Pelvic floor health - “I wish I’d known this sooner”

AIMS Journal, 2024, Vol 36, No 2

By Lara Watson

“I wish I’d known this sooner” - A sentiment I often hear from women consulting me over intimate health issues. Closely followed by, “Is it too late for me to do anything about it?”

Working as a Womens’/Pelvic Health Physiotherapist, I help to treat a wide range of symptoms, many of which are linked to issues with the pelvic floor, or to use medical speak, pelvic floor dysfunctions (PFDs). I’m talking about problems like urinary incontinence (uncontrollable leaking of wee, with or without urgency), bowel incontinence (uncontrollable leakage of wind or poo, with or without urgency), and pelvic organ prolapse (where one or more of the organs within the pelvis, the bladder, womb or rectum, move down from their usual position, bulging into the vagina). We can also help with some PFDs, that are even less talked about, including things like coccydynia (tail-bone pain), diastasis rectus abdominis - DRA (separation of the muscles down the middle of the tummy), dyspareunia (painful sex), vaginismus (spasm of the muscles around the vagina), pelvic girdle dysfunction-PGD (pain, clicking or grinding caused by the pelvic joints), and pudendal neuralgia (pain or tingling in the genitals due to nerve injury or irritation).

Whatever the problems, generally speaking, my short answer to “Is it too late to do anything about it?”, is “no, it’s never too late”. But a fuller answer would be that treatment is most successful when difficulties are dealt with sooner rather than later, and undoubtedly, prevention is better than cure.

However, in order to prevent something, we first need an awareness of its potential to happen, and it’s not just the women who’ve passed through my clinic doors that wish they’d had more information sooner. Studies around this subject highlight that knowledge about PFDs during pregnancy is low¹ and women would like more education, in particular a stronger emphasis on preventative measures around childbirth.²

During pregnancy and in the weeks following birth, around half of all women report having one or more PFD. Urinary incontinence, faecal incontinence, pelvic girdle pain, DRA and difficulties with sex are the most frequently described,^3,4,5 plus around a third of first-time mums will report symptomatic pelvic organ prolapse.⁴ Although there can be natural improvements in the weeks following birth, it’s not uncommon for symptoms to reappear within a year⁶ and giving birth can predispose us to developing PFDs later in life.^7,8,9 In other words, we can’t just ignore things and hope they’ll go away, even though many of us do just that. I regularly meet women who have put up with things like bladder leaks, pelvic pain and tummy separation for years. Lack of awareness, embarrassment and stigma are the reasons given for many of us putting our PFD symptoms on the back burner.² But whatever the reasons, delaying means we miss sweet spots of opportunity for prevention and for treatments when our bodies are at their most adaptive and changeable.

So, whether we’re trying to conceive, are already pregnant, or recently postpartum, heck, for all of us, it’s worth being informed about these very common problems, with an understanding that ‘common’ does not translate to ‘normal’, and that options exist to safeguard us.

So why do PFDs happen? Everyone’s case and experience is individual, but factors such as having a BMI over 25kg/m2, lack of exercise, constipation, chronic lung disease with a cough, and diabetes, have all been identified as increasing our probability of developing PFDs.⁷ Additional risks specifically associated with pregnancy and childbirth are:⁷

• Being over 30 years when having a baby

• Baby’s birth weight over 4kg (9lb)

• Having given birth before

• Assisted vaginal birth (forceps or vacuum)

• A vaginal birth where baby is lying face up (occipito-posterior)

• An active second stage of labour taking more than 1 hour

• Injury to the anal sphincter during birth

In the overview that follows, I’ve focused on some things we can do to help reduce the risks to our pelvic floor. Links have been included for more in-depth guidance along the way, although it’s important to be aware that this information is generalised, and as always, you should follow individualised advice from your health care professionals.

I feel a good place to start is with some of the things we all could and should be doing, irrespective of pregnancy. Pelvic floor muscle training is recommended to help us prevent and treat PFDs.^7,10 But, however motivated we may be with pelvic floor exercises (sometimes known as Kegels exercise), they’re only effective when performed correctly. When assessing the pelvic floor, it’s not unusual for me to find that womens’ sensory awareness of what the muscles are doing is a little off. In fact, at least two-thirds of us have an incorrect perception of our pelvic floor, feeling we’re tightening when we’re not, and nearly half of us are actually bearing-down.^11,12 But it’s also been found that understanding more about these mysterious internal muscles improves our inner mapping and awareness of them (proprioception), which in turn leads to better muscle function.¹³ So take every opportunity, and be proactive in learning about your pelvic floor, because in this case, knowledge literally equals power. Make sure you’re doing your Kegel exercises right, and if you’re unsure, ask for a referral to a Specialist Womens’/Pelvic Health Physio, who can assess your muscles and show you how.

In terms of what to expect from a pelvic floor assessment, be prepared to answer questions about your lifestyle and general health, as well as any PFD symptoms. Your pelvic floor muscles can be assessed simply, using a lubricated, gloved finger-tip just inside the vagina or back-passage (no speculums like a smear test), allowing the muscles to be palpated for tone and stiffness, and checked for their ability to contract and relax, their power, speed, endurance, coordination and flexibility, in other words, the characteristics the muscles need to work well. Other assessments of posture, pelvic joints, movements and muscles that work alongside the pelvic floor (including the respiratory diaphragm, deep abdominal and spinal muscles) may also be carried out according to your individual needs.

