Pelvic floor dysfunction is an issue that we rarely discuss in the United States, yet more than 50% of American women suffer from it in one way or another. Pelvic floor dysfunction (PFD) can present itself in several ways ranging from urinary issues (including stress and urge incontinence, urinary retention, incomplete bladder emptying, and hesitancy), to stool incontinence, chronic constipation, painful sex, an unexplained feeling of heavy pressure or pain in the pelvis, and outright organ prolapse. Women with PFD frequently experience several of these symptoms at once, but commonly do not discuss concerns with providers. Similarly, many providers do not facilitate conversations about pelvic floor health and function, which leaves a very important, core area of the body neglected and operating at a suboptimal level. I propose we start the dialogue with a little anatomy review…
The pelvic floor is a sling of muscles spanning from the pubic symphysis to the sacrum and coccyx. This group of muscles works along with the boney aspects of the pelvis to provide support to the pelvic organs. Normal contraction of the pelvic floor works to shorten the muscles, lifting the pelvic organs higher into the pelvic cavity. Normal relaxation of the muscles allows the organs to settle back into their original position. If these muscles or structures are not functioning properly, a wide array of pelvic disturbances can develop. 
Until recently, the cause of PFD was poorly understood. Many providers blamed weak muscles, or “low tone,” recommending a vigorous regimen of Kegels or multiple contractions of the pelvic floor muscles (squeezing the muscles as hard as you can). In theory, Kegel exercises work to strengthen the maximal contraction of the pelvic floor, with the goal of creating strength and stability in the musculature. However, the most recent research indicates that PFD is in fact much more complex than the oh-so-revered one- dimensional Kegel. Many physiotherapists go as far as to say that Kegel exercises sometimes do more harm than good.
One of my favorite physiotherapists (with a background in engineering) who addresses this topic is Katy Bowman. She explains that doing Kegels repetitively causes the muscles to contract and shorten, pulling the sacrum into the pelvic bowel towards the pubic arch. This continual contracting motion eventually causes shortening and tension in the muscles. Short, tense, contracted muscles cannot move through their full range of motion properly, leading to weakness and dysfunction.
(The pic on the left is of a healthy sacrum and long, taut pelvic floor. The middle pic depicts the action of the Kegel, shortening the muscles and bringing the sacrum forward. The pic on the right shows what happens to the muscles after repeatedly forcing the sacrum forward. They get slack and weak) *This image is shared from http://www.katysays.com/1234-we-like-our-pelvic-floor/)
Basically what Katy and other physiotherapists are saying is that many people’s pelvic floors are “too tight,” not too loose. One of Katy’s favorite sayings is “tension does not equal strength,” which is perhaps best explained by thinking about a bicep contraction. When you contract your bicep, you shorten the muscle. If you kept your bicep muscle in a constant state of contraction, you would no longer be able to generate any force or strength with it (meaning you wouldn’t be able to lift anything or have a functioning arm). What makes a muscle strong is its ability to not only contract, but to also stretch and lengthen. Without these opposing forces you are left with short, tight, dysfunctional musculature. Katy does an awesome job explaining the physiology in more detail here.
So what causes pelvic floor dysfunction anyway? Some of you may have been told that pregnancy and vaginal childbirth are to blame for all of your pelvic floor woes. While pregnancy and birth, specifically interventive births with episiotomies, forceps, or vacuum deliveries, are risk factors for pelvic floor dysfunction, it is far from the only cause. Women who have never carried a pregnancy or given birth suffer from pelvic floor issues, and so do men for that matter (read sexual dysfunction and prostate disorders). Lets take a look at some other risk factors contributing to tight and weak pelvic floors.
Sitting on our sacrum is perhaps the biggest threat to our pelvic floors. The constant pressure forces the sacrum inward, chronically shortening the pelvic floor muscles and restricting full range of motion. Humans were not designed to sit on their butts for long periods of time, but rather meant to change positions frequently with lots of walking, bending, and variations in movement. Constant sitting at work, in the car, and at home has contributed greatly to loosing the full range of motion in our hips and legs. One way to combat this is to walk as much as possible during the day. If you work at a desk, take frequent brakes to walk and stretch (we will go over the stretching in a minute). Standing workstations are great options for people with more workplace flexibility. Here is a post from Katy about alternating sitting positions.
The way that we stand also affects pelvic floor function. Many people have a tendency to roll their pelvis forward, or tuck their tailbone under while standing. Another habit that contributes to this posture is clenching of the gluts in an effort to contain urine, feces, and flatus (in other words squeezing your butt muscles trying to hold it). Both of these actions move the sacrum towards the pubic symphysis, while also disengaging the opposing force of the glute muscles. When the pelvis is shifted in this way, our ligaments instead of the boney prominences of our pubic bone work to support the pelvic organs. Unfortunately, ligaments are not pliable like muscles tissue, and once stretched, they don’t recoil well. By rocking our pelvis back in a neutral spine position, our bones and muscles do the work like they are supposed to, keeping our organs well supported. Check out this helpful video one pelvic range of motion and finding a neutral spine.
