This specialized type of physiotherapy is relatively new in Canada; however, over the past five years, this essential form of rehabilitation has certainly picked up momentum. In other countries such as France, every postpartum woman that delivered vaginally is assessed by a Pelvic Floor Physiotherapist and is taught how to do a kegel correctly. The French government even covers up to ten sessions with the physiotherapist for postpartum pelvic floor strengthening and core muscle retraining! The reason is that the pelvic floor plays an integral role in preventing leaking, supporting your pelvic organs, providing back stability, and sexual health; hence, rehabilitating the pelvic floor after having children is not only restorative, but preventative against these things as well. Today, more and more women are learning about the effective health practices that will benefit them for the rest of their lives.

The pelvic floor muscles are a small group of hammock-like muscles that are situated at the bottom of your pelvis. As you are sitting in a chair, you will feel the bony prominences of your left and right sitz bones in your buttocks, and the pelvic floor muscles are located between them.

These hidden muscles are extremely important for many reasons:

1. They close off the urethra and rectal sphincters to prevent leaking
2. They contribute to sexual function and pleasure
3. From below, they support the organs inside of the pelvis so that they stay within abdominal cavity
4. They provide stabilizing support to the lower back
5. They help circulate blood and other body fluids from the lower extremities upwards towards the heart

Your pelvic floor muscles are part of your inner core muscle group. They work together with three other muscles (the Transverse Abdominis, the Multifidus, and the Diaphragm) to provide the foundation for core stability.

Problems in the pelvic floor generally reflect the state of the muscle group. Like any other voluntary muscle in our body, the state of the pelvic floor muscles can range from being very weak to being very tight.

Signs of weak pelvic floor muscles are:

• Involuntary leaking of urine or fecal matter, known as incontinence
• Difficulty controlling gas
• “Dropping” of pelvic organs, known as prolapse

Signs of tight pelvic floor muscles include:

• Urinary frequency, urgency, retention, hesitation
• Painful intercourse
• Constipation, straining, pain with bowel movements
• Unexplained pain in hips, lower back, pelvis
• Pain arising from Endometriosis, Interstitial Cystitis, Pudendal Neuralgia

Other conditions that also contribute to pelvic floor dysfunction include poor posture, hormonal changes, chronic coughing (such as in asthma), obesity, and poor coordination or timing of pelvic floor contractions.

Nowadays, more and more women and men are learning about effective health practices that can benefit them for the rest of their lives.

Through specific training, the pelvic floor physiotherapist will assess the current state of your muscles, connective tissues and the nerves that make up the pelvic floor through an internal exam. We highly recommend visiting our Physiotherapist during pregnancy in order to support a healthy and happy birthing experience. Post-partum treatment is also recommended but only when you have been given the go ahead by your OBGYN, at least 6 weeks following the birth of your child.

Incontinence is generally caused by weakness in the pelvic floor muscles, making it difficult for them to fully contract and close off the urethra. The most common cause of pelvic floor weakness is childbirth through vaginal delivery. As the baby travels out the vaginal opening, it creates intense stretching of the pelvic floor muscles, tissues, and nerves that often remain weakened post-partum. However, those who deliver by Caesarean Section can also experience incontinence due to overworked and fatigued pelvic floor muscles during pregnancy.

Other conditions that can cause pelvic floor dysfunction, and consequently incontinence, include: chronic coughing (such as in asthma or “smoker’s cough”); long-term constipation; obesity; poor posture; and hormonal changes that occur during menopause. Pelvic Health Physiotherapy can effectively treat:

• Stress Urinary Incontinence
  Leakage of urine with coughing, sneezing, laughing, lifting, exercising, or doing any activity that causes an increase in abdominal pressure that is stronger than the pressure at the urethral sphincter
• Urge Urinary Incontinence
  Leakage of urine after a strong, overwhelming urge to urinate, and not making it to the washroom on time
• Mixed Urinary Incontinence
  A combination of symptoms from Stress Incontinence and Urge Incontinence

The key to improving, and even abolishing, urinary incontinence is strengthening the pelvic floor. A correct pelvic floor contraction can help improve urethral closure to prevent leakage. The stronger the muscles, the better they are at providing tight closure. However, research shows that only 50% of women can perform a kegel correctly with verbal instructions or a handout alone. Many actually push down on their pelvic floor instead of contract them. That can actually weaken them further! Hence, having your pelvic floor assessed internally by a specially trained physiotherapist is the “gold standard.”

