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Hidden in Plain Sight: Pelvic Floor Dysfunction

A story from our Director of Education, Carolyn Appel.

I hand my 42 year-old client, Anna, the jump rope and tell her we are going to do three, 30-second skipping intervals. “OK, but let me go pee first,” she says.

I didn’t think twice about a client hitting the restroom before a bout of plyometrics because (1) it was relatively common and, (2) I remember having to do the same thing when I was a teenage athlete.

Over a dozen years later, I think back to Anna and the many other clients whom I failed. Not out of malice or neglect, but because I didn’t know any better. None of the continuing education conferences I dutifully attended ever mentioned Pelvic Floor Dysfunction (PFD), not even the pre and postnatal course I took as a green, new hire. So, I had no idea that Anna (or I) was experiencing a classic sign of PFD: accidental urine leakage during impact activities.

Does this story sound familiar to you? Unfortunately, PFD is too often viewed as an annoying, but normal, part of life. Perhaps this stems from the subject being too “taboo” to discuss in the past. Thankfully, discussions about the pelvic floor are becoming more mainstream today, so hopefully we are headed toward a shift in how we view this condition. Let us make one thing clear:

Just because it’s common, does not mean it’s NORMAL.

PFD is a core issue that — if not addressed — can lead to pain or other complications, and can certainly have a negative impact on one’s quality of life.

In this post, we’ll help you understand PFD, learn how to spot it, then importantly, provide you some tips that can help you significantly improve your clients’ quality of life.

Your Pelvic Floor: Structure & Function

Your pelvic floor (PF) is comprised of three layers of muscles (14 muscles in total), which form a sling at the bottom of your core. A well-functioning PF supports the pelvic organs, controls continence, provides core stability, aids in sexual response, and assists in guiding a baby out during delivery. In addition, due to the PF’s lateral attachment points on the proximal ends of the femurs (the ischial tuberosities), it helps to provide stability and strength for any movement involving the lower body.

Understanding Pelvic Floor Dysfunction

Now that we know what a PF is supposed to do, we can look at conditions that come from a poorly-functioning PF.

  1. Stress Incontinence: Accidental urine leakage during movements like coughing, laughing, sneezing, or any sort of impact activity in which there is a spike in intra-abdominal pressure. Fecal incontinence can occur as well, triggered by the same conditions as listed above.
  2. Pelvic Organ Prolapse: When one or more of the pelvic organs (bladder, rectum, or uterus) descends lower than its normal position, in some cases protruding through the vaginal or rectal openings. Often, the way it is described as a heavy, “bowling ball” feeling between the legs.

What Causes Pelvic Floor Dysfunction?

Like Diastasis Recti, PFD is caused by a buildup of excess intra-abdominal pressure (IAP) that cannot be adequately managed. This is often a factor for pregnant women, whose growing belly and uterus place a great deal of excess pressure on the PF muscles. In addition, the following things add even more pressure:

  • Alignment Shifts: A growing belly during pregnancy tends to tip the pelvis forward into lumbar lordosis, as you see in the image below. The greater the anterior pelvic tilt, the greater the pressure on the PF muscles.

  • Weak “Core Canister” muscles: These muscles (diaphragm, transverse abdominis, and pelvic floor) act as a pump to regulate intra-abdominal pressure. If the Core Canister muscles are weak, this “pump” does not work effectively, which can lead to a pressure buildup. Yet another reason why 360˚ Breathing is so important.
  • Sucking in and chronically engaging: Women have a tendency to do these behaviors as a way to hide their bellies or attempt to make them look smaller. However, they can end up having the opposite effect because of the pressure buildup they create in side the core. Watch this video to learn about these Behaviors to Avoid (and why).
  • Breath-holding upon exertion: Also known as “valsalva,” this technique of breath-holding upon exertion is sometimes used by individuals attempting to lift max loads because it creates a spike in IAP, which allows for greater force production. However, this pressure buildup often has nowhere to go but downward onto the PF muscles, especially if the TVA is engaged. This is why PFD is also quite common in the powerlifting community. Ensure your pre and postnatal clients exhale on the effort and also encourage them to avoid “bearing down” on the toilet (another form of breath-holding upon exertion).

By the time a woman gets to delivery, her PF muscles are already quite stressed (perhaps even compromised). Then, she must endure the further trauma of delivery. In a vaginal birth, the PF muscles are responsible for helping to guide the baby out during delivery. However, if they are underactive, or in a weakened and shortened state from all the stress they have endured, this could result in increased tearing.

A C-section also traumatizes the PF muscles. During the procedure, the abdominal muscles are moved in order to pull the baby out. Because of how intricately connected the abdominal and pelvic floor muscles are, this major abdominal surgery also impacts the pelvic floor.

So, in summary, pregnancy alone puts a great deal of excess strain on the PF muscles, and that is why PFD is common during pregnancy. However, delivery certainly adds to it, and that’s why PFD is even more common in the postpartum period.

Keys to Mitigating PFD

In our Pre/Postnatal Performance Training Specialist Course, we focus a great deal on proper pelvic floor training — including alleviating excess tension, targeted strength work, labor and pushing preparation, and thorough recovery work. For now, here are a few key tips that can go a long way in helping your clients. FIRST address the behaviors above that place added stress on the PF muscles:

Many women also ask about “Kegels.” While we do teach targeted pelvic floor work in our education, we do not use this term because Kegels have become synonymous with:

  1. Focusing only on the anterior part of the pelvic floor (the “pee-stopping” muscles), neglecting the lateral and posterior attachment points
  2. Focusing primarily on contracting and “squeezing” the muscles

This second point is important, and something we discuss at length in our course. The PF muscles are like any other muscles in the body. They must be worked through a full range of motion. The relaxation, or lengthening, portion of the movement is just as — if not more — important than the contraction, especially during pregnancy when the muscles have to know how to relax and lengthen for delivery.

For this reason, we refer to our pelvic floor exercises as PFAs (Pelvic Floor Activations). Watch the video below to learn a step-by-step process for mastering PFAs-Slow and PFAs-Fast.

If you find that after doing all of the above with your client, she is still experiencing symptoms of PFD, then she likely needs to work with a pelvic floor physical therapist (we recommend looking for this specialty vs. a general physical therapist). Sometimes pelvic floor issues require manual work that is outside the scope of practice of a fitness professional. You can use this PT Locator provided by APTA (American Physical Therapy Association) Pelvic Health to find a qualified Women’s Health PT near you.

We hope this information is helpful to you and your clients. If you would like to learn more, consider becoming a Pre/Postnatal Performance Training Specialist