With management of pelvic floor issues such as vaginal prolapse and bladder leakage, we need to look at the pressures that go through our abdomen and down through the pelvis...
I remember learning early in my pelvic health career that when looking at managing women with prolapse, you need to look at ‘did it fall or was it pushed’? What this means is – did the organ (bladder, uterus or bowel) fall down because of lack of support from the pelvic floor or connective tissue, or was it pushed down from pressure above? Or very likely – was it due to both? And working this out then leads the physio to determine how to manage this patient – do we need to focus on optimizing the pelvic floor muscles, or change the amount of load through the abdomen, or both?
I’m sure that the average person thinks that managing a prolapse or incontinence is all about the Kegels, and getting a strong pelvic floor, but it’s amazing how often you can change symptoms of leakage and prolapse without changing the pelvic floor strength at all. It’s all about how you breathe and what strategies you use to move.
So what causes increases in pressure in the abdomen and the vagina? Often it’s due to things like repetitive heavy lifting, or doing abdominal exercises like planks or sit ups. But sometimes it’s lesser culprits, like getting up from a chair, or going up stairs, or holding your baby.
Multiple studies have shown it’s not what you do, it’s how you do it
Intra-abdominal pressure isn’t necessarily the enemy - we need to increase pressure in our abdomen in order to do lots of daily tasks like coughing or getting up from the ground, and we definitely need to increase intra abdominal pressure to perform tasks associated with sport and exercise. And the strategy you use to increase this pressure should change according to the level of the task. For example, if you want to lift your 1 rep max at the gym, or you need to lift the edge of a heavy couch to get something out from underneath– yes, you will need to hold your breath.
The main issues occur, however, when this strategy of breath holding occurs repetitively at lower level tasks
If you use a high load strategy for something that is a long way below the highest load you can lift, then this unnecessarily puts strain on your pelvic floor and pelvic organs, and may occur multiple times in a day.
It may be to do with a lack of general strength. Once people aren’t strong enough to do a task, maybe they do employ these high load strategies and do things like hold their breath to get up from a chair or pick up their baby.
It may be to do with a learnt habit. What if an abdominal surgery like a Caesarean or hysterectomy caused both pain and an interruption to the pressure system, and after the surgery you wanted to breathe more shallowly and hold yourself more carefully? What if, during your pregnancy, you always held your breath to get up from the floor because of the extra weight, and then continued to use this strategy afterwards? It’s not that these are wrong strategies in the short term, but variance in the way you move and breathe should return afterwards, and when it doesn’t, this can cause problems in the long term.
Check this out yourself, even if you’re not symptomatic for prolapse or incontinence. How much pressure are you exerting during relatively low load activities in your daily life or at the gym? Do you know if you hold your breath with daily activities?
Next time you get up from the ground, or lift a washing basket, or push a trolley round a corner, try talking while you do it. Does your voice change? If it does, you may be holding your breath without realising.
Put your hand on your abdominal wall or between your legs and feel what happens to your pelvic floor and abdominal wall when you sing, cough or shout. Can you feel them going in or do them push out? If they push down and out, knowing that this strategy could set you up for problems, are you able to change this?
So just take this information away with you: what in your life could be inadvertently leading to pelvic floor muscle issues? Sit ups and other exercises that often get the blame are not necessarily the enemy, and in studies they are often not the movements that cause the biggest changes in pressure. Often it’s the transitional movements that are done accidentally with a bearing down action that cause the biggest changes.
The ideal rehabilitation plan for after having a baby or after having gynaecological surgery should be an individual assessment of how your pelvic floor functions, how you breathe and what strategies you use to move.
Lets put this into perspective with a case study
To finish, I want to put this in perspective for you with the example of a lovely patient from my Baby&Me class. She was about 3 months postnatal after her second baby, and had been seeing me for treatment of a moderate vaginal prolapse that was causing her to be quite uncomfortable while she was caring for her baby and her toddler. At her initial assessment, I realised that with movements like getting up from the bed, coughing and lifting any weight, she was pushing her abdomen out. When she was cued to ‘contract her core’, which she had been doing repetitively in her previous reformer pilates classes, she was actually pushing her tummy out and pushing the prolapse down.
During one of her first Baby&Me classes, I made sure I sat next to her while I instructed the class to do a set of modified sit ups. I realised that something had clicked – she was pulling her abdominal wall gently in and breathing out while she did it, in a completely different way to before. I quietly gave her a high five and after class I checked how she was lifting and coughing too – also completely differently. At her next appointment in clinic with me, her prolapse wasn’t giving her any symptoms and her pelvic floor was functioning in a much better way. I gave her a hug and said “do you realise that you may have just changed the trajectory of your life?”. It’s stupid that such a little thing got me so excited, but I honestly think that the fact that she learnt (in only a few weeks!) how to do a sit up, ie how to get up from the bed or the floor, in a way that doesn’t breath hold and doesn’t push her abdomen and pelvic floor out, will stop her prolapse from getting to the point of needing surgery.