Q&A Library

When I "maximise" the anal contraction it has now begun to be painful, right below the tailbone. Am I maximising too much? Or could something else be wrong?

Mary O’Dwyer: Your query has prompted a few questions: Have you injured your coccyx/sacrum at any time, maybe falling? Was your coccyx during childbirth? Did you sustain a significant tear during childbirth? Do you have pain/discomfort during defecation?
Ideally consult a women’s health physiotherapist for assessment of the pelvic floor muscles as you may benefit from soft tissue releases in the area. In the meantime, do the exercises at a level that doesn’t cause any pain.

I notice that it takes a very long time to empty my bladder - and that's not because it's very full....

Question: I mostly empty it and then there is very small trickle that just seems to go on forever. Does this have something to do with a weak pelvic floor?

Mary O’Dwyer: I have a few thoughts for you to consider:

1. Toilet posture and abdominal wall relaxation. Sit tall and try a small forward lean to pass urine. Completely plop your abdominal wall as this relaxes the pelvic floor for easier urine flow.

2. Anterior vaginal wall prolapse (our most common bladder prolapse) can be associated with a hypermobile urethra so it’s harder for the urine to empty. Focused pelvic floor muscle strengthening will help to support the urethra.

3. If the above don’t apply, ask your GP for a pelvic ultrasound to check if there’s any blockage or obstruction causing the slower flow.

4. Keep poos soft and frequent to prevent downward strain/damage to vaginal walls. Keep going until you find an answer to the slower stream.

Case History - TVT (Tension-Free Vaginal Tape)

Question: I want to ask your opinion about TVT. I told my gynaecologist about stress incontinence. Her response was that I MUST DO my pelvic floor exercises EVERY DAY – which from then on I’ve done pretty much every day. It has helped a lot, but at times I’m still not happy. For example sometimes going for a walk and losing a drop with every step. Or sneezing when sitting, and then I leak. The gynaecologist suggested TVT, if the pelvic floor exercises don’t help enough. At this stage it’s not bad enough that I would want to go ahead, but I just wanted to get your opinion for the future. I’ll be 57 years old in a couple of weeks, had 2 pregnancies, and have 2 sons 30 and 33yo. Stress incontinence started after the birth of my 2nd child. No birth trauma. Not overly strong bladder urgency. I’m peri-menopausal with irregular periods.

Mary O’Dwyer: My advice is to continue with your focused PFM training for another couple of months then reassesses your way forward. Options are to trial Ovestin, vaginal oestrogen cream to see what difference this makes to your control; then consider booking into see a WH physio for more targeted advice. You could trial a vaginal Contiform support device for SI which the physio will help you fit and use. If the SI continues to bother you then consider a surgical sling. Please note that some women post birth have a hypermobile urethra which is associated with SI. You may also find the following link useful: https://www.nlm.nih.gov/medlineplus/ency/article/007377.htm

What is your suggestion to disarm my urgent bladder just as I’m getting through my front door?

Mary O’Dwyer: Some strategies to calm the bladder include:

– emptying the bladder before leaving work
– sitting in the car relaxing the abdomen with slow diaphragmatic breathing and
– firmly telling the bladder, ‘forget it’, it’s not time to empty!
– Walk to the door, stand, calm breathing and curl the toes under firmly if urgency starts. Keep them curled, while breathing until the urge lessens, open the door and distract yourself with some other activity.

Practice this until you’re boss of the bladder!

What is the pelvic floor impact of menopause and what can we do about it?

Mary O’Dwyer: There’s no denying that the pelvic floor can be affected by the changes of menopause and ageing! Seems our vaginal tissue, the urethra and pelvic floor muscles love oestrogen. Declining oestrogen levels are related to stress and urge incontinence, prolapse, regular UTIs and discomfort/pain with intercourse. Over 50 percent of women report some degree of ‘genito-urinary’ syndrome post menopause due to reduced collagen, elastin, loss of tissue elasticity and flexibility and reduced blood supply. Treatment includes vaginal moisturises, vaginal oestrogen and dietary phytoestrogens. Some lucky women seem to breeze through menopause due to superior collagen, higher androgen levels and minimal damage in childbirth. BUT, it’s not all doom and gloom! Do you recall what amazing bodies older yoga teachers have? I know several who still have incredible shape and muscle over 75 years of age. Simply, they continued training their muscles. Pelvic floor muscles (PFMs) are no different; they can be trained for strength, quick action and hold. When the nerve supply is intact, PFMs can thicken and develop more closure around the urethra, continue to support pelvic organs and maintain sexual sensation. Training our PFMs throughout life, just like training our arms, butt and thigh muscles, ensures they will continue to work well after menopause. Truly it’s use it or lose it! Stay active and keep moving and be mindful of what you eat to avoid weight gains that add unwanted pressure to that small, precious group of muscles underneath your body.

