments before you begin to learn to relax the muscle in increments.
The last step is to learn to relax, or bulge the muscle. This is the same movement you use to release the flow of urine. After contracting the muscle, bulge it out (if you have difficultly determining if the muscle is bulged, put your hand along the perineum. You should feel it bulge out as you relax the kegel muscle).
The pelvic floor is an internal muscle, so you will not see movement outside the body when you are doing it correctly. The kegel exercise is not squeezing your buttocks. It is also not squeezing your legs together or tilting your pelvis. When the exercise is done properly you will feel the muscle contracting but will not see any external movement.
When first learning to kegel, some women have success at trying to stop the flow of urine while peeing. This lets you know you have the right muscle, however once you learn to contract the muscle ther is no benefit and potential risk of urinary tract infection if you continue to stop the flow of urine. The urine-flow stop method should not be used by women who experience recurrent urinary tract infections. Other women find sitting with their legs in front of them gives them a better feel for which muscle they are tightening.
If you still struggle with finding the right squeeze, talk to your doctor. You may also be able to work with a physical therapist to learn to isolate the appropriate muscle.
Al-Eisa, E. and Tse, C. (2013). Association Between Core Muscle Strength, Stress Urinary Incontinence, and Low Back Pain: A Case-Control Study. Journal of Womens Health, 22(3).
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Soljanik, I., Janssen, U., May, F., Fritsch, H., Stief, C.G., Weissenbacher, E.R., Friese, K., Lienemann, A. (2012). Functional interactions between the fossa ischioanalis, levator ani and gluteus maximus muscles of the female pelvic floor: a prospective study in nulliparous women. Archives of Gynecology and Obstetrics, 286(4):931-8.
Tansatit, T., Apinuntrum, P., Phetudom, T., and Phanchart, P. (2013). New insights into the pelvic organ support framework. European Journal of Obstetrics & Gynecology and Reproductive Biology, 166:221-225.
Yoshida, M., Murayama, R., Haruna, M., Matuszaki, M., Yoshimura, K., Murashima, S., and Kozuma, S. (2013). Longitudinal comparison study of pelvic floor function between women with and without stress urinary incontinence after vaginal delivery. Journal of Medical Ultrasonics, 40(2):125-131.