Alyssa Brunt, pelvic floor physiotherapist, has both a Masters in Physical Therapy and a BSc. Kinesiology from Queen’s University. She has a passion for all things pelvic health and has been practicing in Toronto for the past 6 years. A few other things about Alyssa: She’s a small town girl. She loves travelling. She’s an avid baker. She has a love for the outdoors and hiking. She’s always talking about pelvic floor health.
When you google pelvic floor you will find everything from how to have better sex to how to strengthen and perfect your kegels. However, there seems to be a lot of misinformation floating around. Kegels are only half of the story when it comes to pelvic health.
Most of us are not even entirely sure where or what our pelvic floor is and what its role is within our body. According to Alyssa Brunt, a trusted pelvic floor physiotherapist, it is important for everyone to have a healthy and functioning pelvic floor.
Whether you’ve had a baby or not, you should get to know your anatomy and learn about this important area of the body. As Alyssa explains, because the pelvic floor is inside our bodies, it does not receive as much attention as it should, but really, it is a large group of muscles no different that the muscles inside your arm or leg. It can be stretched or tightened, strengthened or weakened. Often, we don’t even consider our pelvic floor until it has been compromised but prevention is power.
Below, Alyssa unlocks the secrets of our pelvic health.
Can you take us through what exactly our pelvic floor is?
The pelvic floor is an entire group of muscles that lines the inside of the pelvis. When we talk about the pelvic floor, we are really referring in short to the pelvic floor muscles, all of the soft tissue structures (ligaments, tendons, fascia) and the pelvic organs. You can really think of it as a hammock that runs from the pubic bone to the tailbone, supporting all of these structures within it. It is responsible for 5 main functions that are important for our day to day life which include:
- Toileting: Allowing us to be continent (i.e go to the bathroom when we want) and ensure that we don’t have any urinary/fecal leakage or retention, constipation, UTIs and more.
- Organ support: Supporting and protecting our pelvic organs (bladder, uterus, rectum) inside the pelvis and reducing the risk of things like pelvic organ prolapse (POP- a dropping of the pelvic organs into the pelvic floor space).
- Joint stabilization: Providing stability to the joints of the pelvis, including the SI joint in the lower back, the hip joints, pubic joint on the front and even our sacrococcygeal joint (tailbone) in the back.
- Circulation: Many people don’t know that the pelvic floor is the second largest pump back to the heart (the calf being the largest). The pelvic floor helps maintain circulation in the body and reduce pelvic congestion. This is really how our muscles get nutrients for recovery and strengthening.
- Sexual function: Making sure that sex feels good! The pelvic floor allows us to have pain-free penetration (including things like tampons, toys, etc), orgasm, lubrication, adequate blood flow and overall pleasure-filled sex.
Why is it important to strengthen our pelvic floor?
This is such a good question! Our pelvic floor is such a large muscle group that should be strengthened like any other muscle in the body. It’s an area that we should be aware of and that we should be able to both tighten and relax.
Our pelvic floor is also a part of our entire core unit, so really to have good core strength you need to be able to utilize your pelvic floor. Ultimately, knowing how to contract and strengthen this area will help prevent any dysfunction from likely happening in the future.
However, strengthening is NOT for everyone.
Often times in the media or in things we read, the focus is always on strengthening and kegels (a pelvic floor muscle contraction) but really, not everyone should be or needs to be strengthening. If someone is experiencing signs and symptoms of pelvic floor dysfunction related to weakness (like urinary leakage or prolapse), strengthening may be necessary BUT if you’re having tightness related issues (pain with sex, painful periods, pelvic pain, urinary urgency, chronic constipation/UTIs, cystitis etc), kegels are likely not the answer.
That’s why it’s best to work with a physio who can assess you and help determine what your body needs before starting any type of strengthening.
What are some of the signs and symptoms of a weak pelvic floor?
There are many things that could suggest your pelvic floor muscles are weak. Urinary or fecal incontinence with coughing, laughing, sneezing, jumping/running etc can indicate your pelvic floor muscles are weak but so can other things like lower back discomfort, prolapse, the inability to hold gas and difficulty performing a kegel. However, it’s not always so clear because pelvic floor weakness can underly a lot of dysfunctions surrounding pelvic tension or tightness.
