The pelvic floor refers to the muscles, ligaments, and tissues that stretch from the pubic bone to the base of the spine. Pregnancy and childbirth can damage its muscles and connective tissue, causing various kinds of inconvenient and uncomfortable symptoms. It is not only important during pregnancy but throughout a woman’s life as well.
We asked Australian trained Physiotherapist and Founding Partner of PhysioMotion Panda Li about the importance of the pelvic floor in women. Her unique approach lies in the diagnostics and treatment of musculoskeletal issues particularly as they relate to women’s health while addressing them from a truly holistic perspective.
What is the pelvic floor and why is it so important?
It consists of three layers: muscles, fascia (which is connective tissue attached to the pelvic bones) and lastly nervous system with controls the activity of the pelvic floor muscles.
The pelvic floor function is to support the pelvic organs, assist in urinary and faecal continence, aid in sexual sensation, and stabilize the pelvic girdle / lumbar spine. If these muscles and their associated ligaments or nerves become over stretched, they are unable to create sufficient tension to provide a hammock-like support system to the pelvic organs (bladder, uterus and rectum) or ‘close off’ the urethra (outlet of the bladder); vaginal passage; and rectum. This may result in dysfunction, urinary or faecal incontinence, decreased sexual sensation during intercourse or the possibility of a pelvic organ prolapse (POP).
How does pregnancy affect my pelvic floor? What can I do to prevent damage?
During pregnancy, the growing uterus and baby place increased pressure on the bladder and the pelvic floor. The decreased bladder volume and strain on the pelvic floor muscles can cause urinary incontinence, pelvic organ prolapse (POP) and decreased sensation during sexual intercourse. During childbirth, the birth canal (vagina) with its associated nerves and pelvic floor muscles can be excessively stretched – especially if stage two of the delivery is either very fast (less than ten minutes) or prolonged (more than thirty minutes). A stage two labour that is of approximately twenty to thirty minutes duration has been statistically shown to reduce the incidence of nerve and muscle damage. Even though pregnancy and childbirth can cause urinary incontinence, it can be effectively treated with physiotherapy management or surgical intervention if required.
Pelvic floor dysfunction is not only related to pregnancy, but also can be the result of repetitive minor trauma, such as bearing down on the pelvic floor when emptying the bladder or bowel, or a single major trauma such as the vaginal delivery of a baby. It is often caused by stretching and weakening of the pelvic floor muscles that are a result of:
- Pregnancy & childbirth (multiple pregnancies increase the risks)
- Continual straining to empty your bowels (constipation)
- Persistent heavy lifting
- A chronic cough
- Being overweight
- Changes in hormone levels at menopause
- Lack of general fitness
Factors contributing to pelvic floor dysfunction can include problems with: the anatomy of the pelvic floor (i.e. overstretched connective tissue or muscles), the control of contraction of the pelvic floor muscles and the strength or endurance of the pelvic floor muscles. Any other region of the musculoskeletal system that causes bearing down on the pelvic floor or dysfunction in the lower back and pelvic girdle, will most likely also contribute to incontinence and POP.
In such dysfunction, activities which involve an increase in the pressure inside the abdominal cavity and require a transfer of loading across the pelvis and lower back may result in the pelvic organs and bladder being pushed downwards repetitively. Such “bearing down” often leads to stretching of the sling of connective tissue and muscles that make up the pelvic floor. The use of real time ultrasound imaging is a good way to see if the strategies being used are in fact the correct pelvic floor muscle activation (“lifting”), or in fact the “bearing down” strategy which is undesirable.
Research has shown that the pelvic floor muscles function as a team with the core muscles (deep abdominal and back muscles). This indicates that focusing on restoring ideal function of the pelvic floor and the stabilizing deep core muscles is the ideal approach for treating both stress urinary incontinence and low back / pelvic pain i.e., treatment of weakness or incontinence often requires integrating treatment of any other related pelvic girdle or lower back issues and vice versa.
Hence, prevention of pelvic floor dysfunction may include the following:
- For first time mum’s, a pelvic floor muscle ‘dilator’ used in the preceding weeks before delivery can help gently stretch the pelvic floor allowing a more relaxed vaginal delivery.
- Addressing issues above such as managing a chronic cough, constipation, maintaining a healthy weight, exercising and avoiding heavy lifting help prevent pelvic floor damage.
- Having a full musculoskeletal assessment of your pelvic girdle and any regions that affect the neuromuscular function of the pelvic floor by a suitably qualified physiotherapist to treat any issues contributing to poor muscle function will both prevent specific issues and return you to optimal health postpartum.
