Benefits of pelvic floor muscle training

Guidelines from expert committees advise health professionals to prescribe pelvic floor muscle training (PFMT) as a first line treatment option for bladder and bowel dysfunction and pelvic organ prolapse.

Do these recommendations apply to all women?

The guidelines recommend PFMT for all women during pregnancy and post partum and for those with POP. When PFMs are over active (too much tone and unable to fully relax) treatment involves a different approach. Training in diaphragmatic breathing, relaxation, soft tissue releases, muscle stretches, treating trigger points and learning the ‘local’ action of the PFMs. Strength work for over active PFMs is likely to cause pain from exercise induced muscle spasms.

How do ‘healthy’ pelvic floor muscles work?

A healthy coordinated pelvic floor automatically tightens and lifts early (milliseconds) before activity. It has the strength and endurance to stay lifted, keep sphincters closed and support pelvic organs, then releases after the activity finishes.

Research shows women with postpartum dysfunction lose the ‘automatic’ action of their PFMs. Compared with the PFMs of continent women (no children), they have a delayed action and some have weakness on one side. The PFMs then have a ‘timing’ problem due to a slower response.

Why are some women able to do PFXs and others find it difficult?

PFX’s can feel ineffective when weakness is related to muscle tearing or nerve damage. Some women are able to ‘locally’ contract their PFMs while others use a different muscle action. They automatically switch on strong trunk muscles (global action) instead of ‘local’ ones in the pelvic floor.

Local PFM contraction:

  • Relaxed breathing and shoulders
  • PFMs tighten and draw up internally towards the abdomen
  • The lower abdomen slowly firms when the PFMs tighten
  • Able to continue breathing during the exercise

Global contraction:

  • Breathes in and chest rises when doing a PFM lift
  • Firmly switches on upper abdominal or spinal, buttock and leg muscles
  • Sometimes the strong upper abdominal muscles overwhelm the weaker PFMs, which are pushed downwards
  • Practicising this pattern reinforces a muscle action that’s damaging to the pelvic floor.
  • Breath holding during the exercise

What types of pelvic floor injuries sometimes occur with childbirth?

All women undergo maximal stretch during vaginal birth but only some sustain injury. Pushing too early after the cervix has fully dilated may cause detachment of supporting ligaments and fascia.

Pressure during a prolonged? second stage (over 50-60 minutes) may damage nerves supplying the PFMs.

Prolonged forceful pushing can cause varying degrees of tearing within the pubovisceral muscles (previously named pubococcygeus). Sometimes irreversible distension to the muscles or tearing of the muscle attachment to one or both sides of the pubic bone occurs. Avulsion of the PV muscle from the pubic bone triples the risk of anterior wall/uterine prolapse. Damage to the posterior arcus tendinous fascia is associated with posterior vaginal wall prolapse.

Tears to the perineum can involve minor grazing up to major tearing into the anal sphincters and rectal lining. In some women the pressure of crowning causes detachment of the last one or 2 segments of the coccyx bone.

Pelvic organ prolapse (POP) is associated with major muscle tearing and detachment of supporting structures from the pelvic sidewalls.

How does PFMT help damaged muscles after childbirth?

It’s standard for sporting or workplace injuries to receive lengthy rehabilitation until the athlete or worker if fit to return to sport or work. PFMT plays the same role in the pelvic floor following birth or pelvic injury. 

In the 6 weeks postpartum assessment involves:

  • Listening to what sensations the new mother describes, eg: vaginal heaviness or ‘falling out or lack of ability to contract PFMs
  • Location and treatment for pelvic pain or infection
  • Noting bladder and bowel control, frequency, sensation, emptying difficulties, pain
  • Using endoanal ultrasound to assess anal sphincter tearing when there’s loss of wind and stool control
  • Assessment of PFM function: palpation of intramuscular tears and detachment from pubic bones, PFM responsiveness, sensation, strength and endurance
  • Tests for prolapse in standing
  • Testing how the PFMs respond functionally with coughing, sneezing.
  • Checking the width of the diastasis rectus separation
  • Noting movement difficulties (from pelvic girdle pain) and coping ability
  • Healing of the caesarean scar
  • Pain /discomfort with intercourse
  • When indicated, referral for ultrasound to measure the levator hiatus. This is the internal width between the levator or PV muscles. A wider gap is associated with prolapse.

