Gwyneth’s Goop and the Pelvic Floor: What They Missed

In Female Pelvic Pain by Stephanie Prendergast4 Comments

By Stephanie Prendergast

Last week, Gwyneth Paltrow’s popular newsletter featured an article on pelvic floor muscles, which prompted numerous emails and tweets in my direction. Apparently this is a topic that makes my friends and colleagues think of me. While pondering why everyone, except for me,  seems to be reading Goop,  I took a look. I am glad to see the pelvic floor muscles are getting increasing amounts of attention but I’m going to take this opportunity to expand on a great conversation started by the authors.

Goop says:

The Secrets of the Pelvic Floor (click here for the original article)

“If you’ve never had your pelvic floor released, consider hunting down an integrative structural specialist: It’s a weird sensation, for sure, and generally reveals a shocking revelation. While you might assume that this muscle web that acts as a “hammock” for your undercarriage would be stretched out (particularly if you’ve had kids), it’s generally the opposite. “The pelvic floor is one of the body’s primary stress containers,” explains Lauren Roxburgh, our go-to fascia and structural integrative specialist. “That pit in the base of your stomach is your pelvic floor in permanent clutch.” Because so many of us have lost our connection to this web of muscles, we’ve also lost the ability to mindfully relax the area—and so over the years, it loses range of motion, tone, and flexibility. Getting reconnected is essential: “Adore your pelvic floor,” Roxburgh ads: “It’s the key to great sex, a flat tummy, and the key to never laying in a supply of Depends.”

PHRC says:

Ms. Roxburgh explains “That pit in the base of your stomach is your pelvic floor in permanent clutch.” She is describing a unique aspect of pelvic floor physiology: The pelvic floor muscles are under autonomic AND voluntary control. They always have some tone, or ‘permanent’ tone, which keep us from leaking urine or stool. Similar to breathing, this happens without us thinking about it but we can choose to override its normal function if we want to. For example, we can do a Kegel or bear down, just like we can hold our breath or purposely breathe at a rapid rate. The pelvic floor muscles are responsible for urinary, bowel, and sexual functioning. They are involved in and affected by childbirth, age-related and hormonal changes. Generally speaking, these muscles can become too tight, or they can become over-lengthened or weak. Improving your awareness about these muscles and how they work can be very beneficial.

“Q

 So what exactly is the pelvic floor?

A

We’ve all probably once said: “I laughed so hard I nearly peed myself.” Well, for many women that isn’t a joke; it’s reality. According to the Agency for Healthcare Research and Quality, about 25 to 45% of women suffered from urinary incontinence (also known as leakage) at least once in the past year.

There are a number of reasons for this. It can be caused by urinary tract infections or certain medicines, but the most common type of incontinence is called ‘stress incontinence,’ and happens when you laugh, cough, sneeze, jog, or do something that puts pressure on your bladder. The culprit? A little-known group of muscles called the pelvic floor.

The pelvic floor is a group of muscles that attaches to the bones at the bottom of your pelvis. These muscles effectively form a hammock across the base of your pelvis that supports the internal organs above it. Having strong pelvic floor muscles gives you proper control over our bladder and bowels, but that’s not their only role. Strong pelvic floor muscles also improve sexual performance and orgasm, help stabilize the hip joints, and act as a lymphatic pump for the pelvis. You get the picture: They’re important.

There’s actually a pretty simple reason why so many women have issues with incontinence, low back pain, and not so much fun in the bedroom. It’s a lack of connection to the deep core muscles, thanks to the fact that the pelvic floor gets stuck, disconnected, weak, and loses tone because it is an area where we hold stress and tension. In Eastern traditions, the pelvic floor is known as the root chakra—it’s where we tend to literally “hold” fears, specifically fears around primary instincts such as our health, our family’s safety, and our financial security. It is a “stress container,” in that it’s where we process the emotion and house our fight or flight reactions. You know that feeling when you get cut off by someone while driving, get bad news, or are about to go into a high stress situation? This can cause you to clench your pelvic floor (i.e., it feels like a pit in your stomach).

When we lose the connection to those deep muscles, it becomes difficult to relax the area, meaning the pelvic floor becomes perma-flexed. Imagine flexing your bicep constantly and never fully letting go and you get the idea: After a while, this would cause your arm to lose flexibility, strength, and the ability to relax. That’s more or less what happens to the pelvic floor until you become aware of the stress and tension and do some work to alleviate it. Part of this is willfully relaxing and unclenching these muscles—and then directing energy to build strength.”

PHRC says:

As the author mentions, Stress Urinary Incontinence (SUI) is a prevalent problem in the United States. Because the symptoms are so common, many women think that leaking urine is normal and sadly the majority of them do not actually seek help. What they do not realize is that leaking urine is NOT normal, and is actually a treatable problem1.

