Updated: Feb 8
Pelvic floor muscle problems can cause a range of symptoms. It’s not just about weakness and leaking. It’s about other puzzling symptoms and mysterious aches and pains that don’t feel like ‘pelvic floor’ at all.
In this article I’ll address not only why you want to practice relaxation and coordination along with strength, but also give you techniques to practice each one of them.
If you’ve read any of my previous articles on pelvic floor health, you might have noticed that I’m a big fan of the concept that training the pelvic floor isn’t all about strength. We used to think it was, and we still recommend strength training using pelvic floor muscle exercises.
More recently, though, we’ve realised that a surprising number of people have an overactive pelvic floor.
The Need to Relax the Pelvic Floor
What would pain from an overactive pelvic floor feel like? It might not feel like an aching pelvic floor at all.
You might be more familiar with tension in your neck muscles showing up as a headache or feeling like it’s coming from the spinal joints or nerves rather than the muscles. In the same way, tension in these small muscles of your pelvis might be felt as pain in the pelvic joints or lower back.
Another classic pain point is the tailbone - it’s a site the muscles attach to, so it’s under a lot of pressure if the muscles are constantly putting tension on it. It’s also interesting to note that pelvic floor pain symptoms might cycle with your hormones - but they might not, too.
Some genius researcher actually put electrodes in pelvic floors and then had the women watch movies with threatening scenes to mimic a stressful situation. It turns out, the pelvic floor tenses up just like the muscles in our necks when we are stressed.
One big difference is, we’re aware of the neck tension issue. Almost everyone has taken a deep breath and consciously tried to relax their shoulders. Almost no-one has consciously tried to relax their pelvic floor.
How to Relax the Pelvic Floor
EEEEEK! What if I relax "too much" and wet myself??
That shouldn’t happen, because that requires the bladder contracting as well as the pelvic floor relaxing.
But hey, it’s going to be hard to relax if you’re stressing about that – so eliminate the worry completely. Try out your relaxing skills while sitting on the toilet, after you’ve finished emptying your bladder. Keep in mind that you’re only trying to relax - not actively trying to pee.
Many people have practiced muscle relaxation techniques where you relax as you breath out. The pelvic floor just happens to be one end of a cylinder, your core, that is very much involved in breathing. It lifts, along with the diaphragm, as we breath out. This is working in tandem with other stomach muscles - you can feel them contract when you deliberately breath out fully.
This means the pelvic floor has a natural inclination to contract as we breath out.
When we breath in, it descends to make room for air.
This means the pelvic floor has a natural inclination to relax as we breath in.
This is so not what we are used to doing!
So as you are sitting on your reassuring toilet seat, go for the double-relaxation-whammy. Take a deep breath. As you breath out, focus on relaxing your shoulders. As you breath back in, shift your focus to your pelvis and try to apply the same relaxation feeling there.
This technique is helpful because ‘relax your shoulders’ is familiar and understandable. It’s a reminder to our body that this is what relaxation means. Then it becomes a little easier to attempt the same relaxation in a rather foreign area we aren’t used to thinking of that way.
It’s kind of a weird idea and you probably won’t feel like you’re doing much, but if you’re one of the many people with pain from an overactive pelvic floor, then regular relaxation practice can make a big difference over time. Most likely not instantly.
Luckily, once you get the hang of relaxation, you don’t need to be on the loo to practice it!
Of course you can focus on relaxing your pelvic floor in any position you like, but one lovely option for working on relaxation is the stretch on all fours that’s often called cat-cow in yoga.
As you breath out, contract your belly and arch your spine upward like a Halloween cat. This makes both your head and your tailbone tip downward. As you breath in, let your spine drop down so that your head and tailbone tip upward, and let your belly and pelvic floor relax.
Even if you have an overactive pelvic floor, it might still need some strengthening as well. (People with tension headaches don’t have big strong necks like body builders, do they?)
Best to focus on the relaxing for a few weeks first though, or get advice from an expert on when to start what for your particular circumstance.
Strengthening the Pelvic Floor
There are many many versions of pelvic floor exercises. Which is great, but can make it hard to know what’s right for you.
Big picture: there are two types of muscle fibres in the pelvic floor, so it’s good to include some quick contract-and-release squeezes, as well as some longer holds. And releases! If you can’t feel it release, then you tried to hold too long and you should start shorter and build up slowly.
Once you get some practice in you can aim to slowly (weeks or months) build up to holding for 10 seconds, but if this is new to you then a couple of seconds is awesome.
Here’s one way to start: use the position in the image, with your hands prayer-like in front of you.
You can be standing, sitting or lying down. Lying down removes gravity so it can be a good position to start with.
Step 1, forget the pelvic floor and practice for a few breaths simply inhaling nice and deep into your belly, then exhaling fully. Notice that you use your belly muscles a little bit to push that air out.
Step 2, practice a couple more breaths where you breathe in as before, then breathe out and press your hands together as you’re breathing out.
