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.
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.”
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.
So what exactly is the pelvic floor?
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.”
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
- 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.
How can you tell if you’re clutching your pelvic floor?
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.”
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.
How does having a baby impact the pelvic floor?
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!”
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.
- If a Diastasis Recti is present, the entire musculoskeletal system is compromised: https://pelvicpainrehab.com/pelvic-floor-physical-therapy/2306/fix-diastasis-recti/
- Painful scars, myofascial trigger points, and pelvic girdle pain can be treated effectively with pelvic floor physical therapy before initiating an exercise program
- 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.
- Mu Tu: https://mutusystem.com/
- Marianne Ryan: http://www.babybodbook.com/
- 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
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.