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Pelvic Floor Health

Posted Tuesday, 15 September 2020

Date issued: October 2019

For review: October 2021

Ref: C-387/VWH/Physiotherapy/Pelvic Floor Health

What is the pelvic floor?

The pelvic floor is made up of layers of muscle and soft tissue which form a sling, like a hammock, from the pubic bone at the front of the pelvis to the base of the spine at the back. The supportive muscles are called the pelvic floor muscles. Along with the ligaments and soft tissue, they help to keep the bladder, womb and bowels in the right place and working normally.

How does the pelvic floor work?

The pelvic floor muscles usually work without us having to think about them. The muscles are kept firm and slightly tense to stop leakage (incontinence) of urine from the bladder or faeces from the bowel. When you empty your bladder or bowel the pelvic floor muscles relax. Afterwards, they tighten again to restore control. The pelvic floor muscles help to keep your pelvic organs in the correct position (preventing prolapse). They work in combination with other core muscles to support our lower back and trunk and also provide support to the vaginal wall; they can also help you feel more sensation during sex.

Our pelvic floor muscles should silently do their job, allowing us to function without interruption throughout the day and night. There are many factors and life events however that can weaken the muscle, and yet many people are unaware or do nothing to ensure good health of these very important muscles.

Why does the pelvic floor become weak?

Pelvic floor muscles can become weak due to:

Pregnancy and childbirth.
Lack of exercise.
The menopause.
Weight gain.
Increasing age.
Previous surgery.
Straining to empty bowels (constipation).
Persistent heavy lifting.

Signs and symptoms of a weak Pelvic Floor

Incontinence:

Incontinence is the involuntary loss of urine. There are two different types of incontinence.

Stress Urinary Incontinence

The complaint of involuntary leakage of urine on effort, exertion, or on cough or sneeze.

Physical movements or straining causes extra pressure in the abdomen and this puts more pressure on the bladder. If the pelvic floor muscles that support and close off the bladder’s opening don’t work properly, urine leaks out.

Urge Urinary Incontinence

Involuntary urine leakage accompanied by or immediately preceded by an urgency to urinate.

This is also called Over-active Bladder.

Some people have both types which we term Mixed Incontinence.

Pelvic Organ Prolapse

Prolapse

A pelvic organ prolapse refers to the drop, bulging or herniation of one or more of the pelvic organs into the vagina. It occurs when the muscles, ligaments and other soft tissue, called fascia, weakens and is unable to support the organs.

Symptoms include:

A heavy dragging feeling in the vagina and sometimes in the back.
A feeling of a lump in or coming out of the vagina. Some people report it feeling like a loose tampon or small golf ball
Changes to urinary flow, it may slow down or feel like you don’t completely empty your bladder. Some people experience increase in frequency or urgency and some stress incontinence.
Bowel symptoms such as not being able to empty properly, or needing to press on the vaginal wall to empty the bowel.
Prolapse symptoms are often worse at the end of the day, with prolonged standing.

A prolapse can be mild causing little or no bother, or may be severe causing many problems and affecting a person’s quality of life.

Causes of prolapse

A number of life factors can cause damage to the muscles, ligaments fascia and nerves.

The main causes are from:

Pregnancy and childbirth (1 in 3 ladies are affected). The weight of the developing baby puts strain on the structures. An episiotomy, tear or delivery requiring forceps can add to the weakening of the soft tissue.
Aging and the menopause may further weaken the pelvic floor structures.
Obesity, chronic cough, chronic constipation, heavy lifting and straining are all conditions that can cause excessive pressure on the pelvic floor.
Some conditions such as Ehlers-Danlos Syndrome and Marfans Syndrome affect the strength of connective soft tissues.

Where do prolapses occur?

The prolapse is usually described according to the area of the vagina in which it occurs.

An anterior vaginal prolapse generally involves the bladder, and sometimes the urethra. The term cystocele is used by the medical profession. This is the most common prolapse.
A posterior vaginal prolapse occurs when the lower part of the large bowel (Rectum) bulges into the back wall of the vagina, often referred to as a Rectocele.
An apical prolapse occurs when the uterus drops down into the vagina. Often called a uterine prolapse. If you have had a hysterectomy your vagina can drop downwards, this is known as a vaginal vault.

Many women can have more than one prolapse.