Can pelvic floor muscle training help atrophic vaginitis (thinning of the vaginal walls)?

Mary O’Dwyer: PFM training is one of the recommended actions for atrophic vaginitis. Exercising the muscles regularly maintains/promotes muscle bulk and promotes blood supply through the squeezing action of the exercises. Part of that training is regular orgasms to help maintain the quick, explosive muscle fibres in the PF.

Can the postural misalignment of the neck cause pelvic floor dysfunction?

Mary O’Dwyer: We often sit in front of screens for too long with work, study or emails. This can reinforce a slumped spine and the chin pokes forwards. So start by lifting up the sternum and then growing tall through the crown of the head. The great news is this tall position gently engages deep muscles of the neck, upper and lower spine and even the pelvic floor. Keep tall, soften the tummy and breathe.
Visit a physio when it hurts to stay tall or you’re not able to hold the position or even line up your posture. Physios have a great array of tools including joint & soft tissue releases, deep connective tissue work, specific stretches, stabilising exercises and home self treatment techniques.

When we have a slumped posture, the postural muscles of the trunk are not engaged. When we’re upright against gravity these inner postural muscles are meant to be active to take the load off our spine and joints. Just so happens the pelvic floor is the under part of our trunk core muscles. To feel the effect of posture on PFMs try this easy test: let your body slump and feel what happens to your PFMs, then grow tall in the chair and again feel what happens. Repeat this action to feel the opening, relaxation of the PF with slumping and the light, gentle engagement when you grow tall. In space (no gravity) astronauts lose the action of their postural muscles in 7-10 days and develop disuse osteoporosis. Moral of the story, keep engaging PF/core muscles throughout life with tall posture and easy breathing (avoid gripping with waist muscles to flatten the tummy).

Do you have any tips for women who sit long hours in the office?

Mary O’Dwyer: The longer we sit, the more likely we are to lose postural control (i.e. sitting tall to engage PF & core muscles). Short periods of relaxed sitting are fine but with longer periods of poor posture sitting, our PF & core muscles go to sleep! Done often enough, this eventually leads to weakness in these vital core muscles. Specifically, long periods of compression on the pelvic floor can lessen blood flow to the muscles and compress nerves supplying the PFMs. So, the first strategy for office workers is to sit tall with your weight down through the sit bones (not back on the coccyx/sacrum). Keep adjusting your posture with small movements and especially important is to stand up regularly. Certainly have someone from OH & S check your chair to see it suits your body and desk. No matter how ergonomic your chair is, eventually postural fatigue sets in and ruins the tall posture. Standing desks are another option but not for hours as the studies show standing at a desk all day ends up causing more low back pain in the users. Recently a friend showed me her comfy and cheap back support she bought from a bargain shop – she uses this in her office chair to support the low back and prevent slumping. Another option is to buy a small air filled disc to place on your chair as this will encourage small postural movements rather than sitting dead still. A gym ball is an option too but doesn’t suit everyone, best to find what suits your situation.

What would be your best advice to women when it comes to heavy weight training, high impact exercises and abdominal/core work?

Mary O’Dwyer: I can understand that some younger nulliparous women would find the exercise guidelines from Pelvic Floor First somewhat restrictive. My thoughts are: Women need to exercise differently in the various stages of their life, e.g. young/no baby, pregnancy, postpartum, menopause and elderly. One woman’s exercise routine may not suit another with poor collagen or coordination for example. Women should not train the same way as men train. Some styles of gym training that focus on traditional training styles with heavy weights and repetitive abdominal routines can actually train dysfunction into a woman’s body. Just ask the renowned premier fitness trainer Marietta Meheni who now trains the trainers in female friendly exercise. She describes how her body was damaged from years of teaching and doing ‘traditional’ training – BTW female fitness trainers have a much higher rate of pelvic floor dysfunction when compared to non gym women. So…..exercise is an individual choice, to be enjoyed, to improve your health and the best prescription against many disorders. Just don’t subscribe to the belief of punishing your body through exercise, instead stick at various exercise types you enjoy and can modify or change through various life stages. I admire my daughter in law (no babies) who rides a bike, hikes, sings and walks a lot but has never gone to a gym. She’s fit normal weight and delightfully balanced. If you choose a gym for some of your exercise (as I do) be sure to do your homework first. Have the trainers received qualifications and have a sound understanding of training women? Do they provide a questionnaire to determine if your core is at risk of damage with some types of training?