The pelvic floor muscles and supporting connective tissues of the pelvic organs work together to keep us from leaking. Pregnancies, age-related changes, and hormonal factors influence the connective tissues and muscles. As women approach perimenopause they may notice increasing episodes of SUI. While we cannot restore connective tissue integrity, appropriate pelvic floor and girdle muscle strengthening and motor control exercises can help the muscles counteract the connective tissue changes and restore continence. In some cases, pessaries and surgery may be necessary.

In addition to SUI, a host of other symptoms can arise when the pelvic floor muscles become dysfunctional. On the opposite end of the spectrum, 1 in 4 women develop high-tone or ‘too tight’ pelvic floor muscles. When this occurs, the muscles need to be relaxed and lengthened instead of strengthened. Symptoms of high-tone muscles can include:

  • Dyspareunia (pain with intercourse)
  • Urinary urgency, frequency, burning (in the absence of infection)
  • Difficulty/delayed painful orgasm
  • Vulvar, clitoral , or perineal pain
  • anal pain
  • constipation
  • genital pain with sitting, tight clothing, and exercise

And may be associated with diagnoses such as Vulvodynia, Painful Bladder Syndrome/Interstitial Cystitis.

Whether someone has a low-tone disorder such as SUI or a high-tone disorder such as a pelvic pain syndrome, pelvic floor physical therapists can help. Here is a useful recent media post. 

“Q

How can you tell if you’re clutching your pelvic floor?

A

Here’s a way to do a quick alignment reboot. First, slightly squeeze your pelvic floor and take a few steps: Notice how this locks up your jaw and hips? Next, do a kegel, and the release the kegel. Stand down through your feet and notice how much more relaxed your face, jaw, and pelvis are…now take a few steps and feel how much more relaxed and calm you are! Also, watch how others walk, and notice if they look uptight. Another trick? As you drive, mindfully relax the pelvic floor every time you encounter a stop sign or stop light—locate it by concentrating on your lower gut. You’ll quickly become aware of the fact that you might keep it clenched all the time.”

PHRC says:

The majority of people cannot relax or contract their pelvic floors on verbal instruction alone . As I previously mentioned, women with tight muscles need to relax them and women with weak muscles need to strengthen, both groups need to improve their motor control function, or ability to voluntarily control their pelvic floor muscles. These three articles explain this concept further. Ending Kegel Confusion and Why Kegels are Bad for your Tight pelvic Floor sheds light on why people struggle with pelvic floor exercises. A pelvic floor drop is an exercise that is helpful for women with tight pelvic floors to help them relax the muscles. You can read about this exercise here.

It is very hard for people to determine on their own if their pelvic floor muscles are tight, over-lengthened, or weak. If you answer yes to following questions (Quick Screening) it is possible that you have a pelvic floor disorder and may benefit from the help of a pelvic floor physical therapist. To find a pelvic floor PT in your area click here.

“Q

How does having a baby impact the pelvic floor?

A

Let’s face it: Pregnancy and the process of actually giving birth to that beautiful baby does a number on your body, and for many it can lead to incontinence problems, back aches, pain during sex, and even a pooched belly.

During pregnancy, you are awash in hormones and carrying considerable extra weight. Your body supports this extra burden by arching your spine, which tilts the pelvis forward. This anterior tilt and the extra weight and pressure downward stretch the muscles of the pelvic floor, and giving birth stretches them even more. After you have the baby, most healing will happen naturally. Being patient and aware of your body will help you get back to balance.

Give your body at least six weeks to heal. Once you get cleared by your doc or midwife, it’s important to start reconnecting to the base of your core.

These exercises will not only help with incontinence issues, but they’ll also bring back the balance and tone to make sex more enjoyable—for both partners! Doing these exercises also activates the deep abdominal muscles more efficiently which pulls the baby-belly back in and re-aligns the spine, alleviating back pain that is so common post-pregnancy. But whether you’ve had a baby or not, getting your pelvic floor back in shape has a ton of benefits.

Here are a few simple things you can do to help build awareness, tone, and strength in this magical little pelvic hammock!”

PHRC says:

Having a baby is like running a marathon with your pelvic floor muscles, which are only as thick as five sheets of paper! Common postpartum issues include:

  • pain at perineal or C-section scars
  • urinary, bowel, gas incontinence
  • pelvic girdle pain
  • Diastasis Recti
  • pain with intercouse

The general rule is that it is safe to exercise and return to sex at 12 weeks postpartum. The reality is many of our friends and patients confess that they ‘just don’t feel like themselves’ or that they actually ‘cannot perform the exercises right’, even after the 12 week rule-of-thumb.  We understand the frustration and can often explain why this is the case.

