A Functional Approach to the Pelvic Floor
The pelvic floor is typically something we don’t talk about, even though Pelvic Floor Disorders are quite common. We seem to just brush them aside as a normal aging process when we have symptoms such as incontinence, pelvic organ prolapse and pain. Are you aware that Pelvic Floor Disorders also include bowel dysfunction, constipation, instability of the surrounding joints, muscle imbalances/weaknesses and core dysfunction? Did you know that it also occurs in men, women and children of both genders? Well, I’m here to tell you that there are things that can be done and we SHOULD BE TALKING ABOUT IT! The focus of this post is to discuss incontinence, general and functional anatomy, simple drills you can do to test your pelvic floor and provide some information on what the research shows on pelvic floor disorders.
Incontinence can be both urinary or fecal and is defined as the involuntary or accidental voiding of either urine or feces. This can happen during sports activities(running, jumping, lifting), singing, dancing, coughing or sneezing. Urinary is more common than fecal, it can affect as many as 29% of women after pregnancy and 40% of women(Gyhagen 2015). Urinary can be present in roughly 50-60% in women who have given birth(Dolan et al. 2003). If we simply look at incontinence alone from a post-partum, ie. after pregnancy, perspective it should resolve within 6 weeks to 3 months according to the evidence(Burgio 2003, Rogers 2007, Brown 1999). We know that there is an increase chance of incontinence related to vaginal births(Quiroz 2011), but this does not exclude women who had a caesarian section, as around 52% of pregnant women can have symptoms(Pool-Goudzward 2005). This is in large part due to structures being stretched; muscles(pubococcygeus – up to 3.26 times its length)(Delancey, 2003) and nerves(up to 35% longer)(Kuo-Cheng Lien, 2005) and muscles being injured(up to a grade 4 tear). Pelvic Floor Disorders become more complicated when a grade 3 or 4 tear occurs, at which point treatment is recommended to retrain and heal the area. One study has even shown through MRI the prevalence of subcortical pubic bone fractures and edema in the bones and muscles at 7 weeks post-partum(Van delft 2014). Like many conditions, there is also an increased risk associated having a prior incidence of incontinence whether it is related to pregnancy or other trauma, injuries or conditions.
As a Chiropractor, who has rehabilitative training in helping with pelvic floor disorders, it’s refreshing that the leading treatment guidelines and protocols dictate providers to rule out the lumbar spine. It is very common to have derangement(referred pain) from the lumbar spine, usually in the form of disc involvement. Once the lumbar spine is ruled out, other structures of the pelvis, hips, abdominal cavity, pelvic region can be ruled in. Many times these structures are ruled in from a functional aspect = THE KINETIC CHAIN! Respiratory dysfunction for example is highly correlated with incontinence. Reflexively and fundamentally the pelvic floor activates prior to upper extremity tasks, such as lifting. Clinically, I’ve seen hip, groin, knee and foot pain be resolved once respiratory and pelvic floor training was initiated in the treatment plan. What does this mean? Your body craves stability at it’s”core” in order for you move, run, walk or pick up things, ie. your child!
I’ve used this quote before, but it’s so true: “proximal stability allows for distal mobility” – Professor Stuart McGill, PhD.
Moving forward let’s define the function and structures of the the pelvic floor, ie. “the floor of the core”.
- to maintain and increase pressure, especially intra-abdominal pressure
- provide stability for lumbar spine, pelvis & hips
- help unload the spine
- support & control sphincters of pelvic organs(rectum, bladder, uterus)
Structurally its comprised of:
- muscles(levator ani[pubococcygeus, iliococcygeus], pelvic diaphragm, coccygeus)
- Ligaments(puborectal, dorsal sacral ligament, sacrospinous, sacrotuberous)
- Associated Structures(abdominal diaphragm, rectus abdominis, transverse abdominis, internal and external obliques, obturator internus and piriformis)
- Bones(pubic, ischium, ilium, sacrum, coccyx)
The majority of these structures are able to be palpated and be contracted by oneself. Here are some quick tests you can do to assess your pelvic floor:
How to palpate your pelvic floor:
- While seated, find your sit bone in your butt(ischial tuberosity) and place your fingers between it and the anus. You may need to lift your glute muscles up/out of the way
- Then draw your muscles of the pelvic floor from the pubic bone to your anus. You should feel a contraction, now relax.
- Now with your hands in the same position, push your muscles out into your fingers.
- Was one harder to do than the other? If so you may have an imbalance that can be addressed with specific exercises.
Demonstrating the relationship between your breathing and diaphragm with the pelvic floor:
- You can have your fingers in the same position as described above.
- Notice what happens when you breathe in and out. Do you feel the muscles rise up towards your stomach when you breathe in and down into your hands when you breathe out? Well it should.
- Think of the abdominal and pelvic diaphragms working like a piston, going up and down in unison. If this isn’t happening then this could be the reason your experiencing incontinence, pain, injuries and instabilities/weaknesses. Don’t worry there are exercises to help! Such as this one…
Demonstrating the relationship between the core and your pelvic floor:
- Place your hands on your lower abdomen inside and below the ASIS(anterior superior iliac spine).
- Lightly contract your abdominals under your hands so that you feel them flatten slightly(do not suck in and hollow, you should not feel your pelvis rotate, your glutes contract or any movement in your spine).
- Maintain the light contraction of the core and contract the pelvic floor in the same manor as the prior two tests.
- You should feel an increase in power pressure under your hands and a contraction in the muscles. If not, then there is a disconnect between the two, which needs to be addressed.
Lastly, is a demonstration of maintaining pressures between the abdomen and pelvic floor structures:
*Side note: this will affect bladder and urethral pressure; if bladder pressure is greater than urethral pressure or abdominal pressure is greater than pelvic floor structures, incontinence is more likely to occur.*
- Contract abdominal region by pushing out, ie. abdominal brace, lightly.
- Now forcefully contract as if you were filling up a balloon in your belly.
- Notice what happened to your pelvic floor? You should have felt activation of the muscles in the pelvic floor. If not, this needs to be addressed.
I encourage you to do these tests, especially if you recently had a child or have been dealing with incontinence issues for years. Even, if incontinence has never been an issue, these tests could shed light on why you’ve had chronic pain or instabilities anywhere in your body. Do not fall into the trap of telling yourself, well I’ve done kegels and it didn’t help, or well this is just normal. It doesn’t have to be normal, there can always be room for improvement. “The pelvic floor and associated muscles can be trained just like any other muscle to return to their fitness level” – Suzanne Badillo PT, WCS – Rehabilitation Institute of Chicago.
In closing, I hope you find this helpful. Comment below or contact me directly with questions and let me know how I can help.
Yours in Health,