The highest levels of research state that pelvic floor strengthening through internal treatment should be considered the first line of treatment for incontinence.

Important point to remember: Leaking is COMMON with aging and having kids but it simply means that your pelvic floor muscles need some help. Let’s change our perception of what’s normal and start strengthening the pelvic floor.

Among other things, your pelvis contains organs such as your bladder, uterus, and rectum. These organs are kept in place by a dynamic system involving connective tissue, which holds your organs up, and pelvic floor muscles, which provide a bed of support from below. When your connective tissue has been stretched (such as in childbirth, chronic coughing, or long-term constipation), and when your pelvic floor muscles have been weakened, it results in sagging of your pelvic organs into the vagina. This is known as pelvic organ prolapse.

Prolapse is not a disease, it is more of a functional problem. It is also not a painful condition. Actually, most women are asymptomatic. The important thing to remember with prolapse is that, in most cases, prolapse occurs gradually over time. It could even occur 20-30 years post-partum. It may begin with slight falling of one organ into the vaginal space, where you will likely not feel any symptoms at all. Over time, it will continue lower down further into the vagina until one day, you feel a bulge at the vaginal opening. Unfortunately, prolapse doesn’t go away if you ignore it.

The most common types of prolapse are:

• Cystocele: Bladder prolapse – laxity in the front wall of the vagina causes the bladder to drop down into the vaginal space
• Rectocele: Prolapse of the rectum – laxity in the back wall of the vagina causes the rectum to drop down into the vagina
• Uterine Prolapse: Prolapse of uterus
• Vaginal Vault Prolapse: Prolapse of the upper portion of the vagina. This usually occurs post-hysterectomy.

Some signs of prolapse include:

• The feeling as though your insides are coming out
• The feeling of pressure or heaviness in your pelvis
• The presence of a bulge at the vaginal opening
• Pain and discomfort during sexual intercourse
• Difficulty emptying bowels

Since prolapse is caused by a failing support system of connective tissue and pelvic floor muscles, those with prolapse often experience incontinence as well.

The main cause is childbirth. As the baby makes its way down through the vagina, and is then pushed out, it can stretch the connective tissue and pelvic floor muscles creating a weakened support system for your pelvic organs. Multiple vaginal births, prolonged pushing, use of forceps or vacuum, and episiotomy also affect the supporting tissues.

Additional risk factors include constipation/chronic bowel straining, chronic coughing (such as smoker’s cough or asthma), repetitive heavy lifting.

Preventing prolapse is a lot better than fixing it. Since prolapse is the result of weakened connective tissue and pelvic floor muscles, the best thing to do is to strengthen your pelvic floor muscles (kegel exercises) and keep them strong throughout your life, no matter what your age.

Physiotherapists are specially trained in dysfunctions of the musculoskeletal system. Physiotherapists with advanced training in pelvic floor conditions are able to help rehabilitate the pelvic floor muscles to their optimal state. Research has shown that at least 50% of women do not contract their pelvic floor muscles correctly with just written or verbal instructions alone.

The pelvic floor physiotherapist will assess the current state of your muscles through an internal exam, and will then teach you how to strengthen them appropriately. They will also provide you with advice on specific lifestyle changes, activity and diet modifications, and bowel and bladder habits that can help to minimize/prevent the prolapse from getting worse. Current research now states that pelvic floor muscle retraining is effective at reducing prolapse symptoms and should be considered first-line of treatment for women with prolapse.

If the degree of prolapse is large, surgery may be necessary. The surgery for prolapse involves repairing the torn or stretched connective tissue, but may also involve a hysterectomy if the uterus has lowered down. Since surgery only addresses half of the equation, by correcting the connective tissue only, you may be at risk for a recurring prolapse. To help prevent prolapse from coming back again, you should work with your Pelvic Floor Physiotherapist to build your pelvic floor strength and learn the appropriate lifestyle/activity modifications that will protect the newly operated tissue.