What you can do

Pelvic organ prolapses are unfortunately common. It is estimated that approximately 40% of woman over 50 have some form of prolapse.

Woman with prolapses have been found to have weaker pelvic floor muscles. It therefore makes sense, and evidence has shown that a pelvic floor exercise programme can be effective in reducing the prolapse symptoms.

Follow all the advice in this booklet with regards to strengthening your pelvic floor muscle. In addition, make sure you follow all the bowel and life style advice. Try to break your daily activities into shorter periods of standing, taking regular breaks to sit for a while. Keep active, but consider exercises which are lower impact such as low impact aerobics, cycling, swimming and Pilates.

Why should you exercise your pelvic floor?

As has been discussed, weak or untrained muscles can give you less control and support of your bladder or bowel, and so can be the cause of urinary leakage, faecal leakage or prolapse.

Pelvic floor exercises can strengthen these muscles so that they once again give support. This can improve your prolapse, and helps you to regain control of your bladder and bowel to improve or stop leakage.

You may find the exercises difficult at first, but with patience and perseverance over 3 to 4 months you should notice a difference. Like other muscles in the body the more you regularly use and exercise them the stronger they will be.

Evidence has shown that effective strength training of the pelvic floor muscle three to five times a day, every day; over 12 weeks can alter and improve muscle function.

Your physiotherapist will guide you on how to do a proper/good pelvic floor muscle contraction, and how to build fast and slow endurance holds. They will guide you through appropriate challenges to maximise your results and enable you to carry out your everyday activities with minimal problems.

Learning to do pelvic floor exercises

Squeeze/tighten the muscles around your back passage, as if you were trying to stop yourself from passing wind.
Tighten/lift the muscles at the front as if you were trying to stop the flow of urine.
Now squeeze/tighten/lift both the back and front together as tight as you can. We call this your maximum hold.
You should feel your lower tummy muscles gently working, but your thighs and buttocks should not be working.
Make sure you breathe normally and do not hold your breath.

How to check

If you are unsure that you are exercising the right muscles, check the exercises by putting one or two fingers into the vagina. If you are tightening the pelvic floor muscles, you should feel a gentle squeeze and inward lift.

Practising your exercises

To change the quality and strength of your pelvic floor muscle you will need to practice your exercises 3 times a day for 3-4 months. After that, to ensure you maintain the improvement you have made in this time, you will need to do your pelvic floor exercises once a day for life

It is good to practice your exercises in different positions. Try standing, sitting and lying down. Start with the position that is easiest until you have the hang of it.

Many women find it useful to make a list of activities that will prompt them to do their exercises

Whilst having a tea break.
When watching TV.
After using the toilet.
When washing your hands or the dishes.
Driving to work/school run.

‘The knack’:

Quickly tighten the pelvic floor before exertion

When the pelvic floor is working as it should it will automatically contract before, and during any increase in pressure in the abdomen; such as during a cough, a sneeze, when blowing your nose, stepping down heavily, going from sit to stand or when lifting.

Woman often lose the reflex to contract the pelvic floor muscles just before a cough/sneeze. This often happens after pregnancy and childbirth, after prolonged straining to open bowels, or after pelvic surgery.

They will often leak with any increase in pressure from above. By learning to actively contract the pelvic floor muscles just before the increase in abdominal pressure, woman can learn to overcome the bladder leakage. This has become known as “The Knack”.

The contraction of pelvic floor muscles will help to close the urethra (urine tube), and protect the pelvic organs, minimising prolapse and urine leakage.

Practice makes perfect: practise the knack initially with an empty bladder. After you have emptied your bladder, do the knack and have a light cough. Over the next few days challenge yourself with a stronger cough.

Once you are feeling happy with this, leave an hour after emptying your bladder (the bladder will have filled a little) and try again with progressively stronger coughs.

As well as with coughs, put the knack into practice with daily activities which are prone to cause you difficulties, such as lifting.

With practice you will have trained a learned habit, your brain will be used to the sequence of prepare, protect, cough, and you will start to do it on auto pilot.

Sneezes, coughing fits and vomiting are harder to resist with the knack due to the increased abdominal pressure. Work on getting the lighter coughs sorted first and with on-going practice the rest will follow

Exercise Diary

Slow pull-ups

Hold your pelvic floor maximal squeeze for as long as possible (up to 10 seconds) and then let go. Then see how many times you can do that in a row with a 3-4 second rest between each squeeze.

