The function of the pelvic floor is to control emptying of the bladder and bowel, closing of sphincters, supports pelvic organs, contributes to sexual arousal and co-ordinates lower abdominal, spinal and diaphragm muscles.
Urinary incontinence is the involuntary loss of urine (leakage) due to a disturbance of structure and function of bladder and pelvic floor complex (ICS). It is estimated that 1 in 3 women report incontinence. Stress urinary incontinence is most common; occurring during physical exertion (jumping/running) or coughing/sneezing.
An overactive bladder constitutes symptoms of urgency and increased frequency of voiding (passing urine). Sometimes people are anxious about going - often thinking that if they empty their bladder frequently they are less likely to leak. However, this reinforces a habit of excessively voiding; normal range is 5-10 times per day (every 3-4 hours). Nocturia is defined as the need to wake once or more during the night to void. 0-1 times per night is normal, under the age of 50.
Pelvic organ prolapse is caused by relaxation/reduced activity of the pelvic floor and downward movement of the pelvic organs. A prolapse can sometimes be seen using a mirror or palpated (touching with fingers). Symptoms are usually worse during heavy lifting, prolonged standing and emptying bowels. There are different types of prolapse including the lower anterior vaginal wall & urethra (urethrocele), upper anterior vaginal wall involving the bladder (cystocele), uterus, cervix and upper vagina (uterovaginal prolapse), upper posterior vaginal wall containing loops of the small bowel (enterocele) and lower posterior wall of the vagina, involving the rectum bulging forward into the wall of the vagina (rectocele).
Urinary incontinence and pregnancy
Prevalence of stress urinary incontinence during pregnancy is estimated to be 41%! The reason for this high rate is due to the growing uterus and fetal weight combined with hormonal changes which significantly impact the strength of pelvic floor muscles and sphincter function. This leads to increased mobility of the bladder neck and urethra. Increased constipation and straining are due to progesterone levels. Therefore exercising the pelvic floor muscles during pregnancy is strongly recommended.
Effect on pelvic floor after childbirth (2009, Journal perinatal medicine)
- 21% prevalence of stress urinary incontinence after first vaginal delivery and 36% after forceps delivery
- 4% had persistent stress urinary incontinence 3 months after delivery
- 2-6% anal/faecal incontinence associated with forceps or perineal laceration
Evidence based recommendations
It is recommended that pregnant women should perform pelvic floor muscle training daily for approximately 8 weeks (2014, British journal of sports medicine). Intense and supervised pelvic floor exercises during pregnancy have been shown to prevent urinary incontinence both during and after pregnancy (2014, Morkved & Bo).
How to perform pelvic floor exercises
To activate your pelvic floor muscles you should lay on your back (picture below), in a quiet room and try to focus your mind on squeezing the pelvic floor muscles - as if trying to stop the flow of urine. Squeeze from the back passage and "zip up" towards the pubic bone at the front. it is important to SUCK UP - like sucking your thumb or spaghetti. Be sure to breath deeply and relax your pelvic floor fully between each contraction. Avoid BEARING DOWN (pushing) or holding your breath. Do not contract you upper abdominal muscles, inner thigh or gluteal muscles (buttocks).
8-12 pelvic muscular contractions should be performed, 3 times daily. Hold each contraction for 1-10 seconds, increasing contraction time and reducing rest time as your muscle strength improves. Progress exercises by altering your position to TALL sitting and standing.
Please be aware that 2 out of 3 women are unable to contract the pelvic floor muscles correctly. It is advisable to see a Chartered Physiotherapist for internal assessment to be sure you are contracting the muscles effectively and assess for prolapse, scarring and muscles function.
For more information check out www.holditsister.com
ICS/IUGA terminology international Urogynaecology journal (2010) 21; 5-26.
Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention of UI; systematic review. British Journal of Sports Medicine (2014) 48(4); 299-310.
Stress urinary incontinence in pregnant women - a review of prevelance, pathophysiology and treatment. International Urogynecology Journal (2013) 24(6); 901-912.
Post-partum pelvic floor problems. Journal of perinatal medicine (2009) 3(4); 57-59.
Markved S & Bo K (2014). Effect of pelvic floor muscle training during pregnancy and after childbirth on prevention and treatment of urinary incontinence; a systematic review. British Journal of Sports Medicine (2014) 48; 299-310.