A wee problem

If you’re suffering from urine leakage or prolapse, you’re not alone, and there are things you can do to improve your situation, explains pelvic health physiotherapist Liz Childs.

Pelvic floor muscle dysfunction, such as incontinence and prolapse, is often a difficult and embarrassing subject for women to discuss, both with friends and with their health professionals. As a result, it gets ignored and women end up suffering in silence, wearing pads, and restricting their activities rather than getting help.

A 2013 survey in New Zealand found that more than half of all women have urinary leakage at some stage in their lives. 50% of all women who have had a baby have prolapse, and 30% have reduced sexual sensation. All these problems can be helped or even cured with appropriate pelvic floor muscle training, yet many women believe these problems area normal consequence of factors such as giving birth and ageing. Pelvic floor dysfunction is common – you are not alone. However, it is not normal, and you can help yourself do something about it. Studies show that pelvic floor muscle training can have an 80% cure rate for stress incontinence, and there is good evidence that it can help reduce prolapse symptoms.

What are the pelvic floor muscles?

The pelvic floor muscles are a sheet of muscles at the base of the pelvis. They extend from the pubic bone at the front to the tailbone at the back. They are involved in:

  • Support of your pelvic organs (bladder, bowel and uterus), holding them in the right place.
  • Prevention of leakage from the bladder and bowel.
  • Control of problems such as frequency and urgency.
  • Emptying of the bladder and bowel.
  • Sexual function.
  • Core stability around the pelvis and trunk.

Types of pelvic floor muscle dysfunction:

Bladder leakage: There are two types. Stress incontinence occurs if the pelvic floor muscles are weak and you may experience leakage of urine when you cough, sneeze, or strain, or during exercise such as running or jumping. Urge incontinence occurs when you get a sudden strong desire to get to the toilet and you may leak on the way, even if your bladder isn’t particularly full.

Prolapse: If the pelvic floor muscles and/or supporting ligaments are weak, the pelvic organs may drop down. This can create a bulge inside the vagina, or a dragging, heavy sensation. The bulge may even be visible at the vaginal entrance.

Bowel incontinence: Strong and coordinated pelvic floor muscles assist with bowel control, helping to prevent accidents. They also help prevent involuntary loss of wind, another common problem after childbirth.

Sexual dysfunction: Strengthening your pelvic floor muscles can help improve sexual sensation and your ability to have an orgasm. (Sometimes after childbirth there can be pain with intercourse, and you may need to learn how to relax the pelvic floor, or loosen scar tissue).

What are the risk factors for pelvic floor muscle dysfunction?

Pregnancy and childbirth: Any woman who has ever had a baby should be doing pelvic floor exercises, and not just in the immediate post-birth period. They should be done regularly for the rest of your life. Even if you have had a Caesarean section, you should still be doing them, as hormone changes and the weight of the baby still have an impact on the pelvic floor, and can cause weakness.

Ageing: There is a general loss of muscle mass that occurs with ageing. It is important to keep all your muscles, including your pelvic floor, in good condition by doing regular exercise.

Menopause: Hormone changes during and after menopause contribute to an increase in pelvic floor muscle dysfunction.

Other lifestyle factors that impact on the pelvic floor: Constipation or straining, obesity, heavy lifting, inappropriate exercise, chronic coughing, disuse, being overweight.

Pelvic floor muscle training

There is good evidence that pelvic floor muscle training can help to prevent pelvic floor dysfunction. If you already have problems, it can help to cure them. Pelvic floor muscle training involves pelvic floor muscle strengthening, and making lifestyle modifications so that there is less pressure on the pelvic oor muscles. So how do you exercise the pelvic floor?

  • Sit comfortably in an upright chair OR lie on your back with knees bent and thighs, buttocks, and tummy relaxed.
  • Squeeze and lift around your vagina or back passage. Imagine you are trying to stop the flow of urine or stop passing wind. It is fine to feel a gentle pulling in of your lower abdominal muscles at the same time, but there should be no tightening of the buttock muscles, tilting of the pelvis, or sucking in of air.
  • If you are unsure about the technique, you could try to stop your ow of urine on the toilet. If you can do this, or you can slow it, you are using the correct muscles. Be aware though – this is a TEST ONLY. Do not exercise your pelvic floor muscles this way.
  • Start by holding for two to three seconds and gradually build up to 10-second holds. If your muscles are weak, you won’t be able to hold for long.
  • Allow a 10-second rest between each muscle contraction to avoid muscle fatigue.
  • Gradually build up to 10 repetitions of 10-second holds, with a 10-second rest between each one. This is one set, and you should aim for three sets a day.