Fast pull-ups

Maximally squeeze tightly and then relax your pelvic floor, count how many times you can do this in a row until the muscles tire.

Progressing your exercises

Be realistic about how often you can do the exercises, but aim to do them three times daily.

Over the weeks try to beat the score (length of hold) you had previously. If you started with 5 repetitions of a 3 second hold, after a few days try 6 repetitions of a 3 second hold, over time slowly increase.

The aim is that by the end of each session your pelvic floor will feel tired. As the muscles get stronger, you will find that you can tighten for longer and do more exercises.

Build up to being able to hold for 10 seconds and repeat 10 times slow endurance holds, and 10 fast.

Record your progress on the Exercise Diary provided.

It takes time for exercises to make the muscles stronger. You may not notice improvement for several weeks, so stick at it!

Normal Bladder

A healthy bladder can hold around 400-600ml, it is normal to go to the toilet approximately 7 to 9 times a day and once during the night. As you age (over 70yrs) it is normal to go to the toilet twice a night.

As the bladder starts to fill it sends warning messages to the brain. You will normally feel the first warning that you need the toilet when there is roughly 200ml of urine in your bladder. If you decide it is not convenient to go to the toilet your brain will send messages to your bladder to not respond and you can continue with whatever you are doing at the time.

Normally we can hold on for a little longer until your bladder has filled a bit more and it is an appropriate time to visit the toilet. Once sitting on the toilet the pelvic floor muscles will relax and the bladder muscle will squeeze until all the urine has been emptied.

What is Overactive Bladder (OAB)

If your bladder is Overactive you are likely to feel you desperately need to rush to the toilet (Urgency), and sometimes you may leak before you get there (Urge incontinence).

You may go to the toilet more than once at night (nocturia), and a lot more during the day than those around you (frequency).

Some people get into the habit of going to the toilet more often than they need to in an attempt to prevent unwanted accidents. This, however, has the potential to make things worse in the long run.

If you go to the toilet often the bladder gets used to being less full, so overtime the bladder can become more sensitive and overactive when it is only stretched a little.

It is not fully understood what causes OAB, but there are steps you can take to resolve or improve your symptoms.

What you can do to help keep a healthy bladder

Use of Frequency Volume Chart

The first step is to be aware of what your bladder habits are. Frequency volume charts can be used to increase this awareness.

Over three days you will need to take note of what you are drinking, how much you are drinking, and using a measuring jug note how much volume you urinate. If you have to wake at night to go to the toilet this is also noted, as are any leaks.

The overall pattern can then be discussed with your physiotherapist or any other health care professional involved in your bladder control care.

Filling in the chart should also make you aware of which aspects of the healthy bladder training are most important for you.

Making small changes in your daily habits can start to show positive changes in your symptoms.

Re-doing the fluid diary 6 weeks later should hopefully show you how far you have progressed and improved.

If your physiotherapist has not issued you a frequency volume chart you can print one off from University Hospitals Plymouth Website.

https://www.plymouthhospitals.nhs.uk/physio-patient-information

Bladder retraining

The purpose of bladder retraining or bladder drill is to learn to supress or ignore the desire to pass urine, and enable the bladder to tolerate being stretched and steadily increase its capacity. Over time this will lead to a reduction in the frequency and urgency of needing the toilet and a more normal pattern of going to the toilet.

The ideal time between visits to the toilet is 3 to 4 hours, and the average volume of urine should be approximately 300ml. Training your bladder to be able to tolerate this takes effort and time.

Your brain has a big part to play in bladder retraining. The brain has to make a sensible story of all the information it receives, it is the brain that decides how much urgency you feel, not your bladder. The brain will use various centres of the brain to work out what it needs to do. Past memories, emotional centres, thought and learning centres are all involved in the decision to empty your bladder. If the brain uses all these centres and perceives you are in danger of losing control of your bladder, it will communicate this to your spinal cord, and you will act on the urge and rush to the toilet.

If we always give into our urge our bladder and brain get used to the bladder holding less and the brain will continue to trigger the urgency mechanism.

The aim and goal of Bladder Retraining or Bladder Drill is to quieten the nervous system and allow “normal” messages to travel between the brain and the bladder.