Step 3, once you have the above under control, adds another layer to the breathing out part. As you breathe out and press your hands together, you also squeeze up and lift your pelvic floor.
It sounds complicated but just take it one step at a time.
At first you may not hold the squeeze, but with practice you can hold the contraction for as long as it takes to breathe out. And then of course you can take deeper slower breaths so your holds are longer! (Bonus, deep breathing is good for you so it’s double the benefit.)
Maybe you can do one squeeze, maybe three, maybe more. You have plenty of time to build up slowly. There’s no point counting squeezes if nothing is actually happening and the muscle is worn out already!
With a bit of practice, you will be able to feel the difference between a strong squeeze and a getting-tired squeeze, which you can do one or two of. Then stop.
Once it isn’t contracting any more, or you can’t feel it relaxing when you release, your muscles are probably exhausted. If that happens, do one less tomorrow, and try increasing again a couple of days later.
You want each squeeze you do to be giving your pelvic floor a lesson in how to work properly for you. Asking too much will make your body look for a way to ‘cheat’, and that will create bad habits instead of good ones.
Can a pelvic floor be un-coordinated? What would that even mean?
Our skeleton is moved about by hundreds of muscles, and how they all work together is, to me, sheer awesomeness. It’s astonishing.
Just reaching for a glass of water involves dozens of muscles to open the fingers, extend the elbow, flex the shoulder… and what’s more, muscles to stabilize the shoulder as the arm lifts, and muscles to stabilise the trunk so the weight of the arm out front doesn’t make us tip over forwards.
Without even thinking of it, we do this constantly. Our pelvic floors are one part of this grand scheme of stability and movement.
“Core strength” isn’t just about abdominal muscles, it’s a whole cylinder – there are several layers of abdominals interconnected with the spinal muscles around the back, roofed by the diaphragm and floored (aha!) by the layers of the pelvic floor.
In the best of times they work in harmony, but sometimes they don’t.
A nerve squished during pregnancy might not be as efficient after it recovers. A bout of flu with lots of coughing might overwhelm the reflex that used to tell your pelvic floor to hold against a cough.
Frankly, any exercise you choose to do with your pelvic floor is likely to help improve the coordination as well.
A good exercise program will progress from simple squeezes to applying control during other movements and activities – making it functional and meaningful to the activities you actually do in your life.
Lying on your back is a very effective starting place for learning pelvic floor exercises, but not many people are worried about leaking while lying on their back!
And you actually can’t contract-and-hold your pelvic floor for the duration of a 30 minute run. (Or an entire pilates class, just sayin’.) It has to flicker on and off, a little or a lot, as the situation requires. It needs strength to do that, and endurance to continue doing it all day.
But it also needs coordination, and that – just like ball skills or riding a bike - takes practice.
One longstanding technique for retraining the pelvic floor muscles to respond effectively - which means with good coordination - is called The Knack. It’s an American term, but it kind of took hold globally.
What it means is basically common-sense. If you’re about to cough or sneeze, or whatever causes a problem, deliberately contract your pelvic floor. Sure, it should do it automatically, and fast enough that it beats the stress caused by the sneeze. But if that isn’t happening, give yourself a head start.
I’ll grant you, that seems kind of ridiculously obvious, but sometimes the simplest things get missed.
Deliberately squeeze up your pelvic floor just before it is hit by the pressure of a cough, sneeze or jump. Do that routinely, and you create a pattern of actions that can retrain your brain and establish the pattern as the reflex action it should be.
You can practice this on purpose rather than, for example, only when you actually have to run up stairs. Simply squeeze and lift the pelvic floor, then take a step or jump, or fake a small cough. Start small and slow, build up to bigger and faster movements.
This build-up is over days or weeks, not in half an hour!
What you start with will depend on what you’re individually capable of. You need to find the most you can control, and grow from there. There’s no one exercise to suit everyone, and there’s no ‘do it ten times’ or ‘for a month’.
It’s going to vary between people.
Is Pelvic Floor Exercise Right for You?
It may take some experimenting, but many women can improve their symptoms by practicing pelvic floor exercises. If it doesn't seem to be working for you, it may be that your muscles aren't doing what you think they are doing - this sounds ridiculous but is actually really common, especially after childbirth.
Or it may be that your situation is a little more complex than average.
In both of these cases, it is worth seeing a physio for an assessment. A professional can assess exactly what your pelvic floor is doing. Following a plan professionally designed just for you has been shown in studies to be more effective than following a guide like this blog.
So you can start here, but if it isn't working - don't give up on improving. There could still be a program for you that relieves your symptoms without the need for more complicated treatments like surgery.
There are well-trained physios in private practice (you do not need a doctor's referral in Australia) and in public hospitals. Some physios have a special interest in Women's Health and have done extra training. Check websites or telephone your local options to find out what's available for you - there isn't a good database available for this, especially when it comes to who's working in rural areas.
Good luck with your very important exercise plan!
Have you caught the rest of the Bladder and Pelvic Floor Series?
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