Should everyone do pelvic floor exercises?
Updated: Jul 8, 2019
Actually I think not!
Pelvic floor exercises are seen as the gold standard first line treatment for symptoms of urinary incontinence and pelvic organ prolapse (NICE Guidelines 2006, 2019). The knack which is a quick squeeze of your pelvic floor muscles before you cough, sneeze or lift has also been shown to be effective (Miller et al 2008).
If the muscles are found to be weak on internal pelvic floor assessment then this is definitely the place to start. But, what if the pelvic floor muscle is already too tight or constantly switched on and further strengthening is not needed nor required as it may aggravate rather than improve symptoms.
‘Normal muscle function is when the muscle contracts under load and then releases fully when not in use’
Sometimes pelvic floor muscles are never fully released, therefore they do not go through their full excursion. If you apply this to the biceps muscle, it would mean that if the elbow is bent and the muscle is switched on and never stretched out or released, how will it respond to a load when it needs to contract further?
We have discussed previously that the core system is made up of the diaphragm above, the pelvic floor below, the abdominal muscles infront and spinal muscles behind.
We've also seen that on an inhale the diaphragm descends, this will increase the pressure in the middle ‘core’ and the tummy and pelvic floor should relax and slightly let go/widen/drop/open. This is like a co-ordinated dance of breathing, all four parts must do their share, to ensure the other three are not having to do more than they should be. The converse happens on the exhale.
So what can go wrong?
If the spinal or rib cage posture is altered, or there is breath holding and bracing this may mean the diaphragm is unable to descend effectively. This will inhibit appropriate descent and release of the pelvic floor and abdominal muscles.
Conversely, if the pelvic floor is always ‘switched on’ it may not allow the diaphragm to descend efficiently and therefore inhibit the normal relaxation of the abdominals.
How can this present clinically?
I recently saw a fit and active lady that had recently increased her exercise activities and was noticing leaks on running and doing jumping activities such as bounce. On examination, her posture was upright but maybe the rib cage was not directly over the pelvis. She was unable to take an effective diaphragmatic breath. The tummy muscles were unable to release fully. The pelvic floor was not weak, but it was unable to release fully, it had reduced excursion. She was running and jumping in this posture, probably breath holding, or breathing inefficiently with reduced abdominal and pelvic floor muscle descent and lift.
Treatment was based on recent learning with Antony Lo and Julie Wiebe, aimed at "doing something different" (Antony Lo), changing the rib posture, the spinal posture, learning to breathe differently, learning to let the abdominal and pelvic floor muscles go, so that they can recoil and do what they are intended to do under load and exercise (Julie Wiebe). Further pelvic floor muscle strengthening was not indicated and may have made the symptoms worse.
Pelvic floor exercises are an excellent way to strengthen the muscles and reduce symptoms of leakage and pelvic organ descent if they are weak.
If not weak, then further strengthening will not help. Your pelvic health physiotherapist can assess and advice on the best and most appropriate treatment options for you.
Please get in touch if you have any questions or would like to have a chat.
NICE Guidelines, https://www.nice.org.uk/guidance/ph44/chapter/1-recommendations
Miller et al (2008) Clarification and confirmation of the Knack manoeuvre: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence, International Urogynecology Journal 19:773-782
Antony Lo The Physio Detective, http://physiodetective.com
Julie Wiebe, https://www.juliewiebept.com