We should all become experts of our own bodies and listen when it complains. Postpartum and age bring changes to tissue strength and flexibility and while exercise needs to be a regular thing in our lives, be mindful of what you’re aiming to achieve with exercise and treat your body with the utmost respect!

How can I know that I am using the correct muscles while doing the exercises?

Kathi Janssens: The right pelvic floor muscle contraction is when you exclude other muscles from contracting most prominently the outer abdominal wall, so all work is initiated from your base. To exclude the outer abdominal wall from your Discreetly Fit Training, start off the exercises super slowly. If you jump in too fast and too hard, your outer abdominal wall is likely to jump in as well and harden up. This is not desirable. It can help to keep one hand on your tummy to feel that it is staying soft. If your stomach continues to strongly contract, you are probably still trying way too hard. Think of a feather light pelvic floor contraction to begin with. Breath holding can also create abdominal tensioning. So be sure that you are keeping your breath flowing even just a little. It can also help to place your hand on your pelvic floor, telling yourself that this is where all the action is. As you are training you may notice another type of abdominal tightening which does not draw in your stomach, but gently tensions the abdominal wall in the lower regent. This is a desirable action and it can result in enhanced abdominal tone. However, it is also ok if you don’t feel this. If you are still unsure consider making an appointment with a women’s health physio. She can make your pelvic floor work visible with real time ultrasound, so you can receive the visual feedback for reassurance that you are doing your pelvic floor work correctly.

Do you think wearing the cup for 5 or 6 days per month is ok with regards to pelvic floor strength and function?

Kathi Janssens: I think since you are counterbalancing any possible impact of the menstrual cup with your Discreetly Fit Training your vaginal walls are protected. It is also important to be vigilant in how the wear feels.

Mary O’Dwyer: Wow, an interesting question!
Menstrual cups differ, some are soft and pliable while others are a firmer silicone cup. Some suppliers have a couple of different cups depending on whether you have or haven’t had a vaginal birth. The cups are around 7 cms long and an average vagina about 8-9 cps in length. So the tip of the cup should sit slightly about well toned pelvic floor muscles and not cause any issue while doing pelvic floor exercises.
When the tip hangs below the labia this would cause friction and would not be suitable to be worn. A Women’s health colleague writes about an issue she had removing the cup. She found it difficult to remove due to the firm suction attachment. She commented about the downward stretch on the uterus, fascia and supporting ligaments to remove the cup was potentially an issue.
Thanks for the interesting question.

Do you know anything about the link between antidepressants and incontinence?

Mary O’Dwyer: Lexapro is SSRI and yes some women do report a bladder reaction to the drug. Some antidepressants are even used to inhibit bladder urgency and pain.
A couple of suggestions: if you’ve only taken it for a few weeks, allow a little more time for your bladder to adjust and ask your GP if you can get a lower dose. If Lexapro is positively helping you mood, you may want to persist taking it.
I hope the bladder reaction settles soon.

On days that I plan to run, when is it best for me to do pelvic floor exercises?

Mary O’Dwyer: Thanks for your question about running and the timing of your pelvic floor workout. With such thoughtful consideration you’re ensuring ongoing pelvic health throughout your life!
If you enjoy running, experience no leaking, urgency, pelvic heaviness or pain, then there’s no reason to avoid running.
This reply relates to the days you choose to run – it makes sense to alter the timing of your PF exercises to accommodate the load from running.
So, here are a few tips for your consideration:
– Some women experience pelvic heaviness and tiredness before a period so consider walking or stretching on these days as oestrogen levels are lower at this stage of the cycle
– Avoid running with a full bowel which loads more weight onto the pelvic floor.
– Continue with the mid morning PF exercises. After the run, relax with a shower/bath and a 30 -45 second full squat (feet flat or heels on a bolster, knees apart and bottom to floor) to consciously release the PF as you diaphragmatically breathe. Along with this PF release, stretch hams, quads, hip internal/external rotators as PFMs have attachments to these muscle groups.
– As your PFMs get a workout with running, cut your exercise reps by 50 – 60% focusing on full relaxation as Kathi so beautifully describes in her various exercises Keep enjoying those runs.

