In this post we provide an overview of the pelvic floor muscles and outline simple exercises from Pilates and yoga that can strengthen your pelvic floor. Strong pelvic floor muscles have many health benefits, one of the most beneficial results being the prevention of urinary incontinence.  Also, during pregnancy a strong pelvic floor makes delivery easier and reduces time to regaining elasticity in these muscles.  In addition, sexual function can benefit from pelvic floor strength throughout a woman’s life, including the enhancement of orgasm.

Pelvic Floor Muscles
The pelvic floor is shaped like a bowl.  The skeletal muscles that make up the pelvic diaphragm are supported by the pubic bones.  The muscles are suspended from these bones by tendons like a parachute, giving the pelvic floor its dome shape.   The muscles wrap around the urethra (the opening to the bladder), the vagina, and the rectum.  Voluntary contraction and relaxation of the pelvic muscles controls urination and defecation.  Some forms of incontinence can occur because of the inability to control these muscles to prevent loss of urine or stool.  By strengthening the pelvic muscles through directed exercise, women can exert more control over voiding.  During intercourse, an orgasm results from clitoral stimulation that causes involuntary rhythmic contractions of the pelvic floor.  The areas that contract during orgasm include the outer third of the vagina, perineum, and anal sphincter, also referred to as the orgasmic platform.  Strengthening these muscles can lead to more intense orgasm. 

Kegel
Gynecologist Dr. Arnold Kegel popularized the concept of pelvic floor exercise in order to decrease postpartum urinary incontinence. However, in Kegel’s experience, almost 1/3 of all women were unable to voluntarily contract this muscle with instruction only.  Commonly, women contract their abdominal or external perineal muscles rather than the internal pelvic floor.  In order to insure that the exercise is being done properly, a finger can be inserted into the vagina and the woman contracts the ring of muscles inside the vagina that surrounds the finger.  The pelvic muscles can also be engaged when stopping a bowel movement or stopping urination midstream.

A Home Kegel Excercise
1.         While urinating, start and stop the flow of urine until the bladder is empty.
2.         Lie on your back and bend your knees keeping both feet flat on the floor. Visualize your pelvic muscles and squeeze tension there.  Like riding up an elevator, start in “the basement” with no tension, then add tension slowly until reaching the “5th floor,” where you achieve the most tension possible. Then slowly release tension as you return to “the basement.”

How Pilates Helps
In Pilates, we refer to the pelvic floor as “the basement” of our abdominal wrap. Pilate’s exercises strengthen the pelvic floor, because these muscles are engaged at the beginning of every exercise.  To start, we cue the pelvic muscles, and then exhale the navel to the spine in order to pull the core up and in, down and together. When performing the exercises, keep all other muscles relaxed and don’t grip the buttocks.

How Yoga Helps
Mulabhanda is the yogic concept that engages the pelvic floor. Mula in Sanskrit means root, and bandha means lock. The action is similar to the Pilates focus as well as a Kegel exercise. In many yoga poses, mulabhanda is activated by drawing the pelvic floor muscles between the anus and genitals in and up, contracting the perineal muscles. Mulabhanda builds internal heat and balances the parasympathetic and sympathetic nervous systems. When unlocked, prana (life force, energy) flows.

A Combined Yoga and Pilates Practice
Practice this 20-minute workout several times weekly to help build strength in your pelvic floor

