Pelvic Floor Exercises
Introduction[edit | edit source]
The pelvic floor, also known as the pelvic diaphragm, are a collection of muscles that span the floor of the pelvis. The pelvic floor muscles enclose the pelvic viscera, including the bladder, intestines, and uterus (in females) and separate the pelvic cavity above from the perineal region (located between the anus and the overt genitals) below.. The pelvic floor supports abdominal and pelvic viscera, maintains bowel and bladder continence, and functions in voiding, defecating, sexual activity, and childbirth.
Weak, strained, or overly tight pelvic floor muscles can lead to pelvic floor dysfunction, which may include pelvic pain, urinary/bowel incontinence, pain with sex, sexual dysfunction, and pelvic organ prolapse. 
The contraction of pelvic floor muscles during perineal exercises results in elevation of the urethra, vagina, and rectum, resulting in stabilization of the pelvic floor and resistance to downward movement. Pelvic floor exercises can strengthen and increase neuromuscular control over the pelvic floor muscle and may reduce or eliminate symptoms associated with pelvic floor dysfunction.
Indications for Pelvic Floor Exercise[edit | edit source]
The below symptoms may indicate the need for Pelvic Floor Exercises in all genders:
- Urinary incontinence/frequency/urgency 
- Pain in pelvic region, genitals, perineum, or rectum 
- Sexual dysfunction including erectile dysfunction, pain or numbness in the genitals during or after sex See also Sexual Dysfunction After Prostate Cancer
- Pelvic organ prolapse, which may be felt as a bulge in the vagina (feeling or seeing a bulge or lump in the vagina or coming out of your vagina) or a feeling of heaviness, discomfort, pulling, dragging or dropping. 
- Chronic low back pain unexplained by other sources
Activating the Pelvic Floor Muscles[edit | edit source]
Pelvic floor exercises begin with learning to simply activate the pelvic floor muscles.
- The first step is to find a comfortable position, attempt to relax all muscles, and focus on a steady breathing pattern.
- To activate the anterior pelvic floor muscles, replicate the action of stopping the flow of urine mid-stream. 
- To activate the posterior pelvic floor muscles, replicate the action of stopping passing gas. 
- To activate both the anterior and posterior pelvic floor muscles, combine the two above actions. 
When activating the anterior pelvic floor muscles, it is important to not actually stop the flow of urine mid-stream when using the bathroom, as this may lead to difficulty with fully emptying the bladder.
Specific Exercises[edit | edit source]
Kegel[edit | edit source]
The Kegel exercise is probably the most widely known pelvic floor exercise. It consists of an isometric contraction of the pelvic floor muscles.
To do a Kegel exercise, follow these steps:
- Start by holding your pelvic floor muscles in for 5 seconds. It is important to keeping breathing during this contraction.
- After holding for 5 seconds, slowly and completely relax your muscles for 5 seconds.
- Repeat this process 10 times, at least 3 times every day.
Your pelvic floor muscles may get fatigued during this exercise. If this happens, stop and do the exercise at a later time.
Don’t use your stomach, leg, or buttock muscles when doing this exercise.
As you continue to practice these exercises, you should increase the time you hold and rest your pelvic floor muscles. Start with 5 seconds, and slowly build up the time each week until you’re holding in and resting for 10 seconds.
Reverse Kegel[edit | edit source]
Fatigued pelvic floor muscles and imbalanced intra-abdominal pressures can lead to hypertonic pelvic floor muscles. 
The Reverse Kegel is a technique to mindfully relax pelvic floor muscles. The patient focuses their mental attention to the pelvic floor muscles and then voluntarily tries to relax them. The feeling of dropping the pelvic floor is similar to the moment of relief when you have reached the bathroom; when you urinate or have a bowel movement, you first drop your pelvic floor, and let the pelvic floor muscles (PFM) go. 
To perform a Reverse Kegel, follow these steps:
- Start by gently contracting the pelvic floor to feel what tightening the muscles feels like.
- Relax, and release the tension to feel the difference between tension and relaxation.
- Then, try to visualize that the muscles between the pubic bone and tailbone lengthen by gently moving the pubic bone towards the ceiling (if you are lying on your back), and gently move your tailbone towards the surface you are lying on. Imagine that the pelvic floor muscles are getting longer as this happens creating more space in your pelvic floor.
- During the above action, be sure to breath normally.
As you perform a Reverse Kegel, be sure you keep your pelvis and spine still. These can be performed in sitting and standing as well. 
Hypopressive Exercises[edit | edit source]
Hypopressive exercises (HEs) lower intra-abdominal pressure, while concurrently increasing the tone of the pelvic floor muscles and deep abdominal muscles without voluntary activation.
In 1980, Caufriez developed a series of thirty-three consecutive HEs which each involved a posture to be performed in different body positions (standing, kneeling, quadruped, sitting and supine), combined with a hypopressive maneuver, in which the women performed an expiratory apnea (breath hold at end expiration), while drawing-in their abdomen and opening their rib cage.
