The pelvic floor muscles and the surrounding organs of the bladder, uterus and bowel are usually not uppermost in people’s minds in your teenage years but, once pregnancy looms, bladders get sat upon by an ever growing baby and sudden dashes to the loo become commonplace, then what’s going on ‘down there’ becomes more arresting.
So, as I work as a Women’s Health and Continence physiotherapist both in the NHS and private sector, I thought I would share some useful tips that I’ve learnt professionally over the years.
Myths and Legends
Bladders
The bladder is a large muscle which should be allowed to stretch and, in women, is capable of holding up to 600mls. It needs to work efficiently by emptying no more than 6-8 times in 24hours including night time. During the day, an average ‘wee’ should be half a bladder’s worth i.e 300 – 450 mls . So, despite our Mums telling us to go to the loo every time we left the house, otherwise it would damage our kidneys by holding on too long, we shouldn’t go unless we feel we really need to and then we’re training the bladder to increase its capacity.
The difficulty in holding on can be when there is bladder leakage on sudden movement such as coughing, laughing, sneezing, lifting (known as stress incontinence) or leaking by not getting to the loo in time (urge incontinence) and this may be due to weak pelvic floor muscles. That’s often why women start increasing the number of times a day they are going as they mistakenly think it will decrease their leakage.
Bladder frequency can also occur when there is an infection so, if you ever have any pain or discomfort when passing urine get it checked out by your GP or practice nurse who will do a simple urine test.
Two litres of water needs to be drunk every day
1.5 to 2 litres of fluid needs to go through your body but it can be any fluid (except alcohol!) so you can include milk on cereal or a bowl of soup. The best way to know if you’re drinking enough is to check the colour of your urine. It should be straw colour, no darker, otherwise, the kidneys are having to work harder to produce more concentrated urine which, over long periods of time, is thought to be one of the causes of the production of kidney stones.
Constipation is not going to the loo every day
Not true!
Normal bowel function is anything from up to 3 times a day to once every 3 days depending on the amount of fibre in your diet. But, if you strain when passing a motion and it’s looking solid or like rabbit droppings, then you probably are constipated and need to address the symptoms as constipation is one of the major causes of weak pelvic floor muscles.
Hints and Tips
Eat 3 pears a day for constipation
It’s not widely known that pears are the best fruit for controlling the bowel due to their high fibre content. Tinned pears don’t count unfortunately as you need to eat the skin but eating 3 pears within 24 hours i.e one with each meal works wonders and is healthier than taking laxatives, although sometimes both are necessary for the short term particularly if you’ve been taking iron supplements during pregnancy!
Always sit on a loo – don’t ‘hover’
Try and always sit on a toilet rather than hover – a difficult concept I know when using public loos. Lean forwards with your elbows on your knees as this encourages the bladder neck and pelvic floor muscles to relax. When opening your bowels for the first time postnatally it’s useful to hold a sanitary towel in half and gently press upwards over the pelvic floor, particularly if you’ve got stitches, to support and give you the confidence to open your bowels without straining.
Always check that you can get your knees higher than your hips when opening your bowels. This position tilts the pelvis backwards which is a more natural position ( see diagram). If necessary use your toddler’s stool to put your feet on.
Pelvic Floor Muscle Exercises – how and why?
Why?
I hope that in the future all children both male and female will be taught the importance of pelvic floor muscle exercises.
By the way, men don’t realize they have a pelvic floor – just tell them they have because, if they didn’t, all their insides would fall out!
These amazing muscles form a sling which supports all the pelvic organs i. e the bladder, vagina and uterus and the bowel and are 3 layers thick.
They are core muscles and, as well as supporting the pelvic organs, they control the bladder and bowel and also help with sexual satisfaction.
They have 3 main jobs to do – ‘holding everything up’ all day long as we move around (this is why they have to work harder during pregnancy) contracting more strongly when the bladder or bowel is full and we’re trying to find a loo. And thirdly, the ability to contract strongly when we put maximum strain on them when coughing, sneezing, heavy lifting, doing high impact sports (think kids trampoline!) and obviously when pushing in second stage labour.
The way to visualize the pelvic floor is to imagine a structure that stretches from the pubic bone at the front of the pelvis to the tip of the coccyx (base of the spine) at the back and sideways from one side of the inner thigh to the other.
The important point to remember is that these muscles are 3 dimensional and are several centimetres thick so it’s important when doing pelvic floor exercises to pull up vaginally as high as you can before starting to count.
How?
As I’ve already mentioned pelvic floor muscle technique is important as I think this is the problem with women thinking that they can’t do them or that they’re not having a good enough effect.
Statistically fewer than 50% of people do pelvic floor exercises correctly if given only verbal or written instructions. But, your own fingers are the best biofeedback in the world and if you feel comfortable to do so (particularly if you’ve got stitches after childbirth) either lay back in a warm bath or on your bed with your knees bent up and gently introduce 1 or 2 fingers into the vagina just up to the second knuckle and feel that squeeze and lift around your finger. You can then judge how strong that feels, how many seconds you can hold for, the number or repetitions and how many fast pull-ups you can do.
Think of the pelvic floor muscles around the vagina as a clock face where 12 o’clock is up at the bladder and 6 o’clock is level with the bowel.
When testing the pelvic floor, a clinician will note any muscle weakness and record it by noting on a diagram in relation to the numbers on a clock. This gives an objective assessment which can be regularly checked.
What is normal?
It’s not surprising when you think of the work that these muscles have to do that they can take up to 3 months postnatally to recover to normal strength.
By that we mean that there is no bladder or bowel leakage on any activity, no sudden dashing to the loo and the pelvic floor muscles can contract maximally for 10 seconds repeated 10 times (these are the slow twitch muscle exercises) and can do 10 – 20 fast contractions in standing. When you have reached this level then continue doing them once a day for life to keep them toned. The adage’ use it or lose it ‘applies here just the same.
If you are sore in the first few days, then do take mild painkillers and all the advice that your midwife gives you but it does help healing if you can start working the pelvic floor muscles gently as soon as possible as it encourages the blood flow into the area which then speeds up healing.
A note here – if you have a 3rd-degree tear you should be referred for at least a ‘one-off’ session with a Women’s Health physiotherapist and possibly treatment. It does vary from trust to trust but I think we are pretty lucky in Berkshire compared to some. Wouldn’t it be wonderful if we had the French system where every woman gets several pelvic floor sessions in the first 3 months to check that things have returned to normal? It may come in time I hope.
Do make sure that you are totally honest with your GP or midwife at your postnatal check and say if you have any concerns about healing or pelvic floor weakness. You should then be referred to the appropriate person.
Treatment
Pelvic floor muscle treatment should include a full assessment and an internal examination (but only with the full consent and not always at the first visit) and advice on how to progress exercises.
Further methods may include biofeedback where a muscle contraction is seen on a screen, vaginal cones and or muscle stimulation if the muscles are weak and need a little assistance to contract.
There are lots of expensive pelvic floor machines advertised out there which are relatively expensive so do think carefully before buying. There’s nothing like investing time doing the exercises correctly and see how good you can get.
Useful Websites
Pelvic Obstetric and Gynaecological PhysiotherapyL www.charteredsocietyofphysiotherapy.org.uk
Chartered Physiotherapists Promoting Continence (CPPC): www.cppc.org.uk
The Bladder and Bowel Foundation: www.bladderandbowelfoundation.org.uk
If you have any questions or queries and want to contact me my email address is [email protected]
Diane Wootton
Clinical Physiotherapy Specialist in Pelvic Floor Dysfunction and Pelvic Pain