What are the pelvic floor muscles?
The pelvic floor muscles consist of several muscles creating a bowl shape at the bottom of our pelvis. They run from our tailbone and pubic bone and between the two sitting bones. Their main function is to keep us continent, controlling both bladder and bowel movements, they support the pelvic organs and have an important role in sexual function as well.
There are many different dysfunctions that can present in the pelvic floor muscles, for example: weakness, tightness, pain or spasm. Although this muscle group is not much different from other skeletal muscles like the biceps, it requires special considerations and treatment. Due to the various causes of muscle dysfunction, there is no ‘one-size-fits-all’ approach that works.
There is no such thing as a series of exercises or Kegels that work for everyone with pelvic floor symptoms. Without prior examination and supervision pelvic floor exercises are more likely to be ineffective. They may even lead to incorrect movement patterns causing worsening of symptoms. Some women try creating movement in the area by pushing, as if trying to pass stool. This is the exact opposite of what we want to happen with correct pelvic floor exercises. It is also not uncommon for symptoms to arise due to tightness, or more precisely, from overactivity in the pelvic floor muscles. In this case, we can in fact make the situation worse, by doing even more Kegels. We must also not forget that therapy needs to be personalized based on individual circumstances and goals, taking into account the fact that genetics and anatomy can be varied.
However, after a thorough examination of the muscles, exercises online / in a group setting / or individual practice at home can be safe, if deemed appropriate by your physiotherapist.
What happens during a pelvic floor examination?
The examination will depend on the main symptoms. If the most bothersome issue is leaking when you cough, sneeze or jump/run, then a manual ( gloved finger) examination through the vagina is recommended. Intravaginal examination is also recommended if:
- you feel bulging in the vaginal area, either from the direction of the bladder or bowel or if you have the sensation of some foreign object/pressure in the area.
- if you have frequent, urgent surges to empty your bladder and your doctor diagnosed overactive bladder (OAB) or found no pathologies.
- if you are planning to expand your family, but you have not conceived yet and are interested in prevention.
- it is recommended for all mothers after 6 weeks of giving birth whether it was a cesarean or a vaginal birth.
(Examination is always preceded by an in depth explanation, it is never mandatory and your consent is always necessary. If you had a traumatic birth experience for example, we might postpone the intravaginal examination.)
If your main problem is pain, difficulty urinating, spasm or tightness, we might focus on other areas that could decrease mobility and cause issues. We are likely to check your diaphragm, breathing pattern, muscles surrounding the hip and the mobility of your spine. In these cases, there are even more factors that need to be addressed first and the assessment needs to be tailored to your needs even more.
Intravaginal examinations are uncommon on the first assessment if:
- you had a traumatic birth
- you live with a condition such as interstitial cystitis/bladder pain syndrome/ other medical diagnosis and the main complaint is pain
- we never do any assessments that you are uncomfortable with!
What kinds of treatments can be part of therapy?
The aim of therapy sessions is to provide knowledge and guidance for you, so you can learn what to do for yourself. We focus on manual or equipment based treatment when necessary. As soon as we are able, we then move on to all treatment techniques that you can use at home to manage your symptoms. The goal is for you to be confident in managing your health without relying on external assistance.
What types of treatment techniques are there?
Pelvic floor muscle training consists of supervised exercises teaching you to move your muscles around the urethra, vagina and back passage. The goals are to coordinate movement with correct breathing patterns, create movement in isolation from other muscles and making sure movement occurs in the right direction.
EMG (Electromyography) Biofeedback can be helpful, using either an electrode placed in the vagina, the back passage or on the perineal area externally to transfer signals coming from the muscles onto a screen connected to a computer and emg device. This method helps you visualize what your pelvic floor muscles are doing real time, helping you relax or contract the muscles appropriately. There are different feedback possibilities including sound, visual graphs and games.
Electrostimulation can be used with the above-mentioned electrodes for pelvic floor muscle training. Muscle contraction is achieved passively by an appropriate electric current driven into the muscles to provide sufficient stimulation to create a contraction. Use of electrostimulation is indicated when the muscles’ strength is insufficient to create a contraction forceful enough to strengthen the muscles. It is also useful when, despite practice, you are unable to identify what muscles to use or if you bear down instead of doing a proper contraction.
ETS (EMG triggered stimulation) provides a combination of active and passive muscle training with biofeedback and electrostimulation. The aim is to use the muscles voluntarily with feedback from the device, and when a certain threshold is reached the electrostimulation is switched on to create a forceful contraction surpassing what the person could elicit on their own.
We correct postures and breathing techniques that could be contributing to the pelvic floor muscle dysfunction. We may utilize Kinezio tape, a foam roller or other equipment to aid this process along with muscle stretches.
Manual techniques are often used to help with tightness, especially in the hips, lower back, abdominal muscles or thighs, as these muscles have an impact on pelvic function.
Lifestyle factors are important, we discuss bladder training methods, bladder ‘diet’ to eliminate irritants, we discuss what sports are suitable and safe and how to start/ get back to it. I provide ergonomic advice ( e.g. positions to breastfeed in, workplace setup etc.) and we learn optimal lifting techniques.
If you have tightness or discomfort we learn muscle relaxation techniques.
Scar tissue mobilization is important to prevent soft tissue layers from becoming ‘sticky’, which restricts good movement between the layers, creating rigidity and tightness in the area or in the surrounding tissues. Scar tissue mobilization techniques are always based on the stage of healing. First, light touch and stroking of the area should be introduced, and movement in the surrounding tissues, then gentle pressure along the scar can be applied with unidirectional or circular movements. When the scar has healed well, we can work on deeper layers.
A technique we might use is visceral manipulation to aid mobility of the uterus or other organs. You can learn how to do some of it for yourself at home. (Liver and uterus treatment is available, other internal organs or symptoms indicating visceral dysfunction should be assessed and treated by my physiotherapist and osteopath colleague, Benjamin Dupont.)
٭ Not recommended during pregnancy.
Women’s Health Physiotherapy assists women through different cycles of life