Strengthening the PFMs postpartum thickens the muscles, increases strength and reduces the width of the levator hiatus. Strong PFMs improve bladder and bowel control, supports pelvic organs and maintain sexual sensation and orgasm intensity.

PFMT is indicated for all postpartum women even after a caesarean or straightforward vaginal birth. Poor bladder and bowel control and prolapse issues can present 10 - 20 years post partum. PFMT can improve control at any stage during a woman’s life. Give them the same attention and repetition as teeth cleaning.

Can weaker areas in the pelvic floor muscles be improved with PFMT?

Postpartum, some women are aware of weakness in the entire pelvic floor or either the front or back areas. Weakness on one side of the pelvic floor is not always evident when doing PFM exercises. Biofeedback and electrical stimulation may be advised with muscle weakness.

With generalised PFM weakness:

  • Training the wide shelf of iliococcygeus muscle towards the back of the pelvic floor can help recover neuromuscular control. This can flow onto improving control of the urethral striated muscle. Poor PFM function due to birthing nerve compression usually improves within 6-8 weeks.

One-sided PFM weakness:

  • Lie stomach down with one knee bent up, out to the side
  • Breathe out and lift up through the vagina and rectum, hold and breathe for 10 seconds. Repeat 10 times then compare with the PFMs on the other side
  • With one sided PFM weakness initially it will be difficult to repeat 2-3 PFM lifts on the weak side

Front pelvic floor weakness:

  • Start in an anti gravity position (try several to find which one works best): side lie, kneel with bum up, head down or stomach lying
  • Breathe out while slowly drawing an imaginary tampon in vaginally. When the action is correct, the lower abdomen (bikini line area) will firm too. Hold and breathe x 10 seconds. Completely relax before repeating

Back pelvic floor weakness:

  • Sit and relax your low back into the chair
  • Breathe out and slowly draw up through the anal sphincter to increase squeezing and lifting
  • Hold and breathe x 10 seconds before relaxing and repeating
  • The lower abdomen will firm as well
  • This position can help when there’s generalised PFM weakness

Tips for effective PFM exercising:

  • Location, location, location. Take time to slowly learn the sensation of tightening the PFMs first before adding strength. Breathe during the exercise to avoid breath holding. Tighten on the out breath
  • Many women try too hard initially and switch on ‘stronger’ muscles in other areas. Back off the intensity initially to learn the action without others muscles hijacking the action
  • Start with slow gentle exercises and gradually ramp up the squeeze intensity when confident with the localised action.
  • Completely relax between each exercise
  • Ideally aim to repeat 10 exercises x 1-2 sets x 2-3 times a day
  • Initially 4 -5 repetitions may be difficult and the strength may fade quickly.
  • Rest after the PFMs fatigue and repeat more frequently until your training results in 10 repetitions x 10 second holds x 1-2 sets x 2-3 times a day
  • Start in anti gravity positions and progress to training in standing when the PFMs are more responsive and coordinated
  • Exercise throughout the day by lifting the pelvic floor prior to sneeze, cough, sit to stand
  • With a persistent ‘global’ action when doing a PFM lift, seek training from a women’s health PT (physiotherapist)

Always use ‘the knack’ or a quick PFM lift before lifting objects, coughing, sneezing or standing up from a squat.

Following vaginal birth, PFM injury rehab involves 4-6 weeks of low exercise loading then progressive loading to improve strength.

Following pelvic surgery for hysterectomy or prolapse repair, ask the surgeon for his guidelines before commencing PFMT. Avoid exercise until the catheter is removed and pain and inflammation are resolved.