First, Meet Your Pelvic Floor
The pelvic floor muscles are a group of muscles that attach to the front, back and sides of the bottom of the pelvis and sacrum. They are like a hammock or a sling, and they support the bladder, uterus, prostate and rectum. They also wrap around your urethra, rectum, and vagina (in women).
These muscles must be able to contract to maintain continence, and to relax allowing for urination and bowel movements, and sexual intercourse.
Pelvic health physiotherapy is becoming more established in the research as a first line of defense against incontinence and pelvic pain. Pelvic floor dysfunction can be caused by 1) Hypotonicity (Weak Pelvic Floor Muscles): Weak pelvic floor muscles can contribute to stress incontinence and pelvic organ prolapse. Incontinence is NOT a normal part of aging OR 2) Hypertonicity (Tight Pelvic Floor Muscles): Tight pelvic floor muscles can contribute to urinary and fecal urgency, urge incontinence, chronic pelvic pain, dyspareunia, vaginismus, vulvodynia, pudendal neuralgia, and interstitial cystitis.
When our pelvic floor muscles are unhealthy they can cause a host of problems as mentioned above. No other set of voluntary muscles (muscles that we have direct control over) is as important, and yet is so consistently ignored in medicine and in our exercise programs. These important muscles have five major functions including:
Maintaining continence of our bladder and bowel
Allowing sexual function and pleasure
Providing support to our internal organs so that our bladder, uterus, and intestines stay in the abdominal cavity where they belong
Providing support for our low back so that we can function without pain
Helps our circulatory system get the blood and other body fluids from the legs back to the trunk and heart
How Do We Treat The Pelvic Floor?
Specially trained doctors and physiotherapists diagnose pelvic floor dysfunction by using internal and external “hands-on” or manual techniques to evaluate the function of the pelvic floor muscles. They will also assess your ability to contract and relax these muscles. Your bones and muscles of your lower back, hips and sacroiliac joints will be assessed as well since these joints can stress your pelvic floor muscles. If an internal examination is too painful, the connective tissue of your abdomen, thighs, groins and low back are often very tight. The connective tissue forms the container of the muscles, and this tissue often needs to be relaxed before any internal work can be done. When your pelvic floor muscles are tight and weak, the tension is treated before the weakness. Once the muscles have reached a normal resting tone, and are able to relax fully, their strength is reassessed and strengthening exercises are prescribed, if appropriate – “first you lengthen, then you strengthen!”
Self-care is an important part of treatment. Avoid pushing or straining when urinating and ask physiotherapist about how to treat constipation. Relaxing the muscles in the pelvic floor area is important, and doing reverse Kegels may be one way to help lengthen and relax these muscles.
Medication such as compounded vaginal or rectal diazepam can be quite helpful and may be prescribed by your doctor. These medications can be used as local muscles relaxants in the vagina or rectum.
Good posture to keep pressure off your bladder and pelvic organs, and other stretching techniques such as yoga, can be helpful to avoid tightening and spasms in the pelvic floor muscles as well.
Persistent pain education is another part of treating pelvic floor dysfunction since the pelvic area is an area that we often hold our stress. Anxiety, stress and our thoughts, attitudes and beliefs can perpetuate the pain in our pelvis; understanding how our pain system works has shown to be an effective way of reducing the threat of ongoing pelvic floor dysfunction.
We need to connect with our pelvic floor muscles (know how to keep them strong, yet relaxed) throughout our life span to ensure that we have healthy functioning of all of these important activities.
Is There Research To Validate This Form of Treatment?
The Cochrane Collaboration (2010) published a review, ‘Pelvic Floor Muscle Training vs. No Treatment, or Inactive Control Treatments, for Urinary Incontinence in Women’. The Cochrane Collaboration concluded that there is Level I/ Grade A evidence (the strongest level of evidence available) for pelvic floor strengthening for urge and stress incontinence. It was recommended that pelvic floor strengthening should be taught by a physiotherapist using internal assessment and treatment techniques. This is the gold standard now in Britain; this is what evidence-based practice says today, even though it is not standardly happening in Ontario, or most of Canada. Only those who cannot adequately train their pelvic floors should be considered for surgery.
The International Pelvic Pain Society Conference (IPPS 2010) presented a randomized clinical trial (strongest type of study) that has since been published in the Journal of Urology (2012) by Fitzgerald et al. which demonstrated that internal pelvic floor myofascial treatment in chronic bladder pain patients was effective in 59% of patients compared to generalized massage therapy. This trial has shown a positive result for painful bladder syndrome (interstitial cystitis), including medication, surgery and other therapeutic techniques. We now have Level I evidence to support the use of internal pelvic floor physiotherapy for painful bladder conditions.
Pelvic floor physiotherapy is an integral part of pre- and post-partum care. In France, every woman who goes through a vaginal delivery sees a physiotherapist as part of her post-partum recovery process. The muscles are massaged, lengthened, stretched and strengthened to prevent the weakness that can lead to incontinence, or the tightness that can result from a tear or episiotomy. These dysfunctions can contribute to pain, discomfort, and limitations in function.
How Do I Prepare For My Initial Assessment?
Upon scheduling your initial appointment, you will be sent forms to collect relevant personal information and your medical history. Along with this, please bring any reports from special investigations or testing (e.g. urodynamic testing, MRI reports). If you don't have them, we can always request them from your MD if needed. Feel free to wear loose, comfortable clothing, you may be asked to undress from the waist down, we have gowns for you to change into or you may wear a skirt. You will always be draped to your comfort level.
What is Pelvic Floor Tightness?
Many people with pelvic pain have muscular dysfunction, but specifically hypertonic muscles (muscles that are too tight). When these muscles have too much tension (hypertonic) they will often cause pelvic pain, or urgency and frequency of the bladder and bowels. You can also have a combination of muscles that are too tense and too relaxed. When your pelvic floor muscles are tight and weak, the tension is treated before the weakness.
Hypertonic muscles can cause the following symptoms:
Urinary frequency, urgency, hesitancy, stopping and starting of the urine stream, painful urination, or incomplete emptying
Constipation, straining, pain during or after bowel movements
Unexplained pain in your low back, pelvic region, hips, genital area, or rectum
Pain during or after intercourse, orgasm, or sexual stimulation
Uncoordinated muscle contractions causing the pelvic floor muscles to spasm
What is Pelvic Floor Muscle Weakness?
Hypotonicity (weak pelvic floor muscles) contributes to urinary and fecal incontinence, as well as pelvic organ prolapse as we have lost structural support to hold up these organs and keep our external sphincters fully closed. Women often have difficulty sneezing, coughing, jumping, running, or weightlifting without the feeling of 'heaviness' and/or incontinence.
When strengthening your pelvic floor with the guidance of a physiotherapist, the research shows that it is 80% effective. This means for every 10 patients that would be appropriate candidates for surgery (sling repairs, TVT) only 2 require surgery after physiotherapy treatment.
In Britain, the National Institute of Health has declared that every person considered for surgical correction of stress incontinence should first be seen by a pelvic health physiotherapist for conservative care. Only those that are not able to strengthen their pelvic floors sufficiently with exercise alone are then considered for surgery.
The evidence and research supports this approach, especially with ongoing concerns with regards to the potential negative effects of having a sling repair. Surgery should always be approached conservatively and carefully.