Kati Janssens: You can also see how shifting your pelvic floor training to the evening works, so your muscles get a big rest by the morning. If you start experiencing pelvic floor symptoms -or if any existing issue becomes more prominent- take a couple of days break from training, to ensure that your muscles are not overloaded. We aim to achieve optimal training load and avoid pelvic floor muscles that have gone “jelly” :-). Enjoy your runs!

My cyctocele is increasing now I'm 9 weeks pregnant. What can I do to ensure it doesn't continue getting worse?

Question cont.: I barely had symptoms of it and now I can feel it nearly out. I’ve only had one baby before and had no problems until after he was 9 months. Also, do you recommend a posture for sleeping?

Mary O’Dwyer: Unfortunately subsequent pregnancies can worsen a pre existing cystocoele, due to pregnancy hormones which soften pelvic supports. It’s time to go into high protection mode! Here are some suggestions for your consideration:Stop lifting! No toddlers, prams or heavy groceries.Lift PFMs every time before you cough or sneeze and sit down if possible.Sit and stand tall as slumping puts more internal pressure down onto the prolapse.Visit a GP or WH physio who fits a vaginal pessary to help support the front vaginal wall. Learn to put it in and remove it yourself.Wear specific supporting pregnancy shorts, these ones are excellentWww.srchealth.com/src-pregnancy-shorts/Exercise in a pool, best in the morning when muscles are stronger.Continue the great PF strengthening exercises from the Reform.Wait 12 postpartum before considering any surgery and only after religious PFM strengthening. All surgery has a certain ‘life’ and affects nerves and blood vessels supplying the PFMs.Side lying is recommended for sleeping during pregnancy, often the top leg on a pillow. Back sleeping is not recommended over 16 weeks.Take care of your precious self.

Shall I continue running?

Question cont.: I was wondering was your thoughts were in regard to exercise. I have recently started a running program and would like to continue it.

Kati: It is terrific to hear that you are started a running program. From the pelvic floor point of view it is important to be conscious of symptoms that would indicate that your pelvic floor is being pushed over its limit. These would manifest in continence issues, discomfort, pressure or perhaps pain. Maintaining your posture well will ensure that the pressures will pass through your torso without excessive pelvic floor pressure. Keeping your strides low, great shoes and flat surface running can be supportive of your pelvic floor too. Usually a morning run is more agreeable with your pelvic floor for its energy reserves are still full. If you experience pelvic floor issues slow your progress by shorter session and longer rest periods. Your regular pelvic floor muscle training can greatly aid your pelvic floor to cope with running. (I believe there is another running post in our Library section for you to check out.). Enjoy your sessions.

Abdominal Separation

Question cont.: Since having a baby 20 months ago, I had 3cm separation and weak pelvic floor muscles. I now have about 1 cm of separation and a small umbilical hernia. Is it possible to rectify this myself? Are there any exercises I should avoid doing at the gym that would make it worse.

Kati Janssens: Up to 60% of women experience abdominal separation during pregnancy. It is a gap, caused by stretched tissues at the midline of the abdominals. Your gap has closed in well and now it is considered normal. Performing pelvic floor exercises supports the healing progress, so keep them up. Activities that result in abdominal doming for example. fast tummy crunches promote the separation so they perhaps best skipped. Be aware of HOW you perform your chosen exercises, delete access abdominal straining where possible, move with easy and if you notice abdominal doming that you can not alleviate do something different instead

Do I have less strength leading up to my period?

Question cont.: I was thinking training in the evening was harder as I’m physically exhausted, however I’m now thinking my incredibly weak muscles (never experienced this week) may be due to my periods being due and hormonal changes).

Could this be possible, as I’m finding it incredibly difficult to even breathe through these ones as I train?

