Having arrived back to New Zealand in 2020 after 11 years abroad, I was surprised to discover that there was still a lack of awareness for pelvic health (or women’s health) Physiotherapy. It is a unique form of Physiotherapy requiring postgraduate study, and on-going professional development. It encompasses many aspects of urogynaecology and obstetrics, as well as musculoskeletal concerns, return to function and rehabilitation. Urinary incontinence and bladder dysfunction is a common experience that many women will face at some point in their lifetime – after having children, with age, or certain types of exercise. A sneeze, giggle, squat or cough could all be triggers. Unfortunately, many women find that their bladder and pelvic floor issues too embarrassing to discuss openly.
At 'Haven Wellness', my primary goal is to ensure women feel fully supported, educated, and empowered on their treatment journey, with a holistic and multidisciplinary approach. As a part of improving awareness here in New Zealand, I am proud to be associated with the BONDS ‘Damn Strong Mamas’ campaign. As a brand, BONDS is there to make the uncomfortable, comfortable for everyone. They have released Damn Dry® Undies. They are normal looking undies for a normal part of motherhood – because Damn Strong Mamas deserve Damn Dry® Undies.
The Damn Strong Mama campaign heroes a powerful line up of mums to help them feel confident and comfortable to take on the day. BONDS are breaking down long-established stigma associated with bladder leakage. They are empowering mums to embrace this as a part of motherhood, and to encourage them that help is out there.
So, what is this pelvic floor?
Your pelvic floor is a hammock or bowl of muscles that covers the bottom of your pelvis, extending from your tailbone to pubic bone and both sit bones.They support your pelvic organs (bladder, bowel and uterus), help with continence control of the bladder and bowel, and support many joints of the pelvis, hips and spine. They also help support the baby in the womb during pregnancy and help aid
delivery of your baby during labour. Your pelvic floor muscles are just like any other muscle – if you don’t use them and strengthen them, they will weaken. They are sometimes compared
to a trampoline, as it can stretch in response to weight, and bounce up again, however if it bears weight for a long period of time, for example in pregnancy, loading, lifting, increased weight gain, certain structures can become overstretched, and strength may alter. If you couple this with bowel dysfunction like constipation it can increase the strain on the pelvic floor, ligaments, fascia and organs. There is a substantiated link now between weak or hypertonic pelvic floor, bladder and bowel dysfunction, incontinence, pelvic organ prolapse, and back and pelvic pain.
How common are these problems?
It is estimated that 1 in 3 women will experience incontinence at some point in their lifetime [1]. Approximately 50% of women who are pregnant can experience varying types of urinary incontinence [2]. However, in a 2017 Cochrane review [3], the research illustrated that helping continent women early in pregnancy and offering a structured pelvic floor training programme, may prevent the onset of urinary incontinence in late pregnancy and postpartum.
So where do you start?
If all this sounds alarming, the good news is that you can do something about it! Extensive research on this topic has shown that strengthening your pelvic floor muscles and improving their function as a whole with specific exercises can frequently resolve these problems. The UK’s National Institute for Health Care Excellence (NICE) guidelines [4] advise that women with stress or mixed urinary incontinence, (also during pregnancy), should trial a supervised pelvic floor muscle training of at least a 3 month duration as a first line treatment.
First things first – breathe and find your muscles!
Let’s begin with understanding the basics of the anatomy in this extraordinary system. We have a deep connection of connective tissue (fascia) and muscle called the ‘deep front line’, that spreads from the top to the bottom of your body. Relaxing your neck and shoulders, and learning to breathe into the diaphragm properly is integral for a balanced pelvic floor function.
Lying on your back with your knees bent, or in sitting, place one hand on your chest and one around your stomach/ribs. Focus the breath coming down to the stomach, the outer lower ribs and even the ribs in the lower back. Now feel the breath drop down into the pelvic floor muscles to relax them.
The relaxation of the pelvic floor is just as important as the ‘squeeze and lift’. I have seen hundreds of women in my career that struggle to let go of and fully relax their pelvic floor. This connection is so important to understand no matter what age or circumstance you are in. This hypertonic state can lead to all sorts of other issues including sexual pain, emptying issues, and even contributes to incontinence. I encourage self-exploration, but you can also use a mirror to see if your perineum is able to drop and lift with the relaxation and contraction of your pelvic floor muscles, or better yet, ask for assistance from a women’s health physiotherapist,
How do you perform a pelvic floor contraction?
