Pelvic floor exercises - how can one exercise fit all?

Most magazine articles focus on advice to strengthen pelvic floor muscles (PFM) yet lack of strength is only one of the problems affecting this muscle group. It’s certainly not a case of ‘one size fits all’ with pelvic floor exercises (PFXs). When PFXs are indicated I need to know more about the specific muscle problem(s) in order to tailor a suitable program. Consider these different PFM problems, which require different treatment approaches.

Problem: A weak pelvic floor. When PFMs are weak due to chronic coughing, heavy lifting, poor posture, bowel straining, neurological disease or birth injury, the muscles lack tone and fail to lift and hold during activity. If PFMs fail to support the pelvic organs with activity (lifting, coughing) the ligaments supporting the pelvic organs will eventually lengthen and fail in their supporting role (like a piece of over stretched elastic). These women benefit through strength exercises for floor and core muscles, postural control, avoiding heavy lifting and bowel straining, jumping activity and over challenging exercise. A vaginal pessary support (used for prolapse) repositions the prolapsed organ(s) allowing PFMs to strengthen in their ‘lifted’, more anatomically normal position.

Problem: A tight pelvic floor. When PFMs are too tight due to fear, stress and chronic tension or excessive exercise they also fail to control the bladder and bowel and are associated with pelvic and sexual pain. When women with tight PFMs repeat strength exercises, they are likely to develop painful muscle spasms. These women benefit from relaxation and breathing therapy, specific internal and external pelvic muscle releases, muscle stretches and learning to release and coordinate PFMs with other core and trunk muscles. Following pelvic surgery or birth trauma (poor positions, forced pushing, forceps), PFM tightness may be localized to one area in combination with generalized weakness. If post baby pelvic floor exercises are repeated obsessively, the muscles can become tight and stiff (tight muscles are weak muscles). Months or years of incontinence or pelvic pain can result in tight PFMs from constant tension secondary to the pain or fear or losing urine.

Problem: Uncoordinated pelvic floor/abdominal muscles. Some women [especially those with poor bladder control] use strong upper abdominal muscles during activity instead of automatically lifting the pelvic floor early. The action of sucking in the waist reinforces this pattern (in some women).  Automatically tightening the upper abdominal muscles first, increases intra-abdominal pressure, which the PFMs may fail to control. When the abdominal wall is tightened, the pelvic floor must lift simultaneously – this does not happen in many women with continence issues.

Women with uncoordinated pelvic floor and abdominal muscles benefit from specific training to find and use the pelvic floor/core action instead of the upper abdominals. These women typically cannot tighten their PFMs locally and use trunk or buttock muscle action instead. Upper abdominal strengthening exercises are avoided with this muscle problem.

Don’t settle for a generic exercise program, which may reinforce an incorrect muscle pattern. A women’s health physiotherapist will assess specific PFM problems and design an individual program based on the findings.