Tips to help hold for longer:

Keep calm. Stop and stand still if the urge is strong.
Go up and down on your toes, or curl your toes.
Take a few deep breaths.
Distract your mind i.e.: count backwards from 50.
Do 5 quick pull ups.
Pull up your pelvic floor muscle and hold for 10 seconds.

Squeezing your pelvic floor muscles sends messages to your brain which can help to suppress the urge.

Set realistic targets; when you feel the need to go to the toilet try to hold on for an extra 5 -10 mins using the techniques mentioned above. Try to gradually increase the time between visits to the toilet, eventually you will be able to leave around 3 to 4 hours between visits. Remember, when you have regained control, do not go longer than 4-5 hours without passing urine (except of course overnight).

Stop going to the toilet for “just in case” wees. Many people do these before work or before getting into the car. It is better to listen to your bladder and go when it is full even if it means finding a toilet when you are out.

It may take several weeks or months to get to this stage. Retraining your bladder habits requires considerable will power and determination, and only you can do it, just remember giving in to your bladder will only make things worse.

Relationships and OAB

Overactive bladders can often affect a women’s sexual health. It can cause discomfort and leaking during sexual intercourse, and can reduce the desire and ability to achieve orgasm. Visiting the toilet before intercourse may help. It is worth talking to your partner so they understand, and you may want to try different positions that put less pressure on your bladder.

Medications for OAB

There is a range of medication that can help with the symptoms of OAB. Used in combination with bladder drill/retraining and lifestyle changes they may improve symptoms. If you have been prescribed any OAB medications you may need to take it for a few weeks before you notice a difference. Your GP will inform you how long you will need to take this medicine for.

How do the medications work?

Medications called Anticholinergics (e.g. Oxybutynin, fesoterodine, solifenacin) reduce the contractions by blocking the messages sent to the bladder. This will reduce the feeling of needing to go to the toilet and cuts down on the number of leaks. Anticholinergics can have side effects, 1 in 3 people will experience a dry mouth, less common side effects are constipation, taste disturbances, dry eyes, blurred vision and drowsiness. If you experience side effects you may be given an alternative medicine called Mirabegron. Mirabegron relaxes the bladder muscle reducing the activity of the muscle and therefore decreasing the urge, it can take up to 8 weeks to take effect.

Other life style changes that can help

Do pelvic floor exercises

Doing regular pelvic floor exercises have been shown to improve bladder control.

Watch what you drink

Try to reduce coffee, tea, and fizzy drinks and anything containing alcohol or caffeine as these can increase bladder activity and lead to leakage. Other known bladder irritants are drinks with artificial sweeteners, citrus juices, blackcurrant juice and tomatoes. Moderation is the key. If you are planning on cutting out caffeine, do so gradually so you don’t get a headache.

A good amount of fluid to consume is 6-8 cups of liquid each day (about 1.5 to 2 litres). If you drink too little it can lead to concentrated urine which can irritate the bladder and cause urgency or incontinence. Too little fluid can also cause constipation. However drinking excessive amounts can also cause a problem with frequency. If you are pregnant, breast feeding, exercising or it is hot you will require more fluid.

Try to drink non irritable drinks which include water, fruit or herbal teas, milk, soups, and diluted juice drinks.

Try to spread your drinks out in the day and avoid drinking late into the night. Stop drinking 2 hours before you go to bed.

Avoid irritating foods

Some foods can worsen incontinence in certain people. Watch out for chocolate (another source of caffeine), as well as spicy food or acidic foods like tomatoes and citrus fruits as these are common irritants to the urinary tract.

To identify potential culprits, eliminate one type of food every two to three weeks to see if your symptoms improve.

Do not underestimate the effect of food and drink and its effects on your bladder and bowel.

Don’t smoke

Cigarette smoke and nicotine act as immediate bladder irritants. Smoking can also increase the risk of bladder cancer over the long term. The chronic cough often associated with smoking can also lead to accidental leakage and weaken the pelvic floor. If you need help quitting visit: www.smokefree.nhs.uk

http://www.oneyouplymouth.co.uk/

Protect yourself from UTIs

Urinary Tract Infections (UTIs) can cause temporary episodes of incontinence because of the bacteria that commonly invade the bladder and weaken the muscles in the urethra. A UTI will not trigger incontinence for most people, but it can make a difference if you are incontinence prone.

Empty your bladder before and after intercourse to cut your risk of UTIs.

