Incontinence:

Stress Urinary Incontinence (SUI) is a common problem. It happens when you cough, sneeze, laugh, trampoline or do something that increases downward pressure on your pelvic floor. Because it is so common, many women think that leaking urine is normal and sadly the majority of them do not actually seek help. What they do not realise is that leaking urine is NOT normal, and is a treatable problem.

Pregnancies, age-related changes, and hormonal factors influence the connective tissues and PF muscles. As women approach menopause they may notice increasing episodes of Urinary Incontinence. While we cannot restore connective tissue integrity, appropriate pelvic floor and girdle muscle strengthening and motor control exercises can help the muscles counteract the connective tissue changes and restore continence.

Read on to learn all that I know so far about the pelvic floor. It’s a long one but don’t skip ahead. It the elements build on each other.

Eliminate any downward pressure on your pelvic floor. 
What do I mean by that?! The abdominal cavity is a sealed unit, contained within is intra abdominal pressure. Pulling your abdomen in toward your spine means your guts have to go up toward your diaphragm (hiatus hernia?), making breathing more difficult, or down, increasing the load on the pelvic floor. Plus creating a strain on the connective tissue of your abdomen (diastasis recti).

Please do not mistake this for abdominal muscle use, the sucking-in motion creates an increased pressure! Really you’re displacing your abdominal visera and creating long term issues that interfere with your deep core strength, ie it weakens over time and your midsection becomes less toned.

It’s not only sucking it in that can cause this but also overly tight clothing such as super tight jeans, spanx and corsets (waist trainers!) and slumped posture which compresses the rib-cage into the abdominal cavity. Anything which disrupts your natural shape.

Some other negative affects are:

• interfering with the peristalsis of your intestines causing constipation, wind/gas and bloating! The opposite of what you want if you’re sucking in.
• causing the need for you to bear down to push your waste into the toilet. Which is also increased downward pressure on your pelvic floor.
• reducing the circulation of blood down into your lower extremities, which causes higher blood pressure in the rest of your body.
• interferes with the proper function of your respiratory diaphragm.

If you are a chronic “holder inner”, try this: On your hands and knees. Relax your stomach all the way toward the floor. Also allow your spine to droop down toward the floor too. Your tailbone should feel like it’s pointing toward the ceiling. Take some deep relaxing breaths.

If you hold your belly in because you don’t like having a belly. Then it’s much better to get rid of the belly. Which is easier said than done, I know. Don’t hold your belly in when checking how you look in the mirror. I always used to do this, but now I am much more motivated to make good meal choices! Plus, my own pelvic floor issues improved a lot when I released the tension!

Diaphragmatic Breathing
Most people don’t give a second thought to the act of breathing unless they need to catch it! We breathe about 14 times every minute, more than 20,000 times a day, and no fewer than 526 million times in an average lifetime. A full breath cycle spreads energy-giving oxygen throughout the body, gets rid of waste gasses (detoxification) like carbon dioxide, and stimulates the spine and internal organs. But are you breathing correctly?

The body’s primary breathing muscle is the thoracic diaphragm, a huge, dome-shaped muscle at the bottom of the rib cage. When you breath in, the diaphragm should contract and expand downwards against your abdominal cavity. This downward movement creates a vacuum inside your rib-cage causing air to be drawn in and fill your lungs. The lungs sit on top of the diaphragm and cling to its upper surface. So as the diaphragm descends, it pulls down on the lungs, stretching the lungs longer and creating extra space inside them. Exhalation is caused by a different mechanism. When the muscle fibres of the diaphragm relax, the natural elasticity of the lungs and rib cage causes the air to flow out of the lungs. Your diaphragm moves back up into your chest.

Although the diaphragm is active 24/7, it goes largely unnoticed (unless you get hiccups). To get a sense of where it is, touch your fingertips to the middle of your chest. They are now approximately level with the highest point of the dome, which lies deep inside your chest behind your breastbone.

What has this got to do with the pelvic floor?
Our inner core is comprised of the diaphragm, pelvic floor, transversus abdominus and multifidus. When functioning optimally the diaphragm and pelvic floor move in sync, which can help relax the PF muscles with gentle movement. However this way of breathing can be disrupted by poor posture, sucking it in and chronic stress/tension. Luckily this diaphragmatic breath is a fantastic stress buster! 

