By Katie Hunter, DPT
Drop, push, bulge, squeeze. These words are used regularly when talking about pelvic floor function but what do they actually mean?
We often talk about how the pelvic floor muscles become dysfunctional and can cause daily symptoms of pelvic pain, bladder and bowel urgency and frequency, incontinence, prolapse, and sexual dysfunction. Today, I would like to lay out how the pelvic floor muscles normally function and clear up some of the confusing terminology practitioners use. I encourage those that are new to the pelvic floor muscles anatomy to first read Shannon’s blog, Your pelvic floor: what is it good for?
The main functions of the pelvic floor muscles are sphincteric, supportive, and sexual. These muscles close the bottom of the pelvis to support all of our organs and keep the openings closed to prevent leaking, they contract when we achieve climax or orgasm, and they have the ability to relax in order to empty our bladders and bowels. Therefore, these muscles are necessary for our most essential functions.
In order to provide enough support for our pelvic organs, the pelvic floor muscles need to effectively counteract intra-abdominal pressures. When we exert ourselves, such as during coughing, sneezing, laughing, and lifting, a large amount of force is placed on the body and abdomen. If our pelvic floor muscles do not function appropriately, we may leak or feel pressure in the pelvis when participating in these activities.
Two things that most influence how well our pelvic floor muscles function are breathing and posture. Our trunks are supported by our “core” muscles which include the diaphragm (the “roof”), the abdominal muscles, the pelvic floor muscles (the “floor”), and the spinal column and back muscles. The core muscles work in synergy throughout the day to support our trunk, spine, and pelvis; preventing injury and pain.
There should be a natural ebb-and-flow that occurs between all of these muscles and our breath. When we take an inhale, the dome-shaped diaphragm muscle flattens moving our organs down in the abdominal cavity. In order to avoid squashing our organs, our pelvic floor and abdominal muscles lengthen and expand to allow the organs to move down. As we exhale, the diaphragm lifts and the pelvic floor and abdominal muscles return to their resting position.
A common error we see with our patients is the habit of holding one’s breath. People often hold their breath during strenuous activity, in times of stress, or during bowel movements which can lead to a wide variety of pelvic floor dysfunctions. This is why pelvic floor physical therapists focus so much on coordinating the breath with muscle control.
How we sit, stand, walk, and move will affect our pelvic floor muscles. Posture and the pelvic floor muscles have a direct affect on each other, described as an interdependence.6 For ideal standing posture, physical therapists use a plumbline through the body to assess a person’s posture.
Carriere and Feldt describe the plumbline of ideal standing posture as follows:6
- Slightly anterior to the lateral malleolus
- Slightly anterior to the axis of the knee joint
- Slightly anterior to the axis of the hip joint
- Through the bodies of the lumbar vertebrae
- Through the shoulder joint
- Through the bodies of the cervical vertebrae
- Through the external auditory meatus
- Slightly posterior to the apex of the coronal suture
Many factors can affect our posture. Lifestyle and habits, pain, tight muscles, weak muscles, weight, and mood. If your hamstring muscles are tight, they can cause your pelvis to tilt backwards so that you are in a slouched position when you sit which can lead to tight pelvic floor muscles and pelvic floor dysfunction. If your abdominal muscles are weak, they cannot support your abdomen and you may stand with a sway back which can lead to lower back pain and pelvic pain. Becoming aware of healthy, symmetrical posture will help in optimizing the function of the pelvic floor.
Along with our voluntary functions of the pelvic floor muscles throughout the day, these muscles also have a large reflexive role. The urethral and anal sphincters are activated by reflexes to maintain bladder and bowel control. These reflexes are elicited by stimuli to the skin, pelvic organ distension, pain, and intra-abdominal pressure changes. Notably, pelvic floor muscle tone automatically increases with a sudden increase in intra-abdominal pressure (i.e. coughing, sneezing) and with pain to the pelvic organs and pelvic region.5 Neuromuscular re-education can help to strengthen and improve these reflexes to improve bowel and bladder control.
Physical therapists who specialize in the treatment of pelvic floor muscles aim to normalize muscle tone and length, motor control, coordination, strength and endurance. This is done by a combination of posture training, breathwork, exercises, lifestyle changes, and manual therapy to balance the core muscles and improve their function. The following are common terms we as physical therapists use for pelvic floor muscle training:
- Isolated pelvic floor (PF) muscle contractions (aka Kegels): isolated activation of the pelvic floor muscles. There are two types of isolated PF muscle exercises.
