The Practical Pelvic Floor: what is it, where is it, how does it work and making it work better

Deborah J Bowes DPT, GCFT

The pelvic floor describes muscles that are located in the lower part of the pelvis, and are shaped like a sling suspended from bones of the pelvis. The pelvic bones are important for the support and strength of the whole body. The bones, include the sides of the pelvis (ilium), the bottom sitting bones (ischium) and the back of the pelvis (sacrum and tailbone). The ilium and ischium fuse together in childhood, and the sacum is firmly connected by strong ligaments. So when I speak of the pelvis, I’m referring to the bones.

When I speak of the pelvic floor, I’m referring to the muscles that are attached to the bones of the pelvis. The pelvic floor muscles help support the bones and have many other important functions. The pelvic floor muscles keep the the bladder, rectum and the uterus in place. These muscles are also involved with sexuality, digestion, elimination, and giving birth.

These muscles are one part of the pelvic floor system which includes the pelvic floor muscles, the abdominals, the deep muscles of the back, the diaphragm and some of the hip muscles. They all work together in a coordinated and synergistic manner. Any imbalance in the coordination of the system will have an effect on your bladder control, back pain, balance, sexual function, organ position, digestion, elimination and more.

I have designed exercises using the Feldenkrais Method of Awareness Through Movement to improve the coordination and use of the entire pelvic floor system, and to help men and women improve their ability to feel or sense the pelvic floor muscles. Often the the pelvic floor muscles are called the Kegel muscles. My approach does not isolate the exercises to the ‘Kegel’ muscles.

In functional movements, like walking, or using your arms and legs, the pelvic floor muscles are coordinated with the rest of the body. The pelvic floor responds to your breathing and changes in the abdominal pressure, for example in laughing or coughing. These muscles of the pelvis have a special working relationship with those of the inner thigh, the buttocks, the lower abdominals and the external rotators of the hips. These auxiliary muscles assist and facilitate the full use of the pelvic floor.

We all have muscular habits and use our right and left sides in different ways. For instance, you know that one hand is more dominant or one eye. There are habits that you might not be as aware of, such as which foot you use to step off a curb. The uneven wear in the heels of your shoes shows how you walk asymmetrically. Each shoe wears down differently because of your movement habits; that put more weight on one leg. And this uneveness is everywhere in the body.

You have habits in how you use the muscles of the pelvic floor. Your pelvic floor muscles could be stronger on the right, or weaker in the front. Why? Asymmetries occur from the effects of having a baby, getting older, menopause, emotional or physical trauma or stress, breathing difficulties, surgeries or pain. The pelvic floor reflects your life’s experience.

Everyone can improve the use of the pelvic floor. However, in order to improve, you have to be able to sense and feel what you are doing. The sense of movement of the pelvic floor is subtle. If you can’t feel it, you can’t do it. If you can’t do it, you can’t feel it. It can be a self-perpetuating cycle.

For women, it can be difficult to sense anything happening down there because the movements take place inside the pelvis. For men, it may be a little easier because one can see the movement of the pelvic floor in the genitals. Yet, for both men and women, being able to sense where the action happens, makes it possible to improve the way you contract and relax these muscles. Improved awareness of the pelvic floor leads to better control and more functional strength. Functional muscle strength requires both the ability to relax and contract. There’s a unique combination of flexibility, timing, breathing and appropriate use of the whole body.

The Pelvic Health and Awareness program is designed to improve your awareness of what it feels like to contract and relax the pelvic floor muscles. The Awareness Through Movement lessons use gentle full body movements to facilitate the full function of the pelvic floor system. By using novel easy to do movements, with variations, in breathing, in the abdomen, and including movements of the legs and spine, each person explores their own movement and learns how to coordinate the pelvic floor system.

This approach is different from traditional Kegel exercises that require you to isolate the pelvic floor muscles. The isolation approach is often ineffective.

Kegel exercises

Dr. Arnold Kegel taught that women would benefit from strengthening the pelvic floor muscles. He thought women were given a disservice by their health care providers and did not need to suffer from organ prolapse and incontinence. He stressed the need to exercise the pelvic floor, but he never said how to do the exercises.

It’s not just for women. There are importance benefits for men from doing pelvic floor exercise. There was an interesting study of 55 men in Australia, with an average age of 59, who had erectile dysfunction for six months or more. The improvement in erectile function was the same as that from Viagra! That is, 40% regained normal function, 35.5% improved and 25.5% showed no difference. Men who have had a prostatectomy, or abdominal surgery, a hip replacement, or digestive issuses can be helped with this approach.

