Exercising pelvic floor: weak = leak

1 March 2014

Forget about crunchies and taut abs – exercising your pelvic floor and transversus abdominis have rewards all of their own. FIONA CASSIE talks to nurse-turned-personal trainer Lynda Lovatt about exercise to protect and strengthen your pelvic floor for new mums, the middle-aged, and vigorous athletes.

We’ve all seen them in the gossip mags: those before and after shots of Hollywood yummy mummies who seem to bounce back into glamorous shape post-baby in a matter of weeks. Those flat abs on display as they stroll the beach in a bikini with a baby on their hip.

Nurse-turned-personal trainer Lynda Lovatt believes it is likely that a fairly extreme diet and exercise regime was required to be paparazzi photo-ready so quickly.

“It can look good on the outside but what’s happening on the inside of the body could be another story,” says Lovatt. “The pelvic floor could still be weak and the core muscles might not be strong.”

Flat taut abs may look good in the glossy mags but doing crunchies and other exercises that focus on the rectus abdominis or ‘six-pack’ muscle put pressure on the pelvic floor and can actually weaken it.

“The six-pack … you don’t even want to go there. Everybody wants to talk about it but it’s not a good muscle to concentrate on,” says Lovatt.

Concentrate on the core

While it is the most talked about of the abdominal muscles, the six-pack or rectus abdominis is less used in daily living than the deep muscles of the abdominal “core”, says Lovatt.

One particularly hard-working muscle is the transversus abdominis (TVA), the deep core muscle that wraps like a corset around your back and pelvis. It works together with the pelvic floor (that group of muscles stretching like a diamond across the floor of the pelvis supporting the bladder, bowel and reproductive organs), the multifidus (the thin muscle running the length of the spine), and the diaphragm to help stabilise and support the lower back and pelvis.

“You need to get that core strong before you work on anything else.”

New mums need to be particularly careful when exercising abdominal muscles as the effects of the hormone relaxin that loosens your ligaments during pregnancy – particularly around the pelvis – can last for up to six to nine months after giving birth.

So while new mums wanting to return to exercise quickly often seek out high impact activity – as they only have short bursts of free time to exercise – it can put them at risk of injury.

“We need to get the word out that that while new mums can exercise they need to start up slowly again.”

Physiotherapists, continence nurses, and midwives in recent years have also been highlighting the fact that high impact exercise – for particularly mums new and old and menopausal women – can puts them at risk of pelvic floor problems that can lead to a range of bladder or bowel control symptoms.

If you already have a weakness in your pelvic floor, you should consider working on strengthening that group of muscles before undertaking resistance exercises like sit-ups or lifting heavy weights; activities like running, jumping, and skipping; or sports with stop-start running and rapid direction changes like tennis, netball, basketball, and touch rugby. Or avoid them and seek other forms of exercise that your pelvic floor can cope with.

The Pelvic Floor First campaign, begun by the Continence Foundation of Australia and adopted by the New Zealand Continence Association, aims to educate fitness professionals and the public about pelvic floor safe exercises and has just recently launched a smartphone and tablet app as a handy reference tool for what is safe and unsafe (see more info in sidebar).

Gravity, age, and dysfunction

But it isn’t just women who are at risk of pelvic floor problems. The pelvic floor is also battling with gravity as it does its job holding up the pelvic organs over the years.

“As you get older, naturally everything starts to go south,” laughs Lovatt. “So that’s why it’s really important to keep the pelvic floor exercised and strong.”

While people with back problems, multiple births, birth trauma, or women and men who have had gynaecological or prostate surgery are more likely to have pelvic floor issues, incontinence is not an uncommon problem and may affect up to 1.1 million New Zealanders.

Common it may be, but it still isn’t normal for a healthy adult to pee when they cough or sneeze. Just because you’ve had a baby or are middle-aged doesn’t mean you have to accept a lifetime of continence pads.

The TV ads of smiling mums on trampolines may give the impression wearing an absorbent pad is the answer to any embarrassing or uncomfortable leakage, but physios and personal trainers are keen to get the word out that any form of unwanted peeing or leakage is not okay, it is a dysfunction.

“If you are passing water during coughing, sneezing, or laughing, that’s not normal. It’s also not normal if you are having to go to the toilet more often than not and if you are worrying about where all the toilets are when you away from home in case you’ve got to go to the toilet suddenly or urgently.”

What you should do is go off and seek help and advice – either directly to a private women’s health physiotherapist (who are specialists in assessing and teaching pelvic floor function) or talk to your GP, NP, or nurse and seek a referral to a district health board-funded women’s health physio or continence nurse specialist.

Getting it right: old and new ways

There is a good chance people think they have been doing their pelvic floor exercises with no results, but often, they just haven’t been doing them right.

“The pelvic floor can be tricky to isolate. A lot of women think they are pulling up the pelvic floor and lifting it, but in fact, they are squeezing their glutes or they are contracting their abdominal muscles, or clenching their fists, or doing a facial grimace,” says Lovatt.

“It’s a muscle you need to isolate properly for the exercise to be effective. So good exercise instruction is helpful, along with being relaxed and having good posture. You’ve just got to switch off other muscles that may be trying to help you to lift it, but once you’ve got it, you’ve got it.”

Common practice used to be that women were trained to exercise the pelvic floor while peeing by trying to slow or stop the midstream urine flow. That is now seen as an unsafe way to exercise because you should be relaxed when peeing to reduce the risk of bladder retention and UTIs.

