One of my dear friends — who hasn’t had children — recently told me that although she loves my FemFusion classes and videos, she always kind of “ignored” my jibber-jabber about pelvic floor strengthening because she hasn’t had kids. She knew pelvic floor health was important for women in general, but thought that conditions like prolapse and incontinence only pertained to women who’d given birth. It wasn’t until she read my book that she realized that pelvic floor dysfunction can affect women of ALL ages and stages, and that no woman is left behind when it comes to changes that occur to the inner core throughout a lifetime. These inevitable changes require special attention to pelvic floor health and wellness.
What the heck is the pelvic floor?
The pelvic floor consists of a collection of muscles that stretch across the base of the pelvis. To orient yourself, place your hands on the uppermost crests of your pelvis (in other words, “put your hands on your hips”). If you imagine that your hands are on the top edges of a bowl, you can imagine your pelvic floor as the bottom of the bowl.
Let’s break down the pelvic floor into its parts. A group of three muscles fan across the base of the pelvis from the pubic bone in the front to the tailbone in the back. These three muscles form what is collectively known as the levator ani. The levator ani provides most of the pelvic floor’s mass and power. More superficially (below the levator ani) is a thinner layer of muscles that are collectively known as the urogenital diaphragm. The pelvic floor – including the levator ani and urogenital diaphragm – can be pictured as “the bottom of the bowl” as described above, or as a hammock that supports your pelvic organs including your bladder, uterus, and rectum.
What the heck is prolapse?
Pelvic organ prolapse is when one or more of the pelvic structures (including the uterus, bladder, vagina, and/or rectum) fall down or slip out of place.
Although often attributed to pregnancy and childbirth, prolapse is not an issue that is confined to mothers. Women who have never been pregnant can have problems with prolapse and other problems related to pelvic floor muscle weakness.
When I was in clinical practice I worked with multiple nulliparous (never been pregnant) women who experienced problems related to pelvic floor and core weakness.
One of my nulliparous patients was a professional landscaper who had engaged in a long and successful career. Externally, she looked like she was in great shape, but when I completed a pelvic floor muscle examination I found that her pelvic floor was weak and uncoordinated and that she was suffering from significant uterine prolapse. Years of lifting heavy loads with improper body mechanics had pushed her uterus downward and taken a toll on her pelvic floor muscles.
So what causes prolapse?
Of course the process of carrying a growing baby for 9 (plus) months INSIDE of your body, followed by the act of giving birth, and then carrying the baby (and then toddler… And then preschooler… And sometimes even a first grader…) can definitely strain the pelvic floor and is one of the primary contributors to prolapse. But the following factors can cause prolapse as well.
Keep in mind… These can be problems for ANY woman… Not just women who’ve had kids.
1. Heavy lifting — and doing sit-ups/crunches — without first engaging the base of the core (i.e. the pelvic floor).
This is exemplified by the professional landscaper I mentioned above.
Also… CrossFitters, listen up! When lifting heavy things, you need to “zip up” and engage your core muscles, starting at the pelvic floor. This will protect your back and will prevent issues such as pelvic organ prolapse.
I’m all for lifting heavy weights… Resistance training is an essential part of my own fitness regimen and über-important for ALL women, especially as they age. It boosts metabolism, improves bone mineral density, and just plain feels AWESOME to be strong and sturdy… However, you must be able to effectively use your pelvic floor and core muscles if you are going to be a responsible weight-lifter or participate in high intensity interval training activities that use explosive movements.
Think of a toothpaste tube that’s not capped. When you put downward pressure on the toothpaste tube, either by squeezing from the top or by bending it in the middle, what happens to the toothpaste? It splurts out.
This is an excellent — if not a little dramatic and disgusting — parallel to what can happen to the pelvic organs when downward pressure is applied (via weight training and/or certain core strengthening exercises such as crunches) and the pelvic floor muscles are either weak or NOT actively engaged.
Imagine a clean and jerk lift with weak and/or un-engaged pelvic floor and core muscles. You squat down and then jerk that barbell up… Which causes an incredible amount of downward force on the pelvic floor… And splat. Either an accident (bladder control issues are reported to be fairly common among female CrossFit athletes) or risk for pelvic organ prolapse.
Imagine an abdominal crunch (or any other core exercise that involves trunk flexion) with weak and/or un-engaged pelvic floor and core muscles… You bend at the waist to “crunch” and… Splat. Repeated downward pressure on your pelvic organs without support from below (from the pelvic floor) puts you at significant risk for developing pelvic organ prolapse.
So the moral of the story: Zip up when lifting and doing ab work (i.e. engage your pelvic floor and your low abs, like you’re zipping up a pair of skinny jeans). Do what you can to keep your pelvic floor and core STRONG and supple. Walk! Squat whenever you can! Take laundry-doing as an example:
Quick disclaimer before moving on: You don’t need to “zip up” all day long… No, no, no. Conscious, active “zipping” is only required when you are:
- Doing something strenuous such as lifting, bending, pushing, pulling (some examples: moving a box, lifting your dog, vacuuming…)
- Doing focused core strengthening exercises or weight lifting/resistance training
- Doing activities that require extra stability, balance, and control (such as standing on a ladder)
- Doing things that might be jarring to the pelvic floor such as jumping, running, etc.
