I rarely watch TV and was horrified last weekend to notice that a large number of the TV advertisements for female incontinence products..… disposable panties and pantie liners specifically for those “Oops Moments”….. “Oops Moments” that are seemingly experienced on-mass by ALL of the smiling, glamorous and relatively young women enjoying the “Rebounder” class, in their bright form fitting lycra outfits who seem un-phased and even cheerful about being part of the “Oops Moment Crowd” as they took it in turns to announce they had all just experienced an oops moment whilst bouncing vigorously on their rebounder. I know it is common place for many high impact classes to hand out incontinence pads before the class for just this reason. While I am happy to see that this issue is FINALLY being discussed openly...
aren't we missing the point?
We are not only using a bandaid to patch the symptom rather than dealing with the cause, but normalising pelvic floor disfunction.... and may be putting women in a situation that worsens their symptoms or contributes a more serious problem down the line such as pelvic organ prolapse.
Over a third of all women experience some form of pelvic floor disfunction and this figure appears to be on the rise. I don’t know wether the numbers are actually increasing or its the number of women coming forward for help or - as I suspect - a little of each that are contributing to the increase. While I am glad to see the subject is FINALLY being discussed, I do feel we are missing the point.
These advertisements are normalising incontinence and pelvic floor issues. While leaking and even pelvic pain are all too common they should not be treated as normal. In many cases these symptoms can be treated successfully with physical therapy and pelvic floor training. We should be educating women to come forward and get the help they need.... Some women even find that chronic, severe menstrual cramps can be helped by improved strength and muscular balance in the pelvic floor, lower back and hips.
I have been teaching movement in various forms for nearly thirty years and my experience is that women feel embarrassed, dirty, sexually unattractive and restricted by their “Oops Moments” and often too ashamed to seek help. Even when they know (which many don’t) that Physiotherapy and appropriate movement education can help. Most women put this off until they are absolutely desperate fearing that it will be a mortifying and shameful experience. I am still haunted by a woman I trained 25 years ago who had severe pelvic floor issues. At the time I worked part time in a physiotherapy unit with a women's health physio and tried to encourage this woman to seek help but I was too young and too inexperienced to deal with this myself and as is commonly the case the woman involved was too ashamed to seek help.
This is a terrible shame as without exception I find that once a woman asks for help she finds the whole process enlightening and empowering. A good women's heath physiotherapist can help her understand what is going on and how to appropriately recruit her pelvic floor she can take control of the situation and becomes instantly more confident and relaxed.
So its just that one muscle so if we just do our kegels we should be fine right?
The word "Kegel" kinda makes me wince..... not be cause kegels are inherently bad but because the general understanding of a kegel is to "clench" the pelvic floor and hold. Using the word clench is not useful and often women who are not sure where their pelvic floor is or how to engage it will "clench" everything and never let it go. And by everything I mean...... buttocks, upper abs, mid back, inner thighs even the teeth! but often not their pelvic floor.
It is also worth mentioning here that it is not always pelvic floor weakness causing the problem, sometimes the pelvic floor may be over active so trying to tighten it even more is not going to work. In a health pelvic floor programme you will be taught to relax as well as engage.
But more is better - right?
I will say it again.... NO! we slave under the misconception that if something isn't working its not strong enough or not working hard enough so we need to do more kegels and harder.... I have clients who have been told to do a minimum of 300 kegels a day and then wonder why they have developed chronic pelvic pain. We need to understand that the body is not designed to be tight and ridged.
"When you see a body that is moving well how would you describe it.... taught, tight and rigid? or fluid, effortless and graceful?”
The body is a finely balanced tensional system that depends on a delicate balance of push and pull, engage and release. For example If the back of your legs are habitually tight there is no point repeatedly stretching them. You need to discover why they always “feel” tight. Often I find that a muscle feels tight because it is working harder to compensate for something else that isn’t working as well. Once the lazy or inhibited muscle starts pulling its weight this is addressed and balance restored the “tight” muscle no longer feels tight..... Voilà!
So what leads to pelvic floor dysfunction?
Well there is the obvious. Pelvic Floor dysfunction is often put down to the body changing due to child birth. While pregnancy and childbirth can change the body and occasionally cause injuries. However you should be expected to put up with your new leaky body and get on with it, and its not the whole story, many other things contribute to Pelvic Floor Disfunction including the following.
Being postnatal, wether your baby is 2, 20 or 40 you're still postnatal.
Menopause, we experience many changes that can adversely affect pelvic floor function during menopause including a loss of muscle tone. So it becomes even more important to work on your pelvic floor health at this stage of life and beyond.
Habitually wearing high heels…. I know I love them too! but they can affect posture and pelvic floor function.
Very short, locked, hamstrings and calves.
Tucked Pelvis and tight lower gluteals (buttock muscles).
Sitting for prolonged periods and/or poor posture.
Weak gluteals (buttock muscles)
Weak and immobile feet.
Chronic constipation or coughs.
Pelvic floor too tight….. yes can you believe that!
As movement educators we are often exacerbating the issue by over cueing the pelvic floor and core encouraging tight rigid over engaged musculature.
Often the language we use is misleading..... "up tight and out of sight!" is a phrase I have heard several times. Or “squeeze your booty” all of which mislead women into the idea that more is better and they should be tight and tucked. Having a tight and tucked booty will guarantee is that the pelvic floor switches off.
I had a client the other day say she wanted her pelvic floor "so tight she could tuck it behind her tonsils"!! While I hope this client was actually joking it does give you an idea of how unrealistic our expectations and desires for our body can be.
I often have to explain to highly sceptical clients that it is not only functional to be able to engage and release the pelvic floor - but safe…. You won't empty like a toothpaste tube if you relax your pelvic floor. In fact you need to be able to release and lengthen your pelvic floor.