  1. If a Diastasis Recti is present, the entire musculoskeletal system is compromised: https://pelvicpainrehab.com/pelvic-floor-physical-therapy/2306/fix-diastasis-recti/
  2. Painful scars, myofascial trigger points, and pelvic girdle pain can be treated effectively with pelvic floor physical therapy before initiating an exercise program
  3. Pelvic floor muscle re-training may be necessary before more complex exercises can be started

While postpartum pelvic floor physical therapy is mandatory in other countries, it is not in the United States. Pelvic floor physical therapists are well-positioned to help moms with their postpartum concerns and other great resources are also available to ease the musculoskeletal transition.

  1. Mu Tu: https://mutusystem.com/
  2. Marianne Ryan: http://www.babybodbook.com/
  3. Julie Wiebe’s Pelvic floor DVD: http://www.juliewiebept.com/product/the-pelvic-floor-piston-foundation-for-fitness/

Adore Your Pelvic Floor!

I think it is safe to say that the majority of people in the United States have not had their pelvic floor ‘released’, as Ms. Roxburgh mentioned at the beginning of the article. We as pelvic floor physical therapists deploy techniques to decrease tight pelvic floor muscles and use strategies to improve strength and motor control in cases of weak pelvic floor muscles. While we generally do not recommend ‘pelvic floor release’ for everyone, I hope this article shows you why you should adore your pelvic floor!

All my best,

Stephanie Prendergast, MPT

BioPictures_0000_Layer 12

Stephanie grew up in South Jersey, and currently sees patients in our Los Angeles office. She received her bachelor’s degree in exercise physiology from Rutgers University, and her master’s in physical therapy at the Medical College of Pennsylvania and Hahnemann University in Philadelphia. For balance, Steph turns to yoga, music, and her calm and loving King Charles Cavalier Spaniel, Abbie (Abbie is a daily fixture at PHRC Los Angeles). For adventure, she gets her fix from scuba diving and global travel.

1. Curr Urol Rep. 2013 Aug;14(4):298-308. doi: 10.1007/s11934-013-0344-7.Urinary disorders and female sexual function.Chen J1, Sweet G, Shindel A.

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.

Comments

  1. Hi Stephanie, my pelvic floor physical therapist in Santa Barbara, Natalie Hickenbotham, said you recommended Payam Vahadifar, M.D. For pudendal nerve blocks. Do you know if he has done many of them and if his main office is in Encino? I want to make sure I go see the correct doctor. Thank you so much for your help!
    Sincerely,
    Wendy Paley

    1. Hello Wendy,

      We have Dr. Vahadifar on our list of MDs to refer to, but specific questions about the blocks can be answered by him directly. Yes, one office is located in Encino, but he also has a few other offices depending on which is most convenient for you.

      Regards,

      Stephanie

  2. Thanks for this post, Stephanie! It’s lead me to read lots of other posts on your site and I feel like I’m definitely more knowledgeable for it. I am a birth doula and a prenatal yoga teacher with a serious interest in the pelvic floor. I find that there is so much partial information presented to women about their pelvic floors that it’s hard to get a sense of how to best approach working one’s pelvic floor in preparation for a healthy birth and postpartum period. I wholeheartedly agree that the goal should be to improve one’s sense of the pelvic floor and one’s motor control rather than simply to ONLY strengthen or to ONLY release. In a prenatal yoga class with a general population who may not be visiting a pelvic floor PT, what kinds of exercises would you recommend to improve general motor control? Do you have a post that addresses this? Or resources that speak to this question specifically? Would you recommend continuing to practice kegels (with an intentional, mindful release of the muscles after the contraction) to a general population of pregnant women?

    Thanks so much for all that you do, Stephanie!

    1. Author Stephanie Prendergast says:

      Thank-you for your kind email. You ask great questions! Britt Van Hees post titled Kegel What? helps to address motor control exercises, however, we should write one that is focused specifically on motor control. It is tough to direct people to improve their motor control without some sort of confirmation that they are doing the exercise properly. In the clinic we use a finger to monitor how a person is performing the exercises, other people can use biofeedback. As far as kegel exercises, we rarely recommend that women do them for multiple reasons. In no particular order, many women under the age of 30 who have not given birth do not need to do them. The pelvic floor muscles never rest and therefore are rarely weak without a cause. A cause of weakness can be vaginal deliveries or menopause/aging. Another reason we do not recommend them without evaluating someone is because their muscles may be tight instead of weak, in which case kegels are contraindicated. Research shows most women perform a kegel incorrectly with verbal instruction alone, which is another issue. And finally, pelvic floor strength in isolation is not functionally useful like motor control and pelvic floor/core coordination. I hope this helps!

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