It may take three to four months to strengthen your pelvic floor muscles if they are weak. Once your muscles are strong, keep exercising them. Aim for one good set of pelvic floor exercises every day, forever, to ensure that you help to prevent future problems. Doing a few exercises once every few weeks just isn’t going to work.

Lifestyle modifications

  • Keep your weight within healthy range
  • Seek help if you suffer from constipation
  • Get medical advice to help with chronic cough
  • Try to activate your pelvic floor muscles before you cough, sneeze, lift, and when exerting yourself with daily activities.

What is pelvic floor physiotherapy?

A pelvic floor physiotherapist is a physiotherapist with additional specialised training in pelvic floor dysfunction. Treatment involves a thorough assessment, and education about your problem, using diagrams, drawings, and models. You will be given an individualised programme to get your pelvic floor muscles working as well as possible so that you have the best strength and endurance you can. You will also be taught how to use these muscles in a functional way. There will be advice on lifestyle modifications and appropriate general exercise, with appropriate adjustments, so you can keep up the type of activity you wish to do.

Safe exercise

Safe exercise during pregnancy and after birth: Hormone changes during pregnancy result in a softening of the pelvic ligaments and pelvic oor muscles. During childbirth, there is stretching, compression, and traction on surrounding structures as the baby passes through the birth canal. Care therefore needs to be taken with exercise during and after pregnancy, as some exercise can actually be harmful to the pelvic oor muscles and pelvic joints.

Suitable exercise during and post pregnancy:

  • Walking
  • Low-impact aerobics
  • Water aerobics
  • Pregnancy exercise classes • Cycling
  • Swimming

Check with your doctor or midwife if you are increasing your current exercise, to see if you need to take special precautions. Avoid strenuous exercise and drink plenty of water.

Exercises to avoid in pregnancy:

  • Heavy weights
  • Bouncing – e.g. star jumps, trampoline
  • Contact sports – avoid after the first trimester
  • Excessive twisting or turning
  • Quick movements
  • Sudden changes of direction or intensity
  • Exercises that increase the curve in your lower back (your lumbar spine)
  • High impact activities

Urinary leakage during exercise:

Urinary leakage is very common in pregnancy. If you experience leakage while you are exercising, stop doing the exercises that are causing it. Seek help from a pelvic floor physiotherapist.

Returning to exercise after birth

Start doing pelvic floor exercises a few days after you give birth. Start gently and slowly build it up. It is safe to start slowly returning to low-intensity exercise, such as walking, after one to two weeks.

It is recommended that you wait at least four to six months before returning to high-impact exercise such as running. See a pelvic floor physiotherapist for further information.

Long-term pelvic floor safe exercise

Pelvic floor safe exercise is recommended for anyone who is at risk of, or is already experiencing, pelvic oor dysfunction. It can be difficult to work out exactly what is suitable for you. A good guideline is to avoid high-impact or high-intensity exercise, or anything that exerts a downward pressure on the pelvic oor. More detailed information regarding specific cardio, resistance, and core exercise is available at pelvicfloorfirst.org.au.

When should you seek help?

It is important that you are exercising your pelvic floor muscles correctly. If you are having problems or are unsure, see a pelvic floor physiotherapist who has specialised training in this area. If you experience symptoms such as incontinence or prolapse after you have given birth, and it has not resolved within three months, you should seek help. In most cases problems will fully resolve with correct pelvic floor muscle training and advice on lifestyle changes. Even if it is many years since you gave birth, it is never too late to seek help.

How to find a pelvic floor physiotherapist

Most larger DHBs have a Women’s Health department, where you will nd specialised pelvic oor physiotherapists. There are also pelvic floor physiotherapists in private practice. Visit Physiotherapy NZ and look under “Find a Physio”. Continence NZ also have a list of pelvic floor physiotherapists and continence physio providers. Visit continence.org.nz or call 0800 650 659 to find out more.

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