Kati Janssens: Hi, You are feeling it right, our pelvic floor power is not the same all the time. When we are tired (even after a workout), sad, depressed or under hormonal influences you may notice that your pelvic floor does not support you so well and your exercises are more challenging than usual. Period time is most certainly one of these times. Another prominent influencer is peri/menopause. It is also possible if you are new to training that your muscles are adjusting to the new load. It is best to respect the boundaries of the pelvic floor when this happens, it is ok to compromise your training intensity/or skip a day, and stay positive knowing that what you are experiencing is normal.

How do I know if I'm overdoing my exercises? How much is too much?

Kati Jassens: Your pelvic floor muscles – just like any other muscles – can fatigue from exercise. This would mean that their energy stores become temporarily depleted. Imagine a situation when after a challenging running session your legs are not so ready to carry you down a long flight of stairs due to tiredness. Similarly, while your pelvic floor muscles recover from exercise fatigue they may not be able to support you so well when you sneeze for example, or if you go for a gym session. If you have a pre-existing prolapse, it may even become temporarily more prominent.

In this case, initially increasing relaxation times between exercises and training in the evening, when your muscles can recover by the morning, can help. You can also lower your intensity level for a couple of weeks to 60-70% until your muscles adapt to the new workload.

If your pelvic floor muscles spasm or become painful after your training it means that excessive tension exists in your pelvic floor. (This is not from your training – your training was rather the last drop in the glass – if you know what I mean.) This is a different issue and it needs the attention of a pelvic health physio

Pain in lower abdomen after pelvic floor exercises

Question cont.: I have pain after completing the exercise low in my abdomen just above the pubic area. A little like a stitch. 3 hours later and it has mostly gone. Any ideas what I am doing wrong? It may be connected to my back pain but this is low abdominal not back.

Mary O’Dwyer: I agree with your thoughts about the connection between back pain and pelvic floor weakness. This has been constantly evident in my clients and the research shows men and women with back pain are more likely to experience bladder weakness and vice versa!

My answer comes without taking any detailed history, assessment or the benefit of medical tests, so my answer is based on experience rather than detailed fact!

It is possible the ache you experience after completing the exercises is due to muscle fatigue. When the PFMs are contracted, the deepest abdominal layer, the transverse abdominals also co contracts. Some of my clients have reported this ache when beginning a pelvic floor/core focused exercise program.

One positive is that you’re doing the correct action with these exercises! Kathi’s program is excellent and absolutely effective.

My suggestion is to back off to doing 60 to 70% of current reps and see how this stitch like deep abdominal ache reacts. It seems the deep abdominal is being worked above its tolerance and maybe needs more rest time, say every second day for a week then gradually increase to daily again.

Another suggestion is to use heat on the lower abdomen after the session (microwave heat pack, hot water bottle) to improve blood flow to help relax the muscles.

I sit on an exercise ball at work - is this good or bad for my pelvic floor?

Mary O’Dwyer: Sitting on an exercise ball at work is fine for limited periods of time. If you move on the ball, stand and walk regularly, the exercise ball should be well tolerated.

Consider that any ball/chair we sit on will cause problems if we don’t adjust posture and stand up regularly.

The back benefits from some support when sitting for longer periods.

If you work for a larger organisation, ask for an ergonomic assessment to work out the best individual desk setup.

When would you have surgery? Is it still possible to have a baby after surgery?

Mary O’Dwyer: These are tough questions as there are many variables to consider before making this individual decision. As I don’t have your history, assessment or access to test results, I can only provide general information.

Some of my clients considered their urine loss a minimal issue throughout their life yet others were horrified by any signs of urine loss or prolapse.

When pelvic floor symptoms continue to negatively impact a woman’s functional and psychological health then it’s time to speak with health care providers to learn more of the risks involved in repair surgery.

Most surgeons prefer to do surgery after a woman has decided she has finished having babies.

What you think of spin classes as an exercise that is not too impactful upon the pelvic floor?

Mary O’Dwyer: I am often asked this question and my reply starts with, well, that depends! As a suitable PF friendly exercise (definitely lower impact on the PF) it depends on whether the participant has POP, weak/damaged PFMs or overactive PFMs. Spin classes can be intense with sections of the class in the standing ride position. Participating for 30 -60 minutes has the potential to aggravate overactive PFMs and make them tighter i.e., painful. Lower level exercise and rest periods are better for tight PFMs. If the PFMs are weak/damaged along with POP, then strong bracing six pack and oblique muscle activity will dominate and the PFMs could become fatigued and fail to support the organs against the constant intra abdominal pressure. However if you’re coordinated with PF/Core/trunk strength than you could cope with this class, always using your judgement as to the length of the class and whether you sit/stand. Remember to relax your PF for a spell after this class and add other types of exercise, e.g. yoga, Pilates, aerobics, swimming etc.