Keep a healthy weight

The heavier you are the more weight presses on the pelvic floor muscle and bladder. Maintaining a healthy weight can reduce the pressure on the bladder. http://www.oneyouplymouth.co.uk/

Avoid constipation

Constipation can place added pressure on the bladder and increases the need to urinate more urgently and frequently. Common causes of constipation are irregular meals and not enough fibre in the diet, a lack of physical activity, dehydration and some medications.

The word constipated can mean different things to different people. Constipation is generally defined by doctors as a person having any of the following features:

Opening of the bowels fewer than 3 times a week.
Needing to strain to pass stools.
Hard and lumpy stools which may be large or small in size.
Finding it difficult or are unable to completely empty your bowels.
Having to use a finger or hand to help you to pass stool.

You may also experience stomach aches and cramps, feeling bloated, diarrhoea alternating with constipation, and backache.

Don’t ignore the body’s signals to have a bowel movement. This often occurs after a meal, particularly breakfast. A hot drink in the morning may stimulate the contractions of the gut and encourage a bowel movement.

If you have any of the following symptoms for more than 6 weeks, then you need to see your GP: a continuing change in bowel habit, unexplained bleeding from the back passage, abdominal (stomach) pain or discomfort, weight loss or tiredness.

What causes constipation and what to do to improve

The exact cause of constipation may be difficult to identify, however there are a number of things that may contribute to the condition, including:

Not drinking enough: the body needs around 2 litres of fluid a day to function efficiently. Without sufficient fluids, stools dry out making them harder to move through the bowel.

Diet: dietary fibre provides the bulk that helps to speed the passage of waste food through the bowel. Lack of fibre results in harder, more compacted stools which take longer to pass. Keep the bowels running smoothly with a healthy intake of fibre 20 to 35mg a day. Eat regular meals to get your bowels working. Do not skip meals especially breakfast, as it can make your bowel sluggish or irregular. Avoid hurrying your meals and chew your food properly. Avoid processed foods and foods with a high fat content. Eat a diet with a healthy amount of both soluble (vegetables and fruit) and insoluble (cereals /wholegrains) fibre. Try to eat at least 5 portions of fruit and / or vegetables a day.

Lack of exercise: if you don’t exercise regularly, things can slow down, including muscle contractions that move stools through the gut.

Pregnancy: Hormonal changes in pregnancy can slow down the gut movements, and in later pregnancy, the baby pushes the bowel making it more difficult for stools to move. New mothers may find they cannot respond to the urge to open the bowels and they run into problems through a lack of routine.

Some medications: can cause constipation as a side effect. For example, painkillers like co-codamol, codeine and morphine slow down the bowel. Iron tablets and some of the medication used to treat heartburn, high blood pressure, heart problems, depression and Parkinson’s disease.

A decrease in thyroxine levels in the blood, due to a condition called hypothyroidism, can slow down the bowel. Similarly, increased levels of calcium in the blood called hypercalcaemia can slow down the bowel leading to constipation.

Following any major surgery: this is due to a variety of factors such as painkillers, an inability to push due to pain following surgery, decreased food intake and damage to various nerves in the pelvis following some major pelvic operations.

Eating disorders: patients with an eating disorder cannot be expected to have regular bowel actions due to a lack of roughage. They may continue to have constipation even after normalisation of eating behaviour, due to the inability of their bowel to fully recover.

Lifestyle: people sometimes feel unable to open their bowels due to various reasons, for example stress, poor toilet access or their busy life schedule. Consequently, they tend to ignore the sensation of needing to go to the toilet to open their bowels and over the years, their bowel slows down, resulting in constipation.

Psychological disturbances: major events in life such as bereavement can result in constipation. Constipation is common in people suffering with anxiety and depression.

Sit correctly on the toilet

Sitting correctly on the toilet will enable efficient emptying of the bladder and bowel and will prevent straining.

The best way to open your bowels is by using your abdominal (stomach) muscles to push. Feet up on a footstool, leaning forward, supporting your elbows on your thighs and bulge your abdominals outwards (make your waist go wide). Now use these abdominal muscles as a pump to push backwards and downwards into your bottom. Relax your back passage.

Some people see some improvement in their symptoms within a few weeks; however, have patience as for many it can take a few months.

If you have any further questions please do ask your Doctor, Practice/District Nurse, Health Visitor, Continence Adviser or Physiotherapist for help.