We often hear in Hong Kong that a natural childbirth can damage your pelvic floor and that a C-section is better. Is that true?
Many factors need to be considered when deciding whether a woman should have a cesarian section or vaginal delivery. These issues need to be discussed with your obstetrician, but may include your medical history, extent or severity of pelvic girdle / lower back pain, the size of the baby and your personal preference. In terms of the protective role of cesarian section over a vaginal delivery for the pelvic floor, a cesarian section does help reduce damage to the pelvic floor if you only experience two pregnancies or less, assuming the deliveries are uncomplicated. If you have a third pregnancy, this protective role no longer exists.
Do all women who just had a baby (vaginal or C-section) need pelvic floor rehabilitation?
I would say that all woman and men should have their pelvic muscle function assessed given that two-thirds of all women and one-third of all men will suffer incontinence in their lifetime. In addition, given the important role that the pelvic floor muscles play in the management of other musculoskeletal issues such as pelvic girdle and lower back pain, it should be included in any women’s and men’s health check.
How does menopause and peri-menopause affect my pelvic floor?
With the onset of menopause, there is a change in the balance of the body’s hormones – in particular a decrease in oestrogen. This affects the pelvic floor in that oestrogen makes the vaginal tissues more elastic, provides lubrication and ‘plumpness’ to the pelvic floor tissues. More specifically, oestrogen assists in muscle tissue growth and this is important in any muscle of the body to build size and strength. This net increases the tension of the pelvic floor structures thereby providing the ‘hammock-like support’ and tension that is needed in this region.
Vagina dryness and difficult or painful sexual intercourse (dyspareunia) are also symptoms caused by the changes in hormones during menopause.
How does the pelvic floor affect my sex life?
It provides tension around the vaginal passage thereby increasing sexual sensation during intercourse. If these muscles are over stretched and hypotonic (low tone in the muscle), they will not provide the tension required to ‘feel’ as much during intercourse.
What are the preventive measures I can take to maintain a healthy and strong pelvic floor?
To be truly effective in addressing any issues, it is always better to be very specific about what are the underlying causes of any health issues. In fact, what research demonstrates is that approximately 80% of women who are simply instructed to do specific exercises without specific instruction via real time ultrasound or an internal vaginal assessment, will do them incorrectly. In my experience, many women who have weakness in this region and try hard to activate their pelvic muscles often do exactly the opposite and perform a ‘valsalva’ motion (bearing down on the pelvic floor), which places excessive pressure on the pelvic floor – this is the opposite of what we want and therefore can lead to more issues than not doing any pelvic floor exercises.
With this perspective, I would always recommend a full holistic assessment by a suitably qualified physiotherapist to ascertain all relevant health, musculoskeletal factors and lifestyle habits that need changing. However, identifying and changing any of the risk factors mentioned previously would be a great start.
When should I see a physiotherapist? What are the signs and symptoms are should take seriously and seek professional help for? Could you walk me through a typical pelvic floor physiotherapy session?
Medical research confirms that pelvic floor muscle training is the most effective treatment option in addressing both urinary incontinence and pelvic organ prolapse. You should consult with a physiotherapist if you have experienced any of the following:
- Urinary incontinence or have symptoms of a prolapse
- Perineum pain from the episiotomy scar or childbirth
- Pain with sexual intercourse
- A difficult vaginal delivery, prolonged labour or had a large baby (4 kg)
However, for optimal health, we would strongly encourage all women to have a pelvic floor assessment six week’s postpartum to prevent any symptoms from developing.
A women’s health physiotherapist or a musculoskeletal physiotherapist specializing in treating women’s heath will carry out a full assessment using real time ultrasound imaging in addition to an internal examination. If indicated, a pelvic floor muscle rehabilitation program will be prescribed, which may include specific exercises, intravaginal electrical stimulation, bladder training and abdominal core stabilization exercises. In addition, other factors will be addressed during a comprehensive assessment. A thorough explanation should be given to explain what the specific factors which are causing your issues should be given as each person’s issues are different. In my clinical experience, weakness in pelvic floor muscles is often not just from ‘not doing my exercises’, it is often related to other neuromuscular issues in other regions of the body causing excessive intra-abdominal pressure on the pelvic floor. Addressing these issues is what often allows specific exercises to be effective because the increased pressure is removed and the nerve supply to these muscles are optimized, which produces a much more effective contraction – making your exercises much easier.
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