Can I exercise with a pessary in place or when I have my period?

Yes, and Yes

Is there is a ceiling effect with pelvic floor strength?

Question cont.: Will it keep getting stronger if we do the program daily or will it reach a point where you are just maintaining whatever strength you have?

Mary O’Dwyer: The evidence on PFM training shows strength gains after 5 months of very regular sets, reps and varying positions. As with any muscle strengthening or hypertrophy, we need to increase the difficulty and load of the exercise to reach further gains. Ideally we should train our PF to engage early and hold with strength as we move about, lift, carry, exercise and sneeze. Kati’s exercises are designed to achieve these aims. Strength will reach a plateau and ideally be maintained throughout life, but a Reform repeat 2 or 3 times a year makes sense to maintain PFM health.

Why is vaginal PH level checked? How can I check mine?

Mary O’Dwyer: We can use a basic litmus paper test to check vaginal ph levels. The following info is taken from a study paper on vaginal ph and infections.

‘The pH level can be determined by placing litmus paper in the pooled vaginal secretions or against the lateral vaginal wall. The colour is then compared to the colours and corresponding pH values on a standard chart. A normal vaginal pH is between 3.8 and 4.2. Blood and cervical mucus are alkaline and alter the pH of a vaginal sample. A pH greater than 4.5 is found in 80 to 90 percent of patients with bacterial vaginosis and frequently in patients with trichomoniasis. The pH level is also high in those with atrophic vaginitis.’

Often we need a GP to check if the problem is bacterial infection or a candida problem. If you would like to by litmus paper you can ask your chemist or else try online.

Case History - I have a phase 2 bladder/ rectal prolapse. I am 60.

Question cont.: I have had two vaginal births, of just a few hours each and I am only now piecing that together as a potential contributor to my pelvic floor problem. There are many other contributing factors like being an aerobics instructor whilst pregnant (not just with the first but then with the second child…silly me) and now of course a decline in hormones which means that any elasticity I once had has gone and leaves my pelvic floor feeling like an old pair of undies which has lost their elasticity. The Reform is indeed helping and I applaud the way it has been designed and now implemented. Still however, when I return from my morning walk or after a day on my feet, my pelvic floor feels loose and open and heavy (but at least still within my body). So my question is about expectations. Can I expect any sustainable, long lasting change, or, given the laxity of my ligaments and muscles, is it a matter of an everyday practice for the rest of my life!

Mary O’Dwyer: Thanks for this great post and for sharing your story. It’s a credit to your exercise commitment that your prolapses are still contained vaginally! Evidence shows that high intensity trained women and athletes have a higher risk of pelvic floor dysfunction despite the thicker diameter of their levator ani muscles (maybe an exercise adaptation) and have more LA distensibility then non athletic women. When you were pregnant, there was precious little research regarding exercise during pregnancy, let alone effective PFM programs. The hormonal, weight, endocrine and posture changes during pregnancy impact pelvic muscle and soft tissue stability and I love your ‘old pair of undies’ analogy to describe your current PF laxity. The oestrogen deprivation of menopause is like the last straw for upsetting your pelvic stability. Our vaginal tissue thins, loses elasticity and vascularity. Are you using Ovestin vaginal cream? It can make a significant difference to the vaginal mucosa and muscle control (see you GP if breast cancer is an issue). I’ve followed the trails of a promising new product called Vaginorm, due for release by Bayer in 2016. The results are excellent with rejuvenation of vaginal tissue due to atrophy and discomfort/pain with intercourse. Can almost hear you wondering about any benefit to supporting structures but this has not been reported. Its inspiring to read that Kathi’s truly excellent exercise program is helping and Yes, you will always need to be in ‘pelvic floor protection mode’ and adopt Kathi’s exercises as part of your regular health routine, just as you accept regular teeth cleaning. Avoid weight gains (mostly influenced by what we eat), keep poos soft, forget about lifting, treat coughs early and support your perineum/sit down to cough, exercise in water and consider learning Tai Chi for its beautiful slow, controlled, strengthening fluid movements. There is Level 1 evidence showing 5 months of regular PFM strength exercises resolve/markedly improve up to grade 2 POP. I don’t remember any mention being made of participants with pelvic laxity though! As the PF is affected by other forces: posture, coordinated weight transfers through trunk and pelvis when moving/exercising, and whether you’re stronger in upper abdominal muscles or have tight muscle groups acting on the pelvis, I’d advise you to find a women’s health physio who also is a musculo-skeletal physio for assessment and guidance. Furthermore, look into wearing Recovery Shorts (Google them) for the pelvic support they add. Many postmenopausal clients we advise to trial a pessary vaginal support and wear the Recovery Shorts. Check out www.pelvicfloorfirst.com.au for further info and advice on pelvic safe exercise (designed by Australian WH physios). Oh, remember regular orgasm too. PS: Vaginorm is DHEA for the vagina.