Lie on your side or your back back with your knees bent (if early in pregnancy), or with the head and upper body elevated with knees bent (in the second and third trimester). If you are not pregnant, simply lie on your back with your knees bent. Start with some breath awareness as above first.
On the breath out, gently tighten, squeeze and lift the pelvic floor muscles by visualising stopping passing wind and then urination (a back to front direction).
a) Slow and longer holds for 3-5 seconds and relax for one breath. This activates the slow twitch fibres of the pelvic floor, which make up approximately 70% of the complex.
Repeat 10 times.
As you get better at doing them you can try to hold them for longer, or increase the number of repetitions you do in a set. If you are progressing to a 10 seconds hold, the key is no breath holding and relax all other muscles. If you feel you need more time between holds then wait for 1-4 breaths. Remember the relaxation is just as important as the contraction.
b) The second part of pelvic floor exercises are the faster contractions. Strongly squeeze and pull up, the muscles, then let go straight away. This activates the fast twitch fibres of the pelvic floor, which make up approximately 30% of the complex. Aim for 10-20 of these finishing with some breathing and relaxation.
Aim to do Part A and B - 3-5 times per day
c) The ‘Knack’ = This is a fast strong squeeze that you can perform before you laugh, cough, sneeze or lift to help reduce and eliminate stress urinary incontinence.
Please do NOT practice pelvic floor contractions when you are urinating or emptying your bowel! After you have emptied your bowel, you may do it then.
Other positions of pelvic floor muscle training can include sitting; on your hands and knees; sitting on the corner of a chair; sitting on a large gym ball; standing; walking and lastly with functional exercises like squatting; lifting and other upper body movements. Progression into standing can really take time so don’t be too hard on yourself!
Try to spread the sets of exercises out during the day. You can do them almost anywhere. If you would like some added peace of mind, you could wear your BONDS Damn Dry® Undies when out and about and exercising!
Other visualisation cues to help with pelvic floor activation:
Imagine you are picking up a tissue out of a box by squeezing your anus. Then imagine that squeeze and lift is moving forwards towards your vagina and pubic bone.
Imagine a lift going up into the anus and then the vagina from the basement to level 4, and then going back down to the basement.
Imagine pulling up a piece of spaghetti into the anus and then vagina.
Research has shown that up to 30% of women find it difficult to activate their pelvic floor muscles correctly. If you are struggling to feel these muscles working, worried you aren’t doing the exercises correctly or if you have on-going incontinence, contact your local women’s health physiotherapist for an individual assessment and training.
Other urinary symptoms to be aware of:
If you are feeling urinary urgency symptoms are coming on, give your pelvic floor a squeeze, rise up and down on your toes for 10-15x and distract yourself. This can help defer the bladder contraction. Try not to go ‘just in case’. Avoid constipation with a balanced fibre diet and adequate water intake 1.5-2L daily. Avoid fizzy drinks where possible and fluid 1-2 hours before bedtime. Further bladder retraining may be required specific to your issues, which can be advised by a physiotherapist. On the other end of the spectrum…you may actually have hypertonic or ‘overactive pelvic floor symptoms’ or other bladder pathology. This is where a full examination is important to ascertain what is actually going on.
If you have issues with emptying your bladder, this can be due to many causes such as a hypertonic or tight pelvic floor, pelvic organ prolapse, or other pathology. This is something that again needs further assessment. Start with ensuring you are fully relaxing when you urinate. Often we are in such a busy state we forget to consciously relax and let go!
Nocturia or urinating during the night is not normal and you shouldn’t put up with it. After menopause, certain medication, some diseases, and other factors can contribute to this but otherwise, I can assist you here!
What about those annoying leaks with exercise?
Gym goers, runners, HIIT (high intensity interval training) fanatics are amongst some of the higher reporting population of pelvic floor dysfunction, poor breathing technique, pelvic pain, prolapse and incontinence. I also see many women returning to endurance workouts, impact exercise, and weight lifting too soon post natal.
The reality is, your body has just performed something so incredible – it has created a little human! It is so important to make sure that you are respecting the healing and tissue recoiling process, and doing the right exercises post natal to ensure a full recovery of your stomach, pelvic floor, and restoration of your alignment, strength and stability system. It is now generally recommended to wait for at least 4-6 months to return to any impact exercise postnatal depending on your deliver, general strength and fitness levels, and other factors such as symptoms, pain, and other co-morbidities.