To get the pelvic floor back into shape, it’s recommended people should be doing exercises three times a day at first to strengthen the muscle. Lovatt says the exercises need to done in two speed modes – slow and fast – to match the two types of muscle fibre found in the pelvic floor.

The ‘slow twitch muscle fibres’ are the ones you rely on to support your pelvic floor in the normal activities throughout the day from carrying groceries to hanging out washing. The ‘fast twitch muscle fibres’ are the ones that stop you from leaking when coughing, sneezing or laughing.

Initially – particularly just after having a baby or having not exercised your pelvic floor for a very long time – it may feel like nothing is actually happening when you do your exercises, says Lovatt.

“But it will come back. So it’s good to persevere – even if you can’t feel a lift happening straight away – as initially the nerves and muscles are still trying to connect.”

Then, just find a time to do it in your daily routine that works for you, preferably in a relaxed time when you can ensure good posture, which is key.

“The good thing is that it doesn’t take long. Once you’ve started exercising the pelvic floor you can regain pelvic floor strength quite quickly.”

You will be grateful for the rewards next time you sneeze or cough – or when you want to get back into running or netball and know you can rely on your pelvic floor not to let you down.

*Lynda Lovatt trained as a nurse at Waiariki Polytechnic graduating in 1991 and worked mostly at plastic surgery and burns plus paediatrics and has worked in Waikato, London, Starship and Middlemore. After having her children (now 10 and 12) she moved into exercise and is a registered personal trainer in Wellington whose company Puff Fitness specialises in fitness during pregnancy, postnatal fitness and promoting fitness for mothers.

Q. A bit of leakage is normal isn’t it? A. No!

Leaking urine when you cough, sneeze or laugh is not normal just because you’ve had a kid. Nor when jogging, jumping on the trampoline with your kids or doing a workout. If you have been trying to exercise your pelvic floor without any improvement, see your GP or NP and ask for referral to a continence nurse specialist/advisor or women’s health physiotherapist. Women’s health and general physiotherapists are also increasingly using real-time ultrasound so you can see on a screen for yourself how well you are activating your pelvic floor and other core muscles.

Helping your pelvic floor and preventing leakage

More about the pelvic floor

  • The pelvic floor is like a mini-trampoline of muscles that stretches from the pubic bone at the top, to the sitting bones at the edges and the tailbone (coccyx) at the end.
  • The muscle group bears the load of carrying the pelvic organs: the bladder, the bowel and (in women) the uterus.
  • These muscles are also important for sexual function and sensation.
  • Weakened or loose pelvic floor muscles can lead to difficulty controlling the release of urine, faeces, or wind – i.e. incontinence.
  • Pregnancy, childbirth, and hormone changes at menopause make women particularly prone to weakening of the pelvic floor muscles.
  • Age and gravity also impacts on both men’s and women’s pelvic floors over time along with obesity, heavy lifting, or high impact exercise like running and tennis.
  • Correctly isolating and exercising the pelvic floor can strengthen the muscle again and be effective in recovering or building pelvic floor function.

Am I doing it right?

  • Quite possibly not – research shows that up to 50 per cent of women trying to learn pelvic floor exercises from a pamphlet got the technique wrong.
  • The toughest thing is to ensure you are isolating and exercising the right muscles.
  • For both women and men trying to stop or slow the flow of urine in mid flow is one way of checking you are squeezing the correct muscles (but it should not be done repetitively as an exercise).
  • Another method is to imagine stopping the flow of urine and holding in wind at the same time.
  • If you are doing it right nothing above the belly button should tighten or tense. If you are tensing or pushing out your ‘six pack’ tummy muscle you aren’t doing it correctly and you could be bearing pressure down on your pelvic floor.

Found them – what do I do now?

  • Try and do your pelvic floor exercise when you are relaxed and don’t forget to breathe
  • When starting out try them first lying down and then move on to sitting and standing.
  • Repeat these exercises for five or six times in a session. Do quick contractions and then long contractions.
  • Make sure you co-ordinate the breath with the longer contractions.
  • Aim for a 25–30 per cent lift to avoid engaging other muscles other than the pelvic floor.
  • Aim for three sessions a day when you are starting out to strengthen your pelvic floor.

Find a visualisation analogy or technique that works for you:

Elevator: Imagining your pelvic floor is an elevator in the ground floor of a six-storey building. First ‘close the doors’ then lift your pelvic floor slowly up to the ‘top floor’ and then slowly lower it again and ‘open the doors’ and relax.

Silk handkerchief: Imagine you are sitting on a silk handkerchief and are using your pelvic floor muscles from the back passage through to the vaginal area and urethra to gather up the handkerchief and draw it inside your pelvis, then exhale and slowly release.

Drop of water: Visualise a drop of water falling into a bucket and imagine reversing the action to draw the drop back up and out of the bucket.

For more information check out these useful websites:

New Zealand Continence Association www.continence.org.nz (Has links to continence nurse specialists/advisors and women’s health physios in your area)

Home website for Pelvic Floor First campaign www.pelvicfloorfirst.org.au

Continence Foundation of Australia www.continence.org.au

Safe exercise app launched

A free app, based on the Pelvic Floor First website featuring video workouts and pelvic floor safe exercises was launched late last year by the Continence Foundation of Australia. It is suitable for smart phones and tablets and is available from iTunes and Google Play (select ‘iPhone only’ if downloading app to an iPad).