Some doctors and books will tell you to do Kegel exercises for the pelvic floor by stopping the urine stream. This is not a good idea for training the coordination of the pelvic floor system. You can stopping the stream occasionally to give you an idea of where these muscles are, how to contract them, or how strong they are. However, doing this, as a regular practice is not a good exercise. It will interfere with the healthy relationship between the bladder and the muscles of the pelvic floor.

You need to improve your ability to sense what you are doing. If you can sense it, you can start to do something about it. The Awareness through Movement exercises are designed to develop greater awareness of how the pelvic floor works with full body movements. You also learn to use the pelvic floor from four directions, right, left, front and back. This image may give you an idea of where these muscles are in your body. There are four ‘bony landmarks’. The pubic bone is in the front of the pelvic floor; the tailbone is at the back, the sitting bones, are on the right and left sides ( you actually sit on these). Drawing a line to connect these four bony points makes a diamond shape. Divide the diamond into front and back triangles by drawing a line from right to left, one sit bone to the other. The front diamond will have an opening for the urethra and a second one for women, the vagina. The back diamond has one opening for men and women, the anus.

Voiding habits and the pelvic floor

You may have developed habits of using the toilet that weaken the pelvic floor daily. Sometimes these habits started long ago when you were a child or teenager. In childhood, you probably were given instruction in where and when to urinate, but not how to urinate.

For example, voiding, or urination occurs through the work of the bladder. The bladder is an organ whose job is to store urine. You can think of the bladder as a strong muscular balloon. It fills with urine and when there is enough urine, the bladder sends a message to the brain that you sense as the urge to urinate. If you don’t go to the toilet, the urge passes and will return later.

If you do respond to the urge, and go the toilet, the brain sends a message to the bladder and the pelvic floor. This message ‘tells’ the pelvic floor to relax and the bladder to contract. The relaxation is important to allow the bladder to do its job. You don’t have to push down to start the flow of urine. You only have to relax the pelvic floor and the bladder will contract to empty itself.

This is a reflex between the bladder and the pelvic floor. You don’t have to think about it, and it works in the other direction, too. The bladder will relax when you contract the pelvic floor. Understanding this relationship is essential for improving your pelvic floor. One contracts and the other relaxes.

This is why it is important for women to relax and sit on the toilet to urinate. The relaxation spreads to the muscles of the pelvic floor. This allows the bladder to contract normally. The urine only travels 3-4 cm through a women’s urethra, so there is no need to push, not even at the end of the stream. You can learn to let the contraction happen and sense the feeling of it. You can think of pee pee, as private pleasure! Take your time. No power peeing.

Many women have been taught to basically stand over the toilet in public rest rooms. In standing, with the knees slightly bent, holding yourself up, it’s hard to relax the pelvic floor so that the bladder gets the message to contract. Your pelvic floor is working in this position to give support to your hips and legs. To start the stream of urine requires some bearing down. The habit of pushing the urine out through a contracted pelvic floor will weaken it. If you sit on the toilet, the legs, hips and pelvic floor relax, and the bladder can do its job. You won’t have to push the urine out. This one change of NOT PUSHING will make a big difference in the pelvic floor.

Squatting to urinate, like you do when camping, easily relaxes the pelvic floor. The more ‘primitive’ squatting toilets like you may have used in other countries are better for your muscles. For most people, squatting just doesn’t work at home; yet some do find a way and use a frame around the toilet in order to safely put their feet on the toilet seat and squat.

You can also have the benefits of the squat by having your knees higher than your hips, and your feet firmly supported when you are sitting on the toilet. If your toilet is too high there are simple foot supports you can make or buy.

All of this is true for a man. The difference is that a man’s urethra is longer, about 7-9 centimeters. Standing to pee makes it hard for some men to relax the bladder. Or if the prostate is enlarged there may be too much tension in the pelvic floor to relax it enough so that the bladder works. In this situation, a man may find it more comfortable to sit when urinating. Men sometimes urinate in public situations within view of other men. This can be stressful and lead to an inability to urinate, as they are unable to relax the pelvic floor. Some men have called this being ‘pee shy’. Because the pelvic floor is more active in standing, a man may find it helpful to place a hand on the wall and lean on it a little to be able to relax the pelvic floor; or he may prefer to sit down in private and allow the relaxation to occur. This may be especially important for a man with a high stress life.