Transverse Abdominis Activation[edit | edit source]
Activation of the transversus abdominis (TrA) has been shown to facilitate pelvic floor muscle activation and vice versa. TrA activation also leads to increased pelvic floor muscle activity without directly training the pelvic floor musculature.
Transverse abdominis activation can be progressed based on body position, increasing hold times, and increasing sets. Activation can first begin in low-load body positions, including supine, quadruped, sitting, or standing.TrA activation can be challenged by adding arm and/or leg movements and movements like walking or balancing on a tilt board. The plank is a great exercise for TrA
Biofeedback[edit | edit source]
Biofeedback is an instrument-assisted intervention that allows patients to observe real-time pelvic floor muscle activity.Biofeedback can be used to strengthen weak pelvic floor muscles and to relax hypertonic pelvic floor muscles.
Similar to the Kegel exercise, biofeedback exercises consist of alternating periods of contraction and relaxation. Biofeedback interventions may improve sensitivity and neuromuscular control of the pelvic floor muscles.When using biofeedback with a patient, be sure you measure baseline pelvic floor muscle activity before beginning exercise. 
Resources[edit | edit source]
References[edit | edit source]
- Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterology & Motility. 2006 Jul;18(7):507-19.
- Mantle J, Haslam J, Barton S, Polden M. Physiotherapy in obstetrics and gynaecology. Butterworth-Heinemann,; 2004.
- Schreiner L, Crivelatti I, de Oliveira JM, Nygaard CC, Dos Santos TG. Systematic review of pelvic floor interventions during pregnancy. Int J Gynaecol Obstet. 2018 Oct;143(1):10-18. doi: 10.1002/ijgo.12513. Epub 2018 May 18.
- Pelvic Obstectric and Gynaecological Physiotherapy. 2016. Pelvic floor muscle exercises (for men)[online] [viewed 26 March 2018]. Available from: https://pogp.csp.org.uk/publications/pelvic-floor-muscle-exercises-men
- NHS Choices. 2017. Living with incontinence [online] [viewed 28 March 2018]. Available from: https://www.nhs.uk/conditions/urinary-incontinence/
- Women's and Men's Health Physiotherapy. 2017. Leading the way in pelvic health [online] [viewed 28 March 2018]. Available from: https://www.wmhp.com.au
- Male Pelvic Floor. 2012. Sexual Dysfunction and the Male Pelvic Floor [online] [viewed 29 March 2018]. Available from:http://malepelvicfloor.com/sd.html
- Pelvic Floor First. 2017. Pelvic Floor First [online] [viewed 26 March 2018]. Available from: https://www.pelvicfloorfirst.org.au/pages/how-can-i-tellif-i-have-a-pelvic-floor-problem.html
- Bi X, Zhao J, Zhao L, Liu Z, Zhang J, Sun D, Song L, Xia Y. Pelvic floor muscle exercise for chronic low back pain. J Int Med Res. 2013 Feb;41(1):146-52. doi: 10.1177/0300060513475383. Epub 2013 Jan 23.
- Polden, M. and Mantle, J., 1990. Physiotherapy in obstetrics and gynaecology. Elsevier Health Sciences.
- Louis-Charles K, Biggie K, Wolfinbarger A, Wilcox B, Kienstra CM. Pelvic Floor Dysfunction in the Female Athlete. Curr Sports Med Rep. 2019 Feb;18(2):49-52. doi: 10.1249/JSR.0000000000000563.
- Navarro-Brazález B, Prieto-Gómez V, Prieto-Merino D, Sánchez-Sánchez B, McLean L, Torres-Lacomba M. Effectiveness of Hypopressive Exercises in Women with Pelvic Floor Dysfunction: A Randomised Controlled Trial. J Clin Med. 2020 Apr 17;9(4):1149.
- Navarro-Brazález B., Sánchez-Sánchez B., Prieto-Gómez V., De la Villa-Polo P., McLean L., Torres-Lacomba M. Pelvic floor and abdominal muscle responses during hypopressive exercises in women with pelvic floor dysfunction. Neurourol. Urodyn. 2020;39:793–803.
- Ghaderi F, Mohammadi K, Amir Sasan R, Niko Kheslat S, Oskouei AE. Effects of Stabilization Exercises Focusing on Pelvic Floor Muscles on Low Back Pain and Urinary Incontinence in Women. Urology. 2016 Jul;93:50-4. doi: 10.1016/j.urology.2016.03.034. Epub 2016 Apr 5.
- Physical Therapy Nation. Clinician Education: How To Teach Proper Transverse Abdominis Contraction. Available from: https://www.youtube.com/watch?v=p8O04WLXFt8
- Capelini MV, Riccetto CL, Dambros M, Tamanini JT, Herrmann V, Muller V. Pelvic floor exercises with biofeedback for stress urinary incontinence. Int Braz J Urol. 2006 Jul-Aug;32(4):462-8; discussion 469. doi: 10.1590/s1677-55382006000400015.
- Wallace SL, Miller LD, Mishra K. Pelvic floor physical therapy in the treatment of pelvic floor dysfunction in women. Curr Opin Obstet Gynecol. 2019 Dec;31(6):485-493. doi: 10.1097/GCO.0000000000000584.