1.         Begin in Sukhasana (easy pose) and engage mulabandha on an exhale. Contract and release 5-10 times.
2.         Open the feet to the width of the mat and sit into Malasana (squat), engaging and releasing mulabhanda 3-5 times. Your hands can be in Anjali Mudra (prayer pose) at the heart.
3.         Straighten legs (moving your feet as wide as your hips), lower head for Uttanasana (standing forward fold). Rotate the inner thighs back and apart then engage mulahandha.
4.         Alternate between squat and forward fold 5 times, exhaling when releasing into Uttanasana. Reengage and release mulabhandha with each Uttanasana and Malasana.
5.         Lie on back with knees either bent at table top or extended out, engage the pelvic floor, exhale navel to spine and curl head, neck and shoulders up to the shoulder blades while maintaining a neutral pelvis (not pressing lower back into mat). While pumping straight long arms up and down 8 inches inhale for 5 counts and exhale for 5 counts. 10 times. Sink navel deeper and squeeze pelvic floor and inner thighs.
6.         Lie flat on the floor with your arms extended to the ceiling and shoulders plugged into their sockets. Squeeze heels, inner thighs, engage pelvic floor, connect navel to spine. Inhale, curl up, and look at toes, arms extended over legs.  Exhale and continue to roll up articulating one vertebra at a time while engaging pelvic floor and pulling belly back, spine is "c" shape curve rounded, pause, inhale, re-engage connections and exhale entire time rolling down, imprinting one vertebra at a time.
7.         Lie on your back for Setu Bandhasana (bridge pose), engage mulabhanda when raising pelvis. Release the gluteus maximus muscles and focus on the pelvic floor muscles. Release the pelvis to the floor and stretch out your legs straight ahead into Paschimottansana (seated forward fold), engaging mulabhanda. Hold the lock for 3-5 breaths.
8.         Lie on your back in Savasana (corpse pose), engaging and releasing mulahanda and relaxing on the last release for 2-3 minutes.

Take a Class
You might want to join one of the many yoga and Pilates classes in the Charleston area and take advantage of the teacher’s expertise.  During class, pay particular attention to how you can engage the pelvic floor in each exercise. Both Gail and Terry (co-authors of this article) teach at the MUSC Wellness Center.

by:  Gweneth Lazenby MD, Terry Hamilton RN, and Gail Corvette

Urinary incontinence or leaking is a common condition in women. It affects upwards of 16 million Americans and is more common in our population than diabetes or hypertension. Despite this fact, it is often unrecognized or unappreciated as a treatable condition. There may be many reasons for this but one of them is the embarrassing nature of this disease and people’s reluctance to discuss it with their doctors.

Most women manage it by wearing absorbent products. This is why there is more grocery store shelf space for adult diapers and absorbent products than for infant care. Others isolate themselves socially for fear of an embarrassing accident. These women are often doing themselves a disservice as there are many therapies available with excellent results in restoring continence and confidence.

Some myths about incontinence:

• MYTH: It is an inevitable process of getting older. REALITY: There is no doubt that the incidence of incontinence increases with age but that doesn’t make it normal or inevitable. Women over the age of 50 respond to therapy just as well as younger women and get satisfactory relief in the vast majority of cases.

• MYTH: Surgery is the only treatment option. REALITY: Surgery plays a role in some forms of incontinence but most incontinence is treated with either behavioral therapy, pharmacotherapy with medications or physical therapy with pelvic floor muscle strengthening.

• MYTH: Nothing works in treating incontinence, my friend had surgery and it didn’t work. REALITY: There are multiple therapies for treating all types of incontinence. Yes all therapies are not 100% effective, but do improve symptoms in over 90% of patients who seek care. Surgical cure rates for certain types of incontinence are around 90% and surgical failures are uncommon in properly selected patients.

What should I do if I am experiencing incontinence?

• Talk to your doctor (Family doctor, Internist or Gynecologist) by setting up a visit to discuss your incontinence problem. Don’t try to talk about it at a visit where you are also addressing other problems.
• If your doctor is not comfortable managing urinary incontinence ask for a referral to a local physician who can help you with your concerns.
• If you are concerned about surgery ask your doctor for non-surgical options (there are always non-surgical options)

What can I do myself to help with incontinence?

This will depend to some extent on what type of incontinence you are experiencing but here are a few suggestions:
• Avoid caffeinated substances.
• Avoid drinking large volumes of fluids (like some diets suggest)
• Kegel’s exercises are often recommended but research suggests they are difficult to master without the help of a physical therapist and biofeedback. However, there is new evidence that Pilates exercises can mimic some aspects of Kegel’s exercises and help strengthen the pelvic floor which can reduce incontinence episodes.
• Urinate on a regular schedule at least every 2.5 to 3 hours.

by:  Steve Swift, M.D.