This idea of letting the organ do the work and not bearing down relates also to moving the bowels. The intestines can contract to move the stool along to the rectum for elimination. This movement is called peristalsis. When the rectum gets stretched, it signals that it’s time to empty. A neurological message gets sent to the brain and you feel the urge to go. You can respond to it or override the urge if the time is not right. If you use the toilet when you have the urge, the contractions of the intestines and rectum can do the work of elimination. You won’t have to push and strain. If you consistently override the urge to have a bowel movement, you may develop constipation.

If you have a long history of constipation, this will take some time for you to begin to be sensitive to the urge. You may need to add more fluid, fruits, vegetable, grains and fiber to your diet. Some medications can also slow down the peristalsis. Try to find a schedule where you can respond to this sensation and seize the moment for this elimination.

For women, if you have a prolapse (rectocoele or cystocele), or difficulty emptying the rectum, you can support the perineum by pressing on the perineal body (the area between the vagina or scrotum and rectum) with some paper and your hand.

Learning to let the organs of elimination do their job instead of bearing down or straining is another great change you can make to improve the health of the pelvic floor system.

What is incontinence?

Incontinence is any involuntary loss of urine. If you leak when you don’t want to, you have urinary incontinence. One out of five postmenopausal women are incontinent. However it is not only an older woman’s problem. Men and younger women, even those who are very athletic can have accidental leakage of urine. Incontinence is categorized in three ways.

The first type is called stress incontinence. Stress on the pelvic floor causes the leaking of small or large amounts of urine. Activities or movements that stress the pelvic floor also increase the pressure inside the abdomen. These include coughing, sneezing, laughing, jumping, bending over, lifting a heavy item, or running. The increase in intra-abdominal pressure from those types of activiities requires a stronger contraction of the pelvic floor to keep the sphincters closed

The second kind of incontinence is called urge incontinence. This is not only a physical problem; it becomes a thinking problem, too. It is the powerful urge to urinate when you are on the way to the toilet. Often it is difficult to hold the urine and the whole bladder empties before reaching the toilet. This is also called ‘key in the door incontinence’. Your urge increases as you get your keys out to open the door to you house. You have to go or else.

If you have some symptoms of each, it’s called mixed incontinence. This is stress and urge incontinence combined and is very common.

Some standard medical treatments for incontinence include exercise, surgery and medication. Pelvic floor exercise is successful, has no side effects and is the safest approach. There is a lot of research to support this statement. One study showed that women improved their continence by 89% with pelvic floor exercise. Exercise can also help with a prolapse, for example, when the uterus or bladder or rectum is coming down or pressing into the vagina. Surgery for incontinence, on the other hand, is often ineffective and in some cases causes a worse problem. If surgery is absolutely necessary, you will need to exercise after surgery to improve the awareness and control of the muscles. Some studies report a failure rate of 50%, five years after surgery.

Training yourself, using the reflex between the bladder and the pelvic floor can improve incontinence. If you have ‘key in the door’ incontinence, use this reflex to retrain your bladder. Make the bladder relax until you are in the right place to go. Each time you get the urge, stop where you are, breathe and contract the pelvic floor several times to relax the bladder. You may have to stand or sit still to do this.

You can also use this technique to retrain your bladder so that you don’t get up so often in the night or go too frequently during the day. Of course, if you urinate and there is a big volume, then you had to go, but if there is only a small amount of urine, you can try to decrease the sensitivity of your bladder and the frequency of voiding. (I would caution against using this technique of bladder retraining if you have interstitial cystitis.) Begin by listening to the sound of the stream and count the seconds. If you pee only 2-5 seconds, you could have waited longer. Average is 8-15 seconds. The length of time depends on how fast or slow the stream is going, and how much fluid you’ve had. Notice your rhythms, when your bladder is up and running and other times when it seems a little slow and sleepy.

With incontinence, don’t urinate ‘just in case’ or hourly. This can make your bladder too sensitive to small amounts of urine. If you drink 6-8 glasses of water per day, you’ll probably urinate every 2-5 hours. Most people will not go more than 9 times per day. Count the seconds that you pee. If you hear noise only for only a few seconds, you probably didn’t need to go, so hold it by using your pelvic floor muscles to relax the bladder. As you become more aware of your habits, you have the possibility to change.

During the night urinating, 0-2 times is considered ‘normal’. If you go more than this, try contracting the pelvic floor several times to relax the bladder and then see if you can go back to sleep. It seems to take 3-4 nights to change those unnecessary trips to the toilet.

Improve your awareness and you’ll see improvement in the use of the pelvic floor system. Your whole self will feel better.