Another bad postural habit is chronically “sucking in our stomachs.” Sucking in the stomach causes similar issues that butt clenching does to the pelvic floor; causes tension! This increased abdominal tension does not improve strength, but rather causes the pelvis to tilt forward, further tucking the tailbone under. The key here is learning to relax both the core and pelvic floor muscles while also stretching them and encouraging them to lengthen.
Before we get to the stretching, we have to discuss stress. Our modern lives are plagued with chronic stress. Stress causes tension in all of our muscles, including the pelvic floor. We could all benefit from a regular practice of meditation, deep breathing, and yoga to decompress and bring awareness to clenching or tension that we hold in our pelvic floor. Here is a great guided relaxation for the pelvic floor and here is a nice pelvic floor breathing exercise. Remember, muscles have to be able to relax and lengthen as well as tighten in order to function properly.
So some of you may be wondering, what do we do to facilitate this taut yet supple pelvic floor? The two most important things we can do is strengthen our glute muscles and increase flexibility in our hips, knees and calves.  Strong glutes create opposing force on the sacrum, encouraging it to move away from the pubic bone, thereby lengthening the pelvic floor. There is one wonderful movement that addresses both of these issues: The squat.
Before the advent of modern comforts (cars, chairs, sofas, toilets) humans spent a heck of a lot of time in the squatting position. Anthropologists and physiotherapists agree that this movement is biologically important to human health. Unfortunately, many of us were raised in environments where squatting was obsolete, so our bodies lost the ability to preform this range of motion properly. Our hips, calves, and groins are tight, contributing to our pelvic floor dysfunction and other elimination difficulties (including constipation). If you want to see a perfect, instinctual squat, watch a toddler squat to pick up a toy. It is a movement that we intuitively do as children, only to be lost to modern conveniences.
For those of us who are not in the habit of squatting regularly, it may take some time to ease into the proper posture. This video explains how to work on proper squatting form from a seated position (this is a good place to start if you are really tight in the hips and weak in the glutes). In this blog post, Katy explains the importance of untucking the tailbone while squatting, showing step-by-step ways to slowly ease the body into proper squatting alignment. Here is Katy’s follow up post with more squatting tips. Squatting is the perfect exercises for the pelvic floor because it works in two ways. First, it works to lengthen the muscles on the way down and second it works to strengthen the glutes on the way back up. You can also vary your glute exercises with one like this. Pay attention to alignment in this exercise, keeping the thighs rolling inward and in alignment in the hips (we tend to let our legs flop out wide, which doesn’t engage the muscles in the same way).
In addition to squatting, there are other exercises that can be done to open up the hips and stretch the legs. Here are two more from Katy. One for stretching the deep hip muscles and one for tight calves. Many yoga poses can also help with hip flexibility including these ones and these ones.
Walking outdoors on an incline (read NOT** on a treadmill…the moving belt on the treadmill discourages proper use of the glutes) is great for building gluteal strength. When dealing with pelvic floor issues, specifically incontinence or prolapse, it is really important to avoid high impact activities like running. Running increases the force on the pelvic floor, causing it to strain and work harder to hold the weight of the pelvic organs.  Also, any abdominal exercises that increase abdominal pressure should be avoided, including crunches and sit-ups. For some ideas on safe abdominal exercises check out my other post here.
As I am sure you can tell by now, I think Katy is the coolest person ever. Her work is revolutionizing pelvic floor health and the general principals of alignment and wellbeing. Here are some other posts that I highly recommend addressing high heels and their negative effects on the pelvic floor and using a squatty potty to help get those daily squats in the mix.
Incorporating these exercises and alignment strategies into your daily life will help support pelvic floor health, but they are not substitutes for working with a qualified pelvic floor physiotherapist. A physiotherapist will be able to asses your unique pelvic floor needs, including the degree of muscle weakness, muscle tightness, scar tissue, and trigger points that may be effecting muscular function. Pelvic floor therapists implement many healing strategies including pelvic massage, myofascial release, trigger point therapy, scar tissue release, biofeedback, and neuromuscular electrical nerve stimulation to help restore function to the musculature. They can also recommend individually tailored exercises to work on tension or strength. Many insurance companies will cover at least a few sessions of pelvic floor physical therapy, allowing patients to bring exercises home with them for continued training.
This link explains the internal work associated with pelvic floor PT and here is a video explaining some simple techniques to assess tension in your own pelvic floor. To find a therapist near you who trained with Katy, check out this link. Last but definitely not least, check out Katy’s DVD with more recommendations for pelvic floor exercises.
Well, I have officially been sitting on my sacrum for way too long writing this post, so time for me to get moving. Best wishes for your self-care endeavors!
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