Case History - I had a low grade rectal and bladder prolapse after giving birth to my first child.

Question cont.: My labour and in particular the pushing phase was very speedy following induction. I would like to have another child (or two!) but am concerned I would be susceptible to worsening the prolapse. I’m active and in particular love scuba diving which requires carrying up to 30kg of gear. I understand that there is a school of thought that there is little concern around subsequent vaginal deliveries as the ‘damage is done’ in the first delivery, however, I understand too that some mums are advised by their obstetrician that there is a risk and to consider a C-section. Has there been any good research comparing the two groups? Thanks in advance!

Mary O’Dwyer: I don’t know of research comparing POP outcomes after 1st vaginal birth with women who had subsequent CS after a first VB. It’s understandable that you’re concerned about aggravating prolapse with future VB. I wonder if advice from obstetricians is to women with more significant muscle damage who may risk total muscle insertion rupture or even have irreversible PFM distension. The research focuses on prolapse and levator ani muscle trauma and its correlation with anterior, middle and posterior compartment prolapse. Women who sustain anal sphincter injuries do receive advice regarding CS v VB and the possible risk of aggravating the existing injury.
Prof Dietz used US to show early stage prolapse in a significant number of young nulliparous women, so the very fact of being female, having a vagina (he describes it as a hernia portal), then pregnancy is sufficient to cause/aggravate prolapse, let alone birth! You described mild prolapse and a fast 2nd stage which is all positive. Being active is important for strength and weight control. Always remember that once you’re postpartum, your body is always postpartum. Ideally we should then have a protective mindset regarding our pelvis and PFMs as life habits (body weight, straining at bowel, weights lifted, ageing & genetics too) will determine whether prolapse becomes problematic later on. Maintaining PFM/core muscle strength is central in that protection.
Some women may well be able to lift 30kgs if they have strong PFMs along with coordinated trunk control. If all your pelvic/trunk stars align then train for this action if it’s important in your life, keeping touch with any changes in PF control. Hope it helps even though I’m not able to fully answer your query.

Should I eventually be able to do the Discreetly Fit Training in a seated or upright position?

Question cont.: When will I know if I am ready to graduate to doing them in a more challanging position?

Kati Janssens: Changing positions -as you correctly feel- is a great idea. You can venture into a new one any time after you feel confident with your training – so it is more than likely that you are ready now. It is ok if your new position feels “weaker” as long as you are able to maintain your technique – this is your guide of readiness. You can find some suggested positions on this page: http://www.pelvicfloorreform.com/discreetly-fit-training-guidelines. Feel free to mix position within a single training session – so you can even start with only a couple of exercises in your new position. I hope this helps 🙂

A male friend of mine, age 55, is suffering from incontinence. Is there any benefit for men in doing pelvic floor exercises, or does it just not apply?

Kati Janssens: Oh yes! Pelvic floor exercises for men are also very important and can bring great benefit, especially after prostate surgery. There are physios specialising in men’s health. So please advise him to connect with one for further help and also consult his regular doctor.

Case History - Persistent Incontinence

Question cont.: I’ve been doing your pelvic floor exercises for years, and very diligently for the last year and a half, when a gynecologist told me that I HAD to do my pelvic floor exercises EVERY DAY – it really shook me into action… I’m 57 years old, and have had stress incontinence since the birth of my 2nd child at 