What is the pelvic floor?
The pelvic floor consists of a group of musclesand ligaments that stretch from the pelvic bone, at the front of the pelvis, tothe coccyx (tail bone) and from side to side. They support the pelvic organs (bladder, uterus and bowel) and the spine. They are also responsible for helping to control the bowel and bladder.
How does the pelvic floor work?
The muscles within the pelvic floor are always kept slightly contracted (about 30% of their full contraction) to support the pelvic organs and stop any leaking of urine from the bladder, and wind or feces from the bowel. When you pass water or open your bowels these muscles relax to allow you to fully empty your bladder and bowel. Afterwards they contract again to restore control. When you perform any activity which increases the pressure on your abdominal muscles i.e. you sneeze, cough, laugh, lift or exercise, the pelvic floor muscles actively contract to ensure you remain continent.
The pelvic floor muscles also have an important role in sexual function, helping to increase sexual sensitivity and reaction for both yourself and your partner.
What happens when the pelvic floor muscles are weakened?
As the pelvic floor muscles help control and support the organs in the pelvis, when they are weakened it is very common to experience symptoms of leaking urine, wind and faeces or being unable to fully empty the bladder or bowel. As the pelvic organs are less supported many women can experience a heavy dragging feeling within their pelvis or lower back area and some woman report feeling a lump within the vagina.
What causes the pelvic floor to weaken?
The main causes for pelvic floor weakness are pregnancy, child birth, lifestyle and the menopause. Pregnancy and Childbirth During a pregnancy the pelvic floor supports the weight of the growing baby, as well as the placenta and increases in weight. (On average there is an increase of about 2 stone for a 7lb baby). This can weaken the pelvic floor significantly.
Childbirth requires the pelvic floor to be stretched greatly which can lead to weakness if the muscles are not rehabilitated after the delivery. Often women can experience tearing of the perineum which can also extend into the pelvic floor causing further damage. Due to youth, women who are of child bearing years can often find that even after all this potential damage to the pelvic floor they show no symptoms related to a weak pelvic floor. This can be explained due to the elastic properties of the tissues. However as women age and begin to lose this elastic property symptoms often manifest themselves.
Lifestyle Choices
Smoking
Smoking is known to cause blockages within the small blood vessels. This decreases the blood flow and therefore the oxygen supply to the body. The pelvic floor is a group of small muscles supplied by an extensive nerve network. Without a sufficient oxygen supply the pelvic floor cannot contract fully thus decreasing the power the muscles can provide to control the bladder and bowel. As well as a decreased oxygen supply the chemicals found in cigarettes decrease the amount of oestrogen the body has and this has a direct effect on the pelvic floor. Oestrogen is a hormone which has an important role in keeping water within the muscle tissue. As oestrogen is decreased within the body the pelvic floor muscle tissues lose some of their water making it harder for them to produce a strong tight muscle contraction. Without a strong contraction urine can leak out of the bladder.
Body Weight
An increase in body weight means the pelvic floor has more weight to support and lift in order to contract. As the muscles have to work harder, and as the pelvic floor can never relax fully, it results in weaker muscles trying to lift an increased weight. Weaker muscles mean greater risk of incontinence. Research shows just a 10% drop in body weight can improve bladder symptoms by up to 50%!
Diet
A poor diet containing little fibre and fluids can lead to constipation. Constipation leads to increased pressure put on to the pelvic floor due to straining. Eating a healthy diet with plenty of fibre and fluids can decrease constipation and therefore minimise the work load of the pelvic floor preventing further damage to the muscles. Sources of fibre are fruits and vegetables and whole grains.
Menopause
The menopause is the time that marks the end of a women’s reproductive life. There are numerous changes within a woman’s body at this time due mainly to the drop in oestrogen levels. Oestrogen is one of the dominate hormones which drives the female reproductive cycle. As discussed in the section on smoking these changes affect the pelvic floor.
How can I strengthen my pelvic floor?
Exercising the pelvic floor muscles can strengthen them so they give the correct support the pelvic organs need. This can improve bladder control and decrease or stop the leaking of urine. Like any other muscles the more the pelvic floor muscles are exercised the stronger they will be. However unlike other muscles the pelvic floor can’t fully relax even at night, else you would be incontinent.
This means when we exercise the pelvic floor muscles we follow a controlled programme so they don’t become fatigued, which could worsen your symptoms of leakage for a while.
How do I exercise my pelvic floor muscles?
1. Sit comfortably on supportive chair with your knees slightly apart and your feet flat on the floor.
2. Now try to imagine that you are trying to stop yourself passing wind. You do this by drawing together the muscles around the back passage. As you do this you will feel the muscles squeezing together and gently lifting away from the chair.
3. Try to hold this ‘squeeze and lift’ (contraction) for a few seconds.
4. You may feel your lower tummy muscles gently working but the muscles in your buttocks and thighs should stay relaxed. You should also continue breathing normally.