Diastasis Recti or mummy tummy refers to the tummy pouch that women may get after giving childbirth. Regardless of exercise, this pouch remains and actually, many exercises can make it worse. This condition occurs often with pregnancy and labour as the muscles of the abdominals become separated.

A Pelvic Health Physiotherapist can support the prevention of Diastasis Recti by ensuring the integrity of the muscles using various exercises that are performed during your pregnancy. This treatment can also support the postpartum recovery process in which a diastasis is present.

Your pelvic floor muscles are part of your inner core muscle group. They work together with three other muscles (the Transverse Abdominis, the Multifidus, and the Diaphragm) to provide the foundation for core stability. After giving birth, your body, including all of its core muscles, will need time to recover. Starting an exercise program that involves running, jumping, kickboxing, boot-camp, and “core strengthening,” before your inner core muscles have regained their function, places you at risk of developing/worsening a pelvic organ prolapse, developing/worsening urinary incontinence, and straining your back.

Hence, having your core and pelvic floor muscles assessed by a specially trained physiotherapist will let you know how strong or weak your core is and, subsequently, what level of exercise may be appropriate for you. Your physiotherapist will let you know what precautions you may need to take when starting your exercise routine. You will also learn how to do a proper kegel and how to re-train your core so that you can confidently activate your core while exercising.

Another added benefit is that the assessment will make light of any pre-existing injuries or areas of pain, and will be able to make specific exercise recommendations for you.

Pelvic Health Physiotherapy is also covered under Extended Health Care plans as Physiotherapy.

This is a misconception. It is NOT normal to leak with age. If you are leaking, even if it is just a little, your pelvic floor muscles are likely weak. A correct pelvic floor contraction can help improve urethral closure to prevent leakage. The stronger the muscles, the better they are at providing tight closure. There is a substantial level of research that states pelvic floor strengthening should be considered the first line of treatment for incontinence.

Important point to remember: Leaking is COMMON with aging and can be helped with Physiotherapy treatment

This is yet another misconception. If you are leaking, even if it is just a little, your pelvic floor muscles are likely weak. With the incredible amount of stretching that occurs during a vaginal delivery, in many cases, the muscles do not return to optimal status. Like any other muscle that has had an injury, the pelvic floor muscles need to be rehabilitated to their optimal state. If you are leaking, there is likely some (or a lot of) residual weakness from the delivery and your pelvic floor muscles need some help. The reason why this is so important, is that the pelvic floor plays an integral role in maintaining continence, supporting your pelvic organs, providing back stability, and improving sexual health. Hence, rehabilitating the pelvic floor after having children is not only restorative, but preventative as well!

Yes of course! It is never too late to strengthen your pelvic floor and core. Over time, lack of adequate contractions cause your pelvic floor muscles to lose their tone. Add to that, hormonal changes that occur with menopause, and now you’re left with pelvic floor muscles that struggle to do their job. However, this muscle group can be strengthened, just like any other voluntary muscle in our body.

Interesting fact: In France, any woman that has had a vaginal delivery, is directed to see a pelvic floor physiotherapist post-partum for pelvic floor strengthening and core muscle retraining, and their government health plan covers it!

There are two important points to consider when answering this question:

1. Research has shown that at least 50% of women do not contract their pelvic floor muscles with just verbal instructions or a written handout. Hence, you might decide to start strengthening your pelvic floor, but there is a good chance you are doing your kegels incorrectly. Learning how to perform a kegel through an internal assessment is the “gold standard.”
2. Kegels aren’t for everyone. A large number of women actually have pelvic floor muscles that are too tight. Imagine what it may be like to have tight neck muscles. They may be sore, you may have difficulty turning your head, or you may even experience headaches. The treatment in this case wouldn’t involve strengthening the neck to tone the muscles up even more. The treatment would be focused on releasing and relaxing them. The same goes for the pelvic floor. If your pelvic floor muscles are being held tight, doing kegels can actually make your symptoms worse! If you think you might have some issues with your pelvic floor, have them assessed by a Pelvic Floor Physiotherapist