So if I’m not breathing from my diaphragm, how am I doing it?
With upper-chest breathing, or initiating from the shoulders and neck. Also called clavicular (collar bone) or accessory breathing. 
During heavy exercise, in emergency situations and when the contents of the abdominal cavity restricts the movement of the diaphragm (eg, when there is a baby there), you need these accessory muscles: They kick in to supplement the diaphragm’s action by moving the rib cage up and down more vigorously, helping to bring more air to the lungs.
But unlike the diaphragm, which is designed to work indefinitely, the accessory muscles tire more easily, and overusing them will eventually leave you feeling fatigued and anxious with tension throughout your neck and shoulders. Sound familiar?

Also, “reverse breathing”, when we pull the belly in on the inhale, instead of allowing the belly to expand outward when the diaphragm pushes down on the abdominal visera. This requires relaxed abdominal muscles.

How to Practise a Diaphragmatic Breath:

• If you want to see this breath in action, watch a baby sleeping.
• In bed, before sleep is a great time to practise. Lay on your back with your knees bent or propped up underneath with a pillow. Your spine is long, in what Pilates instructors call neutral spine, a position of the spine that allows the natural curves of the spine to be present. Relax your shoulders gently away from your ears. Place a small pillow under your head, if you need to for comfort.
• Rest one hand above your belly button, fingertips just below your breastbone/centre of rib-cage, heel of the hand on one side of the ribs and the other on your upper breastbone/collar-bones to allow you to feel your breath expanding and moving through your body. Your throat is open and relaxed to allow for maximum air flow.
• Take a moment, close your eyes and become aware of your breathing. Notice the way the air feels as it travels in through your nostrils and then back out again.
• The Inhale: Breathe in slowly through your nose so that you feel your upper belly rise under your hand first, your lower ribs move outward and the hand on the sternum move out (and slightly up) last. Try to keep your upper chest and neck muscles relaxed by keeping the shoulders relatively still. Allow the deep inhale to expand your belly a little bit. Don’t try to resist or compress it.
• The Exhale: Let go of your breath and let your chest and belly drop. Try not to force the air out, simply allow it to flow out of the body. Let the air passively leave your body. Encourage a full release of the breath. Think the word R-E-L-E-A-S-E as you exhale.
• The Inhale: Imagine that your lungs are divided into three parts, lower, middle, and upper. Breathe in, as slowly as possible, into your upper abdomen, filling only the lowest part of your lungs so that your chest does not rise at all. As you continue to breath in, imagine that the middle part of your lungs are filling and allow your lower rib-cage to begin expanding at your sides and back. As you complete your inhale, visualise the upper part of your lungs filling. The shoulder can move slightly up and back. Your lungs are now completely full of air. 
• Repeat: Inhale and exhale, each time you consciously relax your diaphragm. Eventually, the motion will become smooth and comfortable. A minute or two of diaphragmatic breathing when starting out is terrific. Try to build on this until you reach 5-10 minutes. 

Tips:

• Do not try to distend the belly in an exaggerated fashion. Your entire “core” area is expanding not just a balloon-like area in your belly. You want the inhale to occur throughout the entire torso both front and back. Therefore correct breathing will involve the belly (just under the ribs) protruding and then the chest expanding.
• Correct posture is very important! It helps your diaphragm, pelvic floor and abdominal muscles “line up” to work well together. If you are practising sitting. Make sure you are sitting in neutral pelvis and not on a slightly tucked one.
• If you feel a little out of breath when starting out, take a break and try again later! Remember the ultimate goal is to promote a pattern of diaphragmatic breathing and reduce upper chest breathing throughout your day. If you find this to be difficult, make it a daily practice to improve your breath!
• At regular intervals throughout the course of your day try, check in with your breath and ease tension from your body.

Once you get the hang of it, you will find that diaphragmatic breathing is both energising and relaxing. A positive feedback loop is also created as the ability of your body to naturally relax will also be enhanced.

Deep Squatting
The deep squat is an essential movement pattern and the most effective and natural glute strengthener, when using the full range of motion. If you want to see a perfect squat in action, watch a toddler pick something up off the floor. Why does a toddler comfortably sit in this position, while the majority of adults topple to their backs, can’t get back up, or can’t get down into it to begin with? Our comfortable chairs, couches, and toilets have made it unnecessary.

Why is it in this Pelvic Floor Post?: The Pelvic Floor muscles attach to the pubic bone and the tailbone. A kegel exerts a muscular force which draws the tailbone toward the pubic bone (counternutation of the sacrum). The closer these bony attachments get, the more slack in the PF (the PF becomes more like a hammock rather than a trampoline). The muscles which balance out this pull are the glutes. So it is essential to have active glutes and to use them throughout your day. (This is why having a flat butt and no lumbar curve (posture)  affects the Pelvic Floor.) Having strong glutes will not only do wonders for your view from the backside but give you nice supple and taut PF muscles.