At other times — during normal, non-rigorous activities of daily living — don’t worry about “zipping.” Simply use good posture and relax the core. Your core muscles are always firing — always “on,” albeit at a low level — throughout the day. If they weren’t “on,” you wouldn’t be able to stand up. Zipping makes them “extra on,” and you do NOT want to overly tax your muscles by zipping up the core all day long. Too much zipping can create excess muscle tension and ultimately pain and dysfunction.
2. Participating in high impact, “pounding” type of activities without having a strong core and pelvic floor.
Sorry to be calling out certain groups of athletes/exercisers, but runners, listen up… The impact of running, especially on unforgiving surfaces such as concrete, can be hard on the pelvic floor (as well as your joints).
The jarring effects of pavement pounding and other high impact exercises can cause you to reach (and exceed) your “continence threshold” more quickly than lower impact fitness activities. The “continence threshold” corresponds to the amount of force and the length of time with which the pelvic floor muscles can withstand the effects of repetitive impact. The threshold is reached and incontinence can occur when the pelvic floor muscles become fatigued and lose their efficiency. The continence threshold is reached must faster if the muscles have not been sufficiently prepared for high impact activities.
The same holds true for pelvic organ prolapse.
Now, this isn’t to say that you should “zip up” or hold a kegel throughout your 20-mile run to prevent prolapse and bladder leakage… Just be sure that your baseline level of core and pelvic floor strength is good.
Runners — and I know this, because I once identified primarily as a “runner” — can be guilty of focusing SO MUCH on their distance/endurance training that they neglect cross-training and doing other activities that strengthen the core. Try adding a pilates class, a yoga class that focuses on core strength and control (such as Ashtanga), or bellydance lessons to your running program. And be sure to squat!
Another note about incontinence and athletes: I have worked with several women in their late teens and early twenties who were heavily involved in high-impact athletics and experienced uncontrollable urinary leakage. One of my younger patients loved dodge ball which, when played competitively as an adult, is incredibly intense! The sport involves high impact, fast-paced activities such as running, jumping, throwing, catching, and (of course) dodging. Although my patient was athletic and strong her inner core muscles were not as fit as they needed to be in order to prevent leakage during competitive games. The good news? Her symptoms were almost completely resolved following physical therapy treatment that involved inner core fitness with a focus on pelvic floor muscle strengthening and coordination training.
3. Bad posture.
You know I have a “thing” about posture. If you don’t stand tall using techniques for proper posture and alignment, just look at all of the pressure you’re putting on your internal organs (not to mention your bones, muscles, and joints):
Standing (or sitting) with poor posture puts excessive pressure on your abdominal and pelvic organs and strains the muscles and connective tissues that surround your joints.
This can cause pelvic organ prolapse from your pelvic organs (bladder, rectum, uterus) being pushed downward and is compounded by the fact that the structure of your bony pelvis prevents downward descent of the pelvic organs when your pelvis is in the correct position. But when your pelvis is NOT in the correct position — when it is tipped back (posterior tilt, as seen at right in the photos above) — the pelvic organs descend right on down through the space that makes the birthing canal. If you have an incompetent pelvic floor (either too tight *or* too long and weak to work well) to boot, you’re almost guaranteed to develop pelvic organ prolapse at some point in your life.
To make matters worse, constant pressure on the bladder and bowels — due to your abdominal and pelvic contents being “squished” because of poor posture — can lead to feelings of urinary and fecal urgency and bladder control issues.
4. Carrying excess weight.
Carrying extra weight (i.e. obesity) correlates with an increased risk of both pelvic organ prolapse and urinary incontinence. This is due to the effect of downward pressure on the pelvic organs and the pelvic floor. Although I have not read studies about the resolution of prolapse after weight loss, it has been shown that when women lose weight, their incontinence tends to decrease on its own without any other intervention.
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In a perfect world, all women would understand the importance of inner core strengthening in order to prevent issues such as incontinence and prolapse before they occur; unfortunately, we are not there yet. But I’m doing my best to change that!
Strengthening the inner core – particularly the pelvic floor – improves muscle tone, increases circulation, and increases innervation to the pelvic muscles and pelvic organs. Increased circulation can improve vaginal lubrication and can improve ability to reach and even extend orgasm, keep you balanced and stable, provides a strong foundation for core strength (which prevents back and hip pain), and can prevent and treat common women’s health issues such as incontinence and pelvic organ prolapse. There are so many great reasons to focus on total core fitness!
So ladies… Even you young, carefree ladies who have never been pregnant or had children… Please consider your pelvic floor when training your core!
Interested in learning more about the pelvic floor? Check out my recent article, kegel clarity (click here).
"Lift" Pelvic Organ Support Series
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~Dr. Bri, PT, DPT