5. Now do this again but also try and tighten the muscles around your vagina and urethra too.
6. After each ‘squeeze and lift’ ensure that you fully relax your muscles. Once you feel confident in completing the pelvic floor exercise we need to practise regularly. We exercise these muscles in two ways. Doing this allows your pelvic floor to be both supportive and quick and reactive.
1. Your pelvic floor muscles need stamina and strength. Gently squeeze the pelvic floor muscles and count for 5 seconds then relax. Try to repeat this five times. If this is too hard reduce the numbers to 4 seconds and 4 repetitions. If this is easy for you then increase the numbers by 1 until you reach 10 contractions for 10 seconds. Between each contraction rest for about 4 seconds.
2. To help your pelvic floor to react quickly to sudden stresses, for example, coughing, sneezing, lifting and exercise; ‘squeeze and lift’ the pelvic floor as quickly as you can, hold for just 1 second and then relax. Again have about a 4 second rest before repeating as many times as you can aim to complete 10 contractions. To strengthen the pelvic floor try to complete both exercises about 3 times a day.
You need to complete this exercise programme daily for at least 3 months before the muscles regain their full strength. There is a great app, available for £2.99, on iOS and android called NHS SQUEEZY which can assist in reminding you. Please ensure you download the female version.
What treatments are available?
It may be necessary to include some, or all, of the treatments listed below:
1. Pelvic floor exercise regime –all patients who attend physiotherapy will be given pelvic floor exercises. These can be very effective but need to be done regularly over a period of months. Therefore they require persistence and commitment.
2. Lifestyle changes - As discussed earlier in this leaflet many pelvic floor problems occur due to lifestyle. Therefore without changing your lifestyle, even with treatment these problems may reoccur. It is important then to make these changes and keep to them to limit those risks.
3. Electrical Stimulation – when pelvic floor muscles are very weak, there has been some nerve damage or your awareness of the muscles is poor, it may be necessary to consider this to help you identify the muscles correctly.
4. Biofeedback – this is a way of increasing your awareness of the pelvic floor muscles, with feedback whilst you are examined and exercise. This allows you to know you are correctly contracting or relaxing your pelvic floor.
5. Vaginal cones (weights) – these are similar to a tampon in shape but are weighted. They provide a means of ‘weight-training’ for the pelvic floor. You have the right to refuse any aspect of your treatment at any time.
Thoughout your treatment you will be re-assessed to make sure everything is going to plan. Repeat vaginal examinations are only performed when needed and with your consent.
Tips to help you
Once you have mastered performing a pelvic floor exercise the hardest part of the treatment is remembering to complete the exercises as prescribed. Below are a few tricks to assist you in sticking to the programme of exercises you have been given.
1. Download the NHS squeezy app on an iphone or android phone. It costs 2.99 but once set up it will discreetly alert you when it is time to complete your exercises and will help you follow the correct program. It also allows the physiotherapist to change your program at appointments without you having to remember those changes.
2. If you don't have a smart phone, get small colourful stickers and place them in locations that you see regularly (i. e. By your house phone, by your tooth brush, on the kettle switch.) Then when you see the sticker it will prompt you to complete your exercises.
3. Equally setting an alarm will help prompt you to complete your exercises.
After care for your pelvic floor
When you have finished your course of physiotherapy it is vital you continue to do pelvic floor exercises daily. The natural strains and workload put on the pelvic floor means that the muscles will weaken again if they aren't exercised regularly.
You are encouraged to complete 10 contractions, held for 10 seconds and 10 quick contractions once a day to maintain the strength, endurance and speed of the pelvic floor contractions.
Also re-read this leaflet regularly and the lifestyle factors that affect your pelvic floor to help you remember how to stay health and limit any damage to the pelvic floor.
We're here to help
As you can see, there is a lot physiotherapy can do to help. Please don't suffer in silence.
The Northampton General Hospital urogynaecology department is open from 8am until 5pm Monday to Friday. We are not always available to take your call, however you can leave a message and we will get back to you as soon as possible on 01604 545267 or 545781.
Other information
Northampton General Hospital operates a smoke-free policy. This means that smoking is not allowed anywhere on the Trust site, this includes all buildings, grounds and car parks.
Leaflets, information, advice and support on giving up smoking and on nicotine replacement therapy are available from the Stop Smoking helpline on 0845 6013116, the free national helpline on 0300 123 1044, e-mail: smokefree@nhft.nhs.uk and pharmacies.
Car parking at Northampton General Hospital is extremely limited and it is essential to arrive early, allowing ample time for parking. Alternatively, you may find it more convenient to be dropped off and collected.
This information can be provided in other languages and formats upon request including Braille, audio cassette and CD. Please contact (01604) 523442 or the Patient Advice & Liaison Service (PALS) on (01604) 545784, email: ngh-tr.pals@nhs.net.
Last update: July 2018
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