Many non-Western cultures (over 2/3 of the global population) opt for the deep squat as a comfortable sitting position, and some countries use squat toilets in their bathroom stalls. If you’ve ever discovered a squat toilet on your travels, you may have been over come with a lack of faith in your quadricep muscles.

With the convenience and hygiene that a toilet brings, it’s hard to argue that it’s even the least bit detrimental to our well-being. According to Giulia Enders, author of Gut: the inside story of our body’s most under-rated organ “1.2 billion people around the world who squat have almost no incidence of diverticulitis and fewer problems with hemorrhoids/piles. We in the west, on the other hand, squeeze our gut tissue until it comes out of our bottoms.” 

Apparently, when we sit on a toilet we put a “kink in the hose”, thereby making everything more difficult to expel. We can iron out the kink by sitting with our feet on this beautiful little stool and leaning forward. Almost like being back in mother nature, but in the privacy of your own bathroom. You can also buy the Squatty Potty stool on Amazon.

Opportunities to squat daily: playing with small children, gardening, pulling laundry out of the machine, getting something out of a low cupboard and with a little lift of your feet, using the toilet.

I have a few videos on YouTube which you may find useful:
My Favourite Pilates Moves for Stronger Glutes
Birth Preparation Flow, this goes through a progression to help you squat deeper.

Kegels or Pelvic Floor Exercises
Kegel exercises or small contractions of the pelvic floor muscles at the vaginal wall and opening—should be a priority early in the postnatal period and also around the menopause. They will help to increase blood-flow to, repair and strengthen the pelvic floor and they can also assist with managing common problems associated with a weak pelvic floor such as a prolapsed uterus, a prolapsed bladder, and possible urinary stress incontinence. If you had an episiotomy, doing this exercise will help increase blood flow to the region, reduce swelling, and speed up the healing process. Kegels may also help with incision sensitivity.

In order to get the full picture of how to do a Kegel, let’s start with the anatomy:
There are two layers of pelvic floor muscles.

1. The most superficial (closest to the skin) are known as the urogenital diaphragm. These are the muscles that are primarily responsible for helping to close the urethra and anus so that we don’t leak urine/gas/stool when we don’t want to. 
2. The deeper layer of muscles (closer to the organs) are called the levator ani. These muscles are largely responsible for supporting our pelvis, bladder, uterus and rectum throughout our lifetimes as the forces of gravity, digestion and pregnancy bear down on it.

Here’s my guide to doing pelvic floor exercises correctly:

• Find your focus. You need to be able to focus on what you are doing. Forget the advice about practising your Kegels while at red lights or when waiting in a queue. This is something which needs your full attention to be done properly. Five minutes before bed? Easy to add to your schedule. It takes diligence to identify your pelvic floor muscles and understand how to contract and relax them properly, if they are to be part of your regime.
• Find the right muscles. Kegels are easy to do, once you find which muscles to target. One of the easiest ways to locate the muscles on your pelvic floor is by contracting the muscles around your urethra as if trying to hold back the flow of urine.
  Here’s how: Halfway through urination, try to stop or slow down the flow of urine. Don’t tense the muscles in your buttocks, legs, or abdomen, and don’t hold your breath. When you can slow or stop the flow of urine, you have successfully located these muscles. This is not something to get in the habit of doing during urination, due to the risk of urinary tract infections, however it is okay to try one time if it can help you isolate the correct muscles. Some find these muscles by imagining that they are trying to stop the passage of wind.
  If you still feel disconnected, you can try inserting a finger into the vagina or anus and actually FEEL the muscles contracting. You want those muscles to squeeze your fingertip and gently pull up (toward your head). These are the right muscles for pelvic exercises. It’s important not to contract other muscles.
• Perfect your technique. Once you’ve identified your pelvic floor muscles, completely empty your bladder and lie down. Always practise with an empty bladder. When you’re first starting, it may be easier to do Kegel exercises lying down, so your muscles aren’t fighting against gravity.
• Focus on the pelvic floor region, specifically the pubic bone and tailbone. On an exhale, imaging pulling the pubic bone and tailbone together. Or focus on the sitz bones, and imagine pulling them together on the exhale. Think of lifting the pelvic floor, as opposed to tightening the pelvic floor. Ensure you are keeping the muscles of the abdomen, buttocks and those deep in the hips relaxed. You will sense engaging these as gripping your bottom each time you do a Kegel. It should not feel like an intense contraction. More of a light sensation.
• On an inhale aim to fully relax your pelvic floor, releasing tension throughout your lower abdominal region, hips and glutes too. 
• Repeat this breath plus contraction sequence for as many repetitions as you comfortably can but don’t overdo it. Like any other muscle group, you don’t want to overdo it, listen to your body.