Generally, those that have tighter pelvic floor muscles may have underlying weakness but the tension has to be addressed or treated first. You can’t effectively strengthen a tight pelvic floor because the muscles are just too tense. Honestly, I feel like most people have underlying weakness in the pelvic floor muscles, simply because no one really knows how to contract them and it’s not an area of the body anyone has really dedicated time and effort to strengthen. It’s not like we go to the gym, sit on a chair and kegel for 10 minutes during our workouts.
Most people could benefit from strengthening or relaxing before those signs and symptoms start to show up.
What are the causes of pelvic floor dysfunction?
Generally speaking, there isn’t really one cause of pelvic floor dysfunction but rather a lot of overlapping things. You really have to consider the whole person when trying to understand the cause – the physical, the emotional/psychological, and the environmental/social. In my opinion, one of the biggest causes of pelvic floor dysfunction is really a lack of education and a lack of use.
Again, a lot of people just don’t know this is a really important area of the body- we need to know what it does, how to engage it and how to know when things aren’t working properly. Other things like poor lifting mechanics, chronic coughing, stress, tight muscles, an inability to relax, scar tissue and adhesions from things like C-sections, perineal tearing at birth, cyst removals or hysterectomies, pre-existing conditions like endometriosis, fear/anxiety, previous trauma and more can all lead to pelvic floor problems. The list really goes on.
Poor toileting behaviours and bad habits can also lead to pelvic floor dysfunction. “Just in case pees” are one of the worst things we can do for our bladder because they re-train how the bladder fills and empties. Think of the bladder as a storage unit- it fills over time, sends signals to the brain to empty and then we sit on a toilet and pee. When we “just in case pee”, we interfere with how the brain and bladder work together and we end up peeing more frequently- we empty sooner than we really should. So, for everyone who “has a small bladder”, it’s likely you just have bad toileting behaviours. Other things like holding in the urge to pee/poop, hovering above the toilet, and having fast, quick pees are also bad toileting habits.
Luckily, habits can be changed with a bit of guidance! We just need to relax when going to the bathroom and a lot of the things above, don’t let us do that and it leads to problems later on. Just sit down, relax, breathe and go. You’ll thank me later.
For someone looking to get pregnant, do you have any tips for supporting pelvic health before birth?
If someone is planning to get pregnant, something they can do proactively for their pelvic health is see a physio, even if they have no signs of dysfunction. Having an assessment will help to rule out pre-existing issues and is a great learning opportunity. Like I said before, so many of us just don’t know what the pelvic floor is and how it works!
The best thing you can do for yourself before pregnancy is know what your pelvic floor is like before having children. Do have tightness? Weakness? Adhesions or scar tissue? If you’re someone who already has painful intercourse, you should definitely see a pelvic physio before getting pregnant so that actual act of conceiving can be enjoyable and comfortable. If you have pain, your body is also going to be stressed so it’s best to address those things early on.
Is it important to strengthen your pelvic floor during pregnancy?
Yes! Absolutely- strengthening will really help to limit pelvic floor dysfunction (leakage, POP, pain etc) afterwards. I always tell my patients the more you do during your pregnancy, the less likely you’ll need my help later on. It’s also not just important to strengthen your pelvic floor but your whole body.
Being active in pregnancy is very important- even if it’s just walking regularly. Now, most people think we want a strong pelvic floor to birth the baby but that’s not true. The uterus pushes the baby out! We need to relax our pelvic floor muscles during birth, not tense them up. Strengthening your body and pelvic floor supports the body during pregnancy and has been to reduce the length of your delivery, assist with your recovery, and reduce pain and the risk of dysfunction postpartum.
It should be noted that pelvic physiotherapists will not treat anyone internally during their first trimester and/or if your midwife/OBGYN has said you’re not able to have intercourse during your pregnancy. Generally, I’ll begin strengthening with patients in the second trimester (if that is what they need- some people may have tension that needs to be addressed first). The third trimester is all about birth prep- breathing, learning possible birthing positions, how to push, manage pain and relax your pelvic floor.
