What is the Pelvic Floor?
The pelvic floor is composed of a group of muscles, ligaments, and connective tissues that work together to support the pelvic organs and perform various functions. The primary muscles that make up the pelvic floor include:
- Levator Ani Muscles: This is a broad, thin muscle group that forms the bulk of the pelvic floor. It consists of three major parts:
- Puborectalis: Wraps around the rectum, forming a sling-like structure.
- Pubococcygeus: Extends from the pubic bone to the coccyx.
- Iliococcygeus: Extends from the ischial spine to the coccyx.
- Coccygeus Muscles: These muscles are located at the back of the pelvic floor and provide additional support.
- Perineal Muscles: The perineum is the area between the anus and the genitals. Several smaller muscles within the perineum, such as the superficial transverse perineal muscle, bulbospongiosus muscle (in males), and bulbocavernosus muscle (in males), also contribute to pelvic floor function.
- Urogenital Diaphragm: This is a layer of muscle and connective tissue that sits just below the pelvic floor muscles and plays a role in urinary and sexual function.
Role of the Pelvic Floor
Its primary role is to support and maintain various organs in the pelvic region, including the bladder, uterus (in females), and rectum. Here are some of the key functions and roles of the pelvic floor:
Supporting Organs: The pelvic floor muscles provide crucial support to the organs within the pelvic cavity. They help hold the bladder, uterus, and rectum in their proper positions, preventing them from descending or prolapsing into the vaginal or rectal areas.
Urinary Continence: The pelvic floor muscles play a vital role in urinary continence. When these muscles contract and tighten, they help control the release of urine from the bladder. A strong and well-functioning pelvic floor can help prevent urinary incontinence, which is the involuntary leakage of urine.
Bowel Function: The pelvic floor muscles are also involved in maintaining bowel control. They help regulate the passage of stool through the rectum and anus. Weakening of these muscles can lead to fecal incontinence, which is the involuntary passage of stool.
Sexual Function: The pelvic floor muscles contribute to sexual function in both men and women. They are involved in achieving and maintaining erections in men and play a role in orgasm in both sexes. Additionally, these muscles help with vaginal tone and function in women.
Childbirth: During childbirth, the pelvic floor muscles need to stretch to allow the baby to pass through the birth canal. They should be able to return to their normal tone and function after childbirth. However, in some cases, childbirth can lead to weakening or injury to the pelvic floor muscles, which may result in pelvic floor disorders.
Core Stability: The pelvic floor is an integral part of the body’s core musculature, along with the abdominal muscles, back muscles, and diaphragm. A strong pelvic floor contributes to overall core stability, which is essential for activities like lifting, bending, and maintaining good posture.
Venous and Lymphatic Drainage: The pelvic floor muscles also play a role in venous and lymphatic drainage in the pelvic region. Proper muscle function helps maintain healthy circulation and drainage of fluids in the lower part of the body.
Urinary Incontinence: Stress vs Urge
Urinary incontinence is characterised by the involuntary loss of urine, resulting in the inability to control when and where one urinates. It can manifest in various ways, from occasional minor leaks to complete loss of bladder control. Urinary incontinence is typically caused by a range of factors, including weakened pelvic floor muscles, nerve damage, hormonal changes, and underlying medical conditions.
Stress Incontinence:
Stress incontinence is characterised by the involuntary leakage of urine during activities that exert pressure or stress on the bladder and pelvic floor muscles. Common triggers include sneezing, coughing, laughing, lifting, or engaging in physical activities.
Urge Incontinence:
Urge incontinence, also known as overactive bladder (OAB), is characterised by a strong and sudden urge to urinate, often followed by the involuntary loss of urine before reaching the restroom. This condition is typically associated with an overactive detrusor muscle in the bladder.
Normal Bladder vs Overactive Bladder
| Normal Bladder Function | Overactive Bladder |
| Volume in the bladder increases, causing the bladder wall to be stretched. This gradually increases the urge to pass urine. The bladder contracts when sitting on toilet | Instead of gradual increase in urge to pass urine, get a sudden onset of an uncontrollable urge, leading to urinary leakage.Detrusor overactivity shown to be caused of involuntary bladder spasms |
Treatment for Urge Incontinence
In order to effectively manage urge incontinence, it is important to address both lifestyle modifications and retraining the bladder
Lifestyle Modifications:
- Fluid Intake Modifications: Overconsumption of fluids prompts the kidneys to produce urine rapidly, heightening the likelihood of experiencing bladder spasms. Conversely, inadequate fluid intake can lead to highly concentrated urine, potentially causing irritation to the bladder’s inner wall. It is also important to spread fluid consumption throughout the day rather than drinking large volumes at once. This encourages your bladder to fill slowly.
- Reducing Bladder Irritants:
- Caffeine: Caffeine is present in beverages like coffee, tea, sports drinks, and numerous carbonated beverages. In certain individuals, caffeine can amplify bladder spasms, causing them to occur more intensely and at smaller bladder capacities than usual.
- Artificial Sweeteners: Artificial sweeteners present in diet drinks are also knon to irritate the bladder and amplify bladder spasms.
Step 2: Retraining the Bladder
In people who experience urge incontinence, their reaction to the strong urge to go to the toilet is to stand up, therefore increasing the pressure in the bladder leading to leakage.
Instead, we should wait for the urge to pass, then walk to the toilet. The following strategies can be used to help the spasm pass:
- Sit on the heel of your foot (place pressure on your genital region)
The pudendal nerve (S3/S4) innervates the muscles of the pelvic floor. The messages from this region are sent to the same area of our spinal cord as the message from the bladder (S2-S4). Our body isn’t good at doing two things at once. Therefore, by putting pressure on your genital region, this distracts the brain from the messages of urgency from the bladder.
- Curling your toes or standing on your toes
The posterior tibial nerve (which originates from S2/S3) controls these movements. This is again from the same area of the spinal cord as the messages from the bladder. Activating this nerve decreases detrusor overactivity and therefore messages of urgency,
- Counting backwards by 7s or making a shopping list
The prefrontal cortex is in control of keeping our bladder relaxed. It is also the part of the brain important for organisational tasks and list-based activities. When we get the urge to urinate, the prefrontal cortex activity decreases and the emotional part of the brain activity increases. By completing these activities, this keeps the prefrontal cortex active, therefore keeping the bladder relaxed.
Treatment for Stress Incontinence
Primary treatment for Stress incontinence includes Pelvic floor Muscle Training (PFMT). Pelvic Floor Muscle Training (AKA “The Knack” or “Functional Bracing”) involves contracting the pelvic floor muscles before and during intra-abdominal pressure rises associated with a stressful activity such as a cough (Miller et al., 1998).
Dosage of this type of training is based on general strength training principles.
Clinical recommendations:
(Bø & Aschehoug, 2007)
3 – 10 second hold
8 – 12 repetitions
3 sets daily
There is no recipe or ‘best program’ as the PFMT programs in literature have used different dosages. Progressions include changing position, increasing the length of the hold, completing higher velocity contractions, and contracting during functional tasks.
Various cues are used by the treating practitioner to ensure the pelvic floors are engaged appropriately:
- Imagine you’re doing up your jeans fly and button
- Trying to not let your tampon fall out
- Stopping the flow of wee
Secondary treatment include other adjunctive therapies to assist with stress incontinence including: Biofeedback, EMG and ultrasound
Lastly, lifestyle interventions can be very useful. These include:
- Weight management
- Defecation training to limit pelvic floor and pelvic organ descent while evacuating
- Stool manipulation