Tips:

• To practice Kegels seated, make sure you are sitting up straight. Aim to have your pelvis positioned upright (neutral) rather than tilted forward or tucked under. The two bony points on the front of the pelvis (where you put your hands on your hips) should be vertically stacked over your pubic bone.You can only have optimal PF function when the pelvis is in it’s correct position. Keep your rib cage over your pelvis rather than slouched down or thrust forward. Ears over shoulders with chin level with the floor. Feel as though a string is pulling you upward through the top of your head.
• If you do have a prolapse, try practising your Kegels in an inversion such as bridge pose, downward dog on the elbows or headstand if you can.
• Here is a list of cues to help you do your pelvic floor exercises:
  -pull your pubic bone and tailbone together
  -bring your sits bones together
  -stop the flow of urine
  -wink the anus
  -nod the clitoris
  -sit on a firm chair and pull your perineum up and away from the surface
  -think of the muscles as an elevator and “lift” up towards your head
  -hold back wind
  -like you’re holding a tampon in
  -lift the testicles

Who shouldn’t be doing Kegels?
For decades doctors, therapists, midwives, fitness coaches, you name it, have been hammering it into us that if you want to improve your pelvic floor, you must do Kegels. However, Kegels are no good for a hypertonic or “tight” pelvic floor or one with trigger points.

If you’re asking, what is that? I’ll explain. 

When you do a Kegel, you are doing a muscular contraction, and if you already have a tight pelvic floor, contracting these muscles will only make it tighter, making your pelvic floor problems worse. When this occurs, the muscles need to be relaxed and lengthened, instead of strengthened with Kegels.

Bear this in mind, forever, tight does not equal strong, just tight. A tight muscle cannot be strengthened until it is first released. Do you need a super strong Pelvic Floor? Your Pelvic Floor is underneath the weight of your organs (when you have optimal alignment), and the strength your Pelvic Floor needs is equal to this weight. The Pelvic Floor is like Goldilocks. The strongest muscle is one that is the perfect length for the job with the right amount of strength to optimise physiological function. Juuust right. You can “over do it” with Kegels.

So, the pelvic floor muscles do not need extra strengthening from doing Kegels, unless something has happened that has overstretched them or injured them in some way that has made them truly weak. If you are just after birthing a baby, approaching menopause, experiencing pelvic organ prolapse or recovering from a gynaecological surgery, you will most likely need Kegels.

It is very hard for people to determine if their own pelvic floor muscles are tight, over-lengthened, or weak. Here are some symptoms of a tight pelvic floor:

• urinary urgency and/or frequency
• constipation
• incomplete emptying of bowel
• painful intercourse (dyspareunia)
• genital pain, anal, perineal, vulvar or clitoral
• difficult/painful orgasm

What to do if you have a tight Pelvic Floor?
Preferably, see a pelvic floor therapist who can examine you for trigger points and give you feedback to help you release tension from your pelvic area. ie. Pelvic Floor, hips, glutes and lower abdomen. I know several people who have had amazing results after seeing a specialist.

You can also practise relaxing your Pelvic Floor with the diaphragmatic breath in the deep squat position. This uses a contraction of the pelvic floors antagonistic muscles, the hip flexors, abductors and the diaphragm itself to help inhibit the pelvic floor muscle activity. Because these muscle have been held in tension they can be difficult to relax. So have patience, you should feel like you have better bladder control within a few weeks.

Caveat: You can have a tight and weak pelvic floor. So first you must release the pelvic floor, deal with any trigger points. Then introduce Kegels/pelvic floor exercises.

If you are already experiencing organ prolapse (it is way more common that people realise) you need to skip the high impact activities and running and switch to longer, endurance walks, reduce downward pressure, spend more of your day in good alignment and do your pelvic floor exercises every day.

If you’re having trouble.
Please do not take this article as a substitute for medical advice. When nothing is working or you’re in pain, seek a physiotherapist who specialises in the pelvic floor. Preferably one who has experience in “hands on” examination of the muscles of the pelvic floor. (This cannot be done with a speculum in place, that is only to see the vagina and cervix, which are deeper.) The therapist can examine you for and release trigger points, and give you feedback when you are relaxing or contracting your PF.

I hope you received some useful information in this post. I enjoyed writing it!
Ask me any questions you may have in the comments below.

Emma x