Bottom line is, you don’t have to put up with leakage whilst running or exercising. It may be that you need to stop and modify in the short term while we build up your strength and improve your function for the long term!
Some 'old wives' tails…
“It’s normal to be incontinent during or after pregnancy...” It’s common but NOT normal, and can be prevented and helped with specific pelvic floor exercises, breathing retraining, and other pelvic strengthening.
“Pelvic floor muscle exercises make the vagina tighter and therefore make labour harder...” Correct pelvic floor exercises do not ‘tighten’ the vagina, in fact research has shown that doing regular pelvic floor exercises during pregnancy has no adverse effects on the baby or your birth, but can actually reduce your chance of having a prolonged second stage of labour.
“You don’t need to do pelvic floor exercises if you’re having a C-Section...” Not true! Just carrying a baby around for 9 months on your pelvic floor is enough to weaken it!
“I will wait to do my pelvic floor exercises until my 6 week check with my LMC….” After the birth of your baby, pelvic floor exercises will help get the blood flowing through bruised or damaged soft tissues and help with healing. Start squeezing your pelvic floor gently as soon as you can - NB - if you have a urinary catheter in, start the exercises when this is removed.
“Once I have done my pelvic floor training, I will be ok…” Unfortunately muscles will weaken if you don’t continue the exercises. In general these muscles can take up to 3-4 months to strengthen with daily practice. Even when they are strong, it’s vital to keep doing them to maintain your results. I would recommend at least a set a day, plus conscious contraction and breath awareness with other exercise and daily function.
What does a women’s health physiotherapy consult with Renée include?
It starts with an in depth subjective assessment, where I investigate your current and past symptoms and injury history, the musculoskeletal system, bladder and bowel behaviour, and other lifestyle factors including fluid intake, nutrition, sleep, stress, types of exercise and history, and other medical and gynaecological history in order to understand your symptoms fully.
I assess the spine, pelvis and abdomen, also doing a neurological screen to rule out cause or contribution. I also perform a strength and biomechanical screening specific to you and your functional goals. With consent, I then examine the pelvic floor externally and internally, which ensures I am able to ascertain your strength, endurance, power and ability to relax in more detail. From there, I provide relevant education, lifestyle modification, a pelvic floor exercise programme tailored to your specific type of incontinence, and also lifestyle is given to you.
Other treatment can include, manual therapy techniques, needling, further strengthening and control exercises, stretches etc. Many women’s health physiotherapists have a strong musculoskeletal background and are very passionate about helping women with pelvic health concerns and achieving functional goals.
If you are postnatal, you don’t necessarily have to wait for your six-week check up. If you have concerns feel free to contact me sooner. I am happy to give any woman with concerns about their pelvic floor and bladder/bowel control, a free short phone consultation. Please refer to my booking page to make an appointment and also book in your free phone consultation.
To wraps things up...
If at the beginning of reading this blog you thought that running to the loo, leaking when either lifting your little one or coughing/sneezing is just a part of your normal daily life, then think again. There is help out there, and it starts with making an appointment with a women’s health physiotherapist.
Remember to check out the Damn Dry® Undies for light bladder leaks from BONDS to help support you throughout your journey.
- Blog written by Renée Malyon, and sponsored by BONDS*
Reference List
1] Gomelsky, Alexa; Dmochowski, Roger R.b. Treatment of mixed urinary incontinence in women. Current Opinion in Obstetrics and Gynecology: October 2011 - Volume 23 - Issue 5 - p 371-375. doi: 10.1097/GCO.0b013e32834a9298
2] Wang, X., Jin, Y., Xu, P. et al. Urinary incontinence in pregnant women and its impact on health-related quality of life. Health Qual Life Outcomes 20, 13 (2022). https://doi.org/10.1186/s12955-022-01920-2
3] Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2017 Dec 22;12(12):CD007471. doi: 10.1002/14651858.CD007471.pub3. Update in: Cochrane Database Syst Rev. 2020 May 6;5:CD007471. PMID: 29271473; PMCID: PMC6486304.
4] https://www.nice.org.uk/guidance/ng210/chapter/Recommendations#non-surgical-management-of-pelvic-floor-dysfunction
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