Archive for category: Movement & Exercise

By Sharon Brock, MS, MEd

For most women, discussions about the pelvic floor are typically tinged with embarrassment. When our pelvic floor muscles (which form a hammock-shaped barrier across the base of the pelvis) are compromised, we can experience a variety of taboo-laden symptoms such as incontinence, constipation, and painful sex. Even though pelvic floor disorders affect twenty percent of women in the U.S. (and more than half of women over 80), many suffer in silence because they are too embarrassed to speak about them, even to their healthcare providers.

“It’s time for us to normalize the discussion,” says Brooke Gurland, MD, FACS, colorectal surgeon and member of the Stanford Medicine Pelvic Health Center. “We don’t talk enough about what happens to women in middle age and beyond. But just like menopause, we need to have more discussions about pelvic floor health with middle-aged women so they can potentially prevent incontinence in their advanced years.”

What is the Pelvic Floor?

Pelvic floor muscles act as a sling that holds the organs within the pelvis in place so they can function correctly. A woman’s pelvis includes organs that serve urinary (the urethra and bladder), reproductive (the vagina and uterus), and digestive (the rectum and intestines) functions.

 

Pelvic floor disorders (PFDs) occur when pelvic floor muscles and connective tissue are too weak, too tight, or don’t have the coordination to facilitate proper functioning of the pelvic organs. The most common PFDs are urinary incontinence, fecal incontinence, and pelvic organ prolapse (when a pelvic organ drops from its original position).

When Pelvic Floor Muscles are Too Weak

During menopause, women’s estrogen levels begin to decline, resulting in the reduction of muscle mass and decreased capacity for muscle to adapt and recover from strenuous exercise. Also, as we age, we often experience sarcopenia, a decline in muscle mass and function. Women between the ages of 40 and 70 typically lose approximately 25 percent of their peak muscle mass. At 75, a dramatic decline often results in the loss of around 60 percent of peak muscle strength and 30 percent of physical function.

“We need to remember that we are not just losing muscle mass in our arms and legs; our pelvic floor muscles also weaken with age,” says Dr. Gurland. “Just as we need to lift weights in midlife to stay strong and mobile as we age, we also need pelvic floor strengthening activities to potentially prevent PFDs in the future.”

Dr. Gurland’s recommendations for strengthening pelvic floor muscles to reduce incontinence:

• Physical Exercise – Regularly practice Kegel exercises or other exercises that strengthen the pelvic floor, such as Pilates. To perform a Kegel exercise, contract the muscles you use to stop the flow of urine, the muscles of the perineum (located between the vulva and anus), and the muscles around the anus. “The great thing about Kegels is that you can do them while working at your desk, and no one knows you’re doing them,” says Dr. Gurland. “If you’re having trouble identifying the pelvic floor muscles, I recommend putting a rolled-up washcloth underneath the perineum while sitting in a chair and then tightening and pulling up from there.”
• Nutrition – Get enough fiber, whole grains, leafy greens and protein to support a well-balanced diet and benefit overall muscle mass.

Along with age-related strength decline of the pelvic floor muscles, childbirth can also cause weakening. Dr. Gurland shares that in France, pelvic floor physiotherapy is part of post-partum care; however, in the US, that care is not standard and pelvic floor care isn’t addressed until after the patient has a problem.

“I want to send the message that we can be proactive about our pelvic floor health and not wait until something goes wrong,” says Dr. Gurland. “PFDs are more common than you think, and you should talk to your provider about what you can do now to reduce their severity as you age and improve the quality of your life into your 80s and 90s.”

When Pelvic Floor Muscles are Too Tight

Although we don’t want our pelvic floor muscles to be weak, we can also experience PFDs when they are too tight. Symptoms of tight pelvic floor muscles include constipation or difficulty emptying the bowels, anal fissure and hemorrhoids, difficulty urinating and painful sex. Chronic stress and trauma can contribute to the pelvic floor muscles being too tight

“People tend to know about strengthening the pelvic floor, but many don’t understand that it’s equally important to relax the pelvic floor muscles to urinate and defecate properly,” says Dr. Gurland. “For example, some people can’t go to the bathroom in public. They feel too anxious, which causes the muscles to tighten up. There’s a mind-body connection. When we are too stressed in the mind, we aren’t able to relax the pelvic floor muscles in the body.”