It really is advisable to get on top of any niggles you may have, in particular, because if you go into pregnancy with any existing PFDs, it is likely that symptoms will worsen during pregnancy, and may persist this way afterwards.⁷

During pregnancy, if you haven’t already gotten going with pelvic floor exercises, it’s advisable to start. Doing so can prepare the muscles and tissues for the increased work -loads they will experience during pregnancy and birth, as well as lessen the likelihood of pelvic floor injury during childbirth, a strong risk factor for long-term PFDs.^7,14

Another way to prepare and protect your pelvic floor from birthing injuries is to perform daily perineal massage from around 35 weeks onwards. Be sure to choose an unscented oil. It doesn’t need to be special, olive oil will do the job nicely.

With regards to general activity, we’re long past the days when pregnancy was considered a condition of confinement, the latest advice being to remain active. In addition to following general guidelines for physical activity during pregnancy, my advice is to know your own capabilities, and listen to your body, adapting to changes as your pregnancy progresses.

Throughout, try to be candid in conversations with your doctors and midwife so you can access support in dealing with any difficulties or symptoms arising.

Postnatally, take special care of your pelvic floor area as it is recovering following birth. Remember to keep an eye on staying well hydrated, particularly if you are breastfeeding, and to avoid constipation. And, whilst we’re on the subject, take care of hydration down below too. Hormone fluctuations in the postnatal period can cause vaginal dryness and irritation which in turn, may impact on the pelvic floor muscles’ ability to work comfortably and can make sexual intercourse difficult or painful. There are numerous over the counter lubricants and moisturisers to try, but I use and recommend products that are made with organic ingredients, are paraben¹⁵ and glycerine free, supporting the natural pH of intimate areas.

You may resume your Kegel exercises as soon as you are comfortable, and should do so whether you’ve experienced a vaginal delivery or not.^7,10,16 However, don’t over-do it, and avoid getting into the bad habit of gripping with the pelvic floor. Time after time, I see overly tight muscles being just as problematic as weak ones. Again, if you’re unsure or experiencing persistent symptoms of PFD, request guidance. Specialists like myself are here to treat and guide you, and women say that physiotherapy helps to regain control over PFD symptoms, which enhances their life.² Women tell me they’ve often avoided asking for help for fear of being seen as a complainer. But by reaching out, not only will you access the help you need, but you will also be contributing to the data that helps to inform decisions around future health care provisions for others in similar situations.

As time goes on, you may wish to look at options, other than Kegels, for exercising your pelvic floor. My choice for a more engaging alternative is Hypopressive exercise, a relaxing whole-body technique combining specific rhythmical breathwork and postural flows. Initially developed in Europe in the 1980s, to promote womens’ postnatal recovery, Hypopressive exercise is now practised by women of all ages. The exercise is effective,^17,18,19 rebalancing and retraining the pelvic floor and core muscles reflexively, whilst improving body image and overall sense of well-being.¹⁸

Finally, avoid rushing back to impact activities, and anticipate that you will need to make any return to sports gradually. Guidelines for physical activity from birth to twelve months, along with those for a structured return to running postnatally can help direct you.

So to sum up, exercising our pelvic floor should be part of our regular selfcare in preventing PFDs, especially around pregnancy and childbirth. Our future selves who might want to enjoy a Zumba class, a belly laugh with friends or dare to wear light coloured trousers without fear of leaks or embarrassment, will thank us for it. But remember it takes a combination of sound technique and consistency over time to see results. I believe it’s important to find a type of pelvic floor exercise that we find enjoyable, in order for it to be sustainable, supporting our pelvic health long-term, and through different phases of life. But, if despite everything, you find yourself experiencing PFDs, you are not alone. There are many non-surgical treatment options that you can access through NHS or private healthcare providers, professionals like me whose purpose is to advise, treat, support and guide you.

Author Bio: Lara Watson has worked as a Physiotherapist for over 25 years. Specialising in Womens’/Pelvic Health since 2012, Lara is the proud recipient of 2 NHS awards for ‘Excellence and Innovation” in the field of Womens’ Health. More recently, Lara opened ‘MyCorePhysio’ in North Wales, supporting feminine health through 1:1 physiotherapy appointments, as well as Womens’ Health-Hypopressives Workshops and Retreats.

Links used in this text

Accessing specialist services within the NHS: www.nhs.uk/conditions/physiotherapy/accessing

Care of your pelvic floor following birth: www.nct.org.uk/labour-birth/after-your-baby-born/perineal-tears-recovery-and-care

General guidelines for physical activity during pregnancy: www.rcog.org.uk/for-the-public/browse-our-patient-information/physical-activity-and-pregnancy

Guidelines for physical activity for women after childbirth to twelve months: https://assets.publishing.service.gov.uk/media/620a2ff9d3bf7f4f0ec9b574/postpartum_infographic.pdf

Guidelines for returning to running postnatally: www.csp.org.uk/news/2020-06-03-physios-postnatal-running-guidance-recognised-aligned-government-advice

Pelvic floor exercises: https://thepogp.co.uk/patients/pelvic_health_advice/pelvic_floor_muscles.aspx

Perineal Massage: www.rcog.org.uk/for-the-public/perineal-tears-and-episiotomies-in-childbirth/reducing-your-risk-of-perineal-tears

Other useful resources

Bladder and Bowel Foundation (Information and support for bladder and bowel conditions): www.bladderandbowel.org

The Pelvic Partnership (for information and support for pelvic girdle pain in pregnancy): https://pelvicpartnership.org.u

References