Patients that do physio during pregnancy typically require far fewer visits postpartum and the typically feel more comfortable and supported throughout pregnancy.
What about after birth?
Yes again! Strengthening is so key postpartum because everything is really overstretched and weak after birth. You can start doing kegels, pelvic floor strengthening and gentle core work literally right after the baby has been born. Now our expectation of strengthening and exercise REALLY needs to change postpartum. In the first few weeks, short walks, core breathing and kegels are really our focus. Then things will progress based on how you are feeling. Everyone will strengthen at their own rate, depending on how they feel, how much time they have, and how their body responds.
What we are able to do will also depend on how your birth went (C-section vs. vaginal; tearing; assistive devices), your activity level during pregnancy, and how you physically and emotionally feel. So it’s really person dependent but bottom line is that strengthening is good after birth. I always see my patients after birth and I encourage everyone to do this whether they worked with a physio during their pregnancy or not.
The earliest I’ll see patients for internal work is 6 weeks postpartum or 4 weeks if someone has had a C-section but we can begin breathing, stretches and core work at any time. Basically, my goals with each person postpartum is to ensure there are no signs of pelvic floor dysfunction (leakage, prolapse etc), sex and penetration feel good, and patients are back to exercise. Outside of the pelvic floor, strengthening can also help with neck and upper back pain from holding and feeding, lower back pain, wrist/thumb pain and more.
What is diastatis recti?
Diastasis recti (DR) is the separation of the abdominal muscles, during or after pregnancy. It is not an injury, it’s an adaptation of pregnancy which means it’s going to happen- no matter what. The abdomen must get larger to accommodate a growing baby during pregnancy so the abdominal muscles will separate to make space.
The abdominal muscles aren’t connected to one another anyways, they run like columns so there is always space between them- most people just don’t know this. Although diastasis will happen naturally during pregnancy, we don’t want to be doing things that can make things worse or widen further. Throwing yourself up out of bed or off the couch and not focusing on your core or abdominals during workouts can encourage coning/doming and progress diastasis recti.
Postpartum, it’s all about strengthening the abdominals and core to stabilize and support this area. Really, everyone should work with a physio early postpartum to know the exercises they should be doing for their body and how to incorporate tools like ab wrapping (compression wrap around your abs) to improve their recovery. Physios are there to support you through the introductory movements, after that it’s best to incorporate a trainer or look into an intermediate level postnatal program.
How can we know if we are contracting our pelvic floor?
There are many cues that we can use when trying to contract our pelvic floor. The most common one is to think of stopping the flow of urine, but you can also think of sucking a milkshake through a straw, pulling a ping pong ball or marble inside the vaginal opening, or trying to touch your tailbone and pubic bone together. It’s also important to know that kegels should not be done on the toilet- remember toileting means relaxing the pelvic floor not contracting it!
Kegels are like a secret vagina exercise, no one should be able to tell when you are doing one. If you see your knees shake, glutes contract or feel that you are tucking/tilting your pelvis, you are likely recruiting other muscles to help you. This will get better with time! Your brain and this group of muscles don’t work together in isolation often because we rarely train the pelvic floor so most of the time, we just need to dust off the cobwebs and practice.
Now to really feel if you are contracting, you can insert your finger into your vagina up to the first knuckle, do the cues and see if you can feel your muscles tighten around your finger. If you can- good job! That’s a kegel. You can strengthen the pelvic floor in so many ways too: shorter pulses or contract and hold for a few seconds to improve both power and endurance.
What is one thing we should start and one thing we should stop doing today for our pelvic floor health?
One thing we should stop doing is the “just in case” pees. It is the fastest and simplest thing you can change. If there’s one thing we could stop it would really be to stop neglecting our pelvic floor and start thinking of it as an important part of our body. One thing that we can start doing is learning more about our anatomy, learning more about signs and symptoms of dysfunction and just normalizing conversation around our pelvic health.
The primary aim of this article is to provide information. Although it may include advice from physicians and medical practitioners, it is not intended to serve as a replacement for professional medical advice, diagnosis, or treatment. It is not recommended to rely on this article for specific medical advice.