Dr. Gurland’s recommendations for relaxing pelvic floor muscles and relieving constipation:

• Stress Reduction – Take deep breaths and visualize breathing into your pelvic floor to relax these muscles before going to the bathroom. Try a full body scan.
• Elevate Feet – When sitting on the toilet, putting the feet onto blocks or a toilet stool can relax the rectal muscles so you can defecate without straining. “You want to avoid straining to prevent hemorrhoids and prolapse,” says Dr. Gurland.
• Toileting Time – Carve out time in the morning to relax the body and defecate before starting your workday. “I recommend waking up an hour earlier, having a glass of water, and relaxing so your body can go to the bathroom. If you’re waking up last minute and running out the door, your body doesn’t always comply,” says Dr. Gurland.
• Nutrition – Drink adequate water daily and consume enough fiber in your diet.

What is Pelvic Floor Physical Therapy?

Regarding our pelvic floor, we can take a cue from Goldilocks. We don’t want them too weak or too tight, so how do we get them “just right”?

“When we talk about pelvic floor health, we consider not only the tightness and weakness but also the coordination of the pelvic floor muscles,” says Dr. Gurland. “For proper rectal functioning, the muscles must be coordinated enough to ‘hold it’ until you’re in the right place, then relax when the time is right.”

Unfortunately, many common things can lead to a loss of coordination of the pelvic floor muscles, such as nerve damage caused by chronic straining, childbirth injuries, back surgery, and radiation.

To help patients have more pliable and coordinated pelvic floor muscles, or that “just right” level of competence in their bladder, bowel, or sexual functioning, Dr. Gurland refers them to a Pelvic Floor Physical Therapist who offers exercises to strengthen, relax, and retrain their pelvic floor muscles to contract properly. This therapy is also recommended for pregnant and postpartum women.

“It is important for the provider and patient to have a good relationship because the work is very personal,” says Julia Barten, DPT, Pelvic Rehabilitation Practitioner at the Stanford Pelvic Health Center. “It may take a few sessions to fully figure out proper control or coordination for pelvic floor muscles and sometimes multiple techniques are required to find the best treatment plan. It helps when there is good communication and the patient has an open mind to treatment recommendations, however, if a patient is not comfortable with a recommendation, it is always best to speak up so that the therapist can modify the program to something that is effective for the individual.”

Pelvic Floor Exercises

1) To strengthen pelvic floor muscles (to prevent incontinence, organ prolapse):

Before starting the exercise, Barten emphasizes the importance of isolating the pelvic floor from other muscles (such as abdominal or gluteal) when building strength. She recommends practicing long holds as well as quick squeezes to address endurance, coordination, and flexibility. Even with quick squeezes, she stresses the importance of full relaxation between each squeeze.

“Pelvic floor strengthening is more than just squeezes. To strengthen the muscles effectively, they must contract and relax within a full range of motion,” says Barten.  “Complete relaxation between each contraction is necessary to effectively build strength.”

Barten recommends these videos for pelvic floor strengthening:

•  Pelvic floor isolation: https://youtu.be/LZpovAEIjBU
•  Pelvic floor endurance holds: https://youtu.be/mu57PQ5-S64
•  Pelvic floor quick squeezes: https://youtu.be/tFi_iAVknnc

2) To relax pelvic floor muscles (to relieve constipation, painful sex):

“Pelvic floor relaxation can be very difficult to sense,” says Barten. “There are ways to gently stretch your pelvic floor with breath and yoga stretches. It is also possible to gently drop the pelvic floor or bear down to actively lengthen the muscles.”

Barten recommends these videos for pelvic floor lengthening and relaxing:

•  Diaphragmatic breathing for pelvic relaxation: https://youtu.be/FrJowV5-k1I
•  Pelvic floor drop: https://youtu.be/9tA1Hak7y9M
•  Pelvic Relaxation Stretches: https://youtu.be/ULepx3e9frU

3) To increase coordination of pelvic floor muscles (to improve incontinence):

Barten says that coordination of pelvic floor muscles is best assessed with an exam and individualized recommendations, but home biofeedback devices (i.e. Kegel exercisers or trainers) can also be helpful. These devices can be purchased over the counter and inserted vaginally to improve a woman’s awareness and control over her pelvic floor muscles.

Lastly, Barten is passionate about breaking the stigma of talking about pelvic floor issues and enjoys creating musical videos to spread awareness about the pelvic floor and bring some humor to the topic. Here she sings about “The Kegel Routine” while parodying a song from the musical Hamilton.