- Quick flicks: focusing on recruitment of the urogenital triangle to close the urethra, these exercises help to gain strength in the “fast twitch” muscle fibers of the pelvic floor to improve control of the bladder and reduce leakage with coughing, sneezing, and laughing.
- Quick kegels: this is an isolated contraction of the pelvic floor muscles throughout the entire range of motion including recruitment of the levator ani muscles. We focus on full tissue excursion including complete relaxation between contractions. They can be coordinated with our breath on the exhale to train the synergy of the diaphragm and pelvic floor.
- Slow (endurance) kegels: similar to the quick kegels, but this exercise aims to train our slow-twitch muscle fibers. This is where you hold the pelvic floor contraction to build endurance in the muscle for activities such as prolonged standing, carrying items, and walking. Slow kegels can be coordinated with or without our breath.
- Abdominal brace: isolated activation of the transverse abdominis muscle which works to stabilize the spine and pelvis during activity. On the exhale, this is a drawing of your belly button back towards your spine and “hip” bones towards each other. Research shows that people are less likely to suffer from lower back pain when this muscle is actively working throughout the day.1-3
- Pelvic brace: co-activation of the transverse abdominis and pelvic floor muscles for lower back and pelvic stability. The pelvic brace helps to support our joints and organs to minimize injury/leaking/prolapse. Performed on the exhale, activating the two muscle groups together can reduce pain and improve bladder/bowel control; focus on performing a pelvic brace with exertion (i.e. getting in and out of bed, standing from a chair, pushing/pulling, lifting, etc.) can also help reduce stress incontinence.
- Diaphragmatic breathing: Because of the way the pelvic floor muscles and diaphragm are shaped and work together, when we practice diaphragmatic breathing, this encourages the pelvic floor muscles to relax. Diaphragmatic breathing is deep belly breathing that focuses on activation of the diaphragm for the greatest lung ventilation and muscle relaxation. As we inhale, the diaphragm flattens and the pelvic floor muscles lengthen.
- Pelvic floor muscle bulge: described by Rhonda Kotarinos as reciprocal inhibition which is defined as “relaxation of an agonist muscle during contraction of the antagonist muscle.”4 I teach activation of the abdominal muscles while facilitating relaxation of the pelvic floor muscles with the cues, “belly big, belly hard while blooming a flower with the pelvic floor muscles” during an exhalation. A PFM bulge can help to initiate a bowel movement followed by PF drops and relaxation.
- Pelvic floor muscle relaxation: also called a pelvic floor “drop,” this is a voluntary relaxation of the pelvic floor muscles where the muscles lengthen down towards the feet. Imagery assists in achieving pelvic floor relaxation by imagining blooming a flower or spreading the sit bones. This is also termed as the ante-Kegel or reverse Kegel.
A pelvic floor muscle training program is not one-size fits all. We recommend being evaluated by a pelvic floor specialist who can prescribe a combination of these exercises in order to improve your daily function that is specific to your individual needs.
- Kang, J. Jeong D. Choi, H. (2016). Effect of exhalation exercise on trunk muscle activity and oswestry disability index of patients with chronic low back pain. J Phys Ther Sci. 28(6). 1738-42.
- N. Hooper, T. Dedrick, G. Brismee, J. Sizer, P. (2017). The effect of current low back pain on volitional preemptive abdominal activation during a loaded forward reach activity. Physical Medicine and Rehab Journal. 9(2). 127-135.
- Watson, T. McPherson, S. Fleeman, S. (2011). Ultrasound measurement of transverse abdominis during loaded, functional tasks in asymptomatic individuals: rater reliability. Physical Medicine and Rehab Journal. 3. 697-705.
- FitzGerald, M. Kotarinos, R. (2003). Rehabilitation of the short pelvic floor. II: treatment of the patient with the short pelvic floor. Int Urogynecol J. 14. 269-275.
- K. Bo, B. Berghmans, S. Morkved, M. Van Kampen. (2007). Evidence-based physical therapy for the pelvic floor. 19-20.
- B. Carriere, C.M. Feldt. (2006). The pelvic floor. 68-81.