In general we have this idea that a "tight" pelvic floor is better... better for preventing incontinence... better for our bodies... better in the bedroom. This is actually a terrible misconception. It would not be functional if our hamstrings were so tight and short we could not release them to straighten our legs? so why would this work for the pelvic floor.
We want a group of muscles that can engage and release in response to our activities allowing fluid movement, running, dancing, going to the toilet and having sex, its that quality of muscle that will be able to react quickly to support us when we sneeze or laugh or can't get the keys out of the bottom of our over stuffed handbags fast enough.
So what should you be doing?
NICE recommends we should perform three sets of up to tens second holds and three sets of up to ten quick flicks three times each day..... EVERY DAY. This means
Engage your pelvic floor and hold for up to 10 seconds and release x 3
Engage and release your pelvic floor up to 10 times fast x 3
This should be repeated three times a day
If you'r not sure find a physiotherapist who specialises in women's health or a good pelvic floor training programme and learn how to recruit your pelvic floor effectively.
Combine this with a holistic movement programme that will address the body as a whole to ensure that the entire muscular system is working well. This should normally include the following (although you need to check with your physiotherapist to be sure this works for you)
Learn how to engage and release the pelvic floor.
learn how to ensure your posture isn't exacerbating the issue.
Learn how to recruit the lower abdominals.
Strengthen your gluteals to support your lower back and pelvis.
Work on mobility thoughout the spine and hips.
Develop a healthy balance between your hip flexors and hamstrings.
Ensure your feet are strong and mobile.... yes your feet can make a huge difference.
As for the vilified kegel. People usually go wrong in in the following ways:
Engage all muscles in the general pelvic area to a maximal level... ie "clench"!
Using the upper abdominals to brace or bearing down.
Squeeze their butt.
Tuck the pelvis under.
This combination gives a good strong sense of support as everything is braced, tight and absolutely ridged. But, this is not functional and will exacerbate Pelvic Floor Disfunction by preventing it from engaging effectively.... ie stop it working!
When engaging the pelvic floor you want the engagement to be a gentle and fluid engagement that lifts forwards and up and should be initiated from the pelvic floor….. never brace and especially not in a downward direction.
I find women often find it very difficult to "feel" what they are doing when engaging the pelvic floor. I think there are a couple of reasons for this.
Firstly we cant see the pelvic floor fire..... it is internal and will lift our bladder up by 10mm... maybe. You cant see that and and can barely feel it if you'r not sure what your feeling for. Its not like a bicep muscle where you see your arm bend and can feel the weight of the kettlebell or the weeks groceries in your bag for life carrier.
Also these are deep postural muscles. As with all postural muscles they are not designed to fire up 100% at maximum effort for a short blast of effort. I always think of postural muscles as working like a relay team so they can keep you supported all day. So maybe 20% will work and hand the baton on to the next 20% of the fibres when they are fatigued.... occasionally (when you sneeze for example) 60% might fire up for a second. But essentially they are working at a lower level. This allows them to work all day but the lower level of engagement means they can be harder to pin point.
If you are used to gripping for dear life, trying with all your might to tuck your pelvic floor behind your tonsils this gentler engagement can feel very strange to begin with. Especially if your are used to tucking your pelvis, when you soften this tucked posture and find a nice neutral spine and pelvis and maintain the natural curves of your spine it can feel precarious to begin with. Stick with it and you will soon discover that you are better able to engage your pelvic floor.
I have several cues I find useful, probably the one I use most is this:
You know the hole in the middle of the pelvis? imagine that is the hole in a paper hankie or tissue box..... now think of the pelvic floor being the top hankie. you are going to gently pull that top hankie into a dome and then release and allow the dome to sink back into its original position. I like this as it is gentle, you don't want to tear the hankie or pull it out of the box completely.
Others I use:
Think about drawing your sits bones, your coccyx and your pubic bone gently towards each other and slightly up and back wards and then release... this is the same as the above cue but thinking more anatomically rather than visually.
To imagine a loose zipper that runs from your tail bone forwards between your legs and up the front seam of your body to the ribs just above your navel.
As mentioned before you can imagine drawing up to stop the flow of urine (don't actually do this while your mid pee, although after you have finished is a good time as your pelvic floor should be nice and relaxed and you may find you get a better engagement)
Imagine squeezing a tampon on drawing it up and in towards your cervix, then fully release.
You should be able to gently hold this engagement while talking without anyone knowing.... something to practice next time you are at the post office buying stamps.
If you are interested in training with me, I'd love to hear from you so feel free to contact me directly. I teach in Edinburgh and the Lothians in Scotland as well as offering online training.https://www.fionacarterpilates.co.uk
To find an Adore Your Pelvic Floor Coach in your area: https://adoreyourpelvicfloor.co.uk/courses/adore-your-floor-course/
If you are interested in training to be an Adore Your Floor Coach: https://adoreyourpelvicfloor.co.uk/courses/teacher-education-classes/
This Blog is not meant to be used as a treatment programme. While I hope you find the information I have shared interesting it is based on what I have found useful in my teaching over the years and the best and most current research. However, you should always seek the guidance of medical professionals in treating any condition. As a Pilates teacher I am not qualified to diagnose any condition. I would recommend seeking the advice of a good Physiotherapist or your General Practitioner. I would also recommend training with a Pilates Teacher who has completed a in depth training in the field. Pilates courses can vary vastly from short online trainings to three or four year in-depth full time apprenticeships. don’t be afraid to ask questions about your teachers training and experience. If you would like to train with me as a Pilates Teacher or as a Pelvic Floor Coach or find an Adore Your Pelvic Floor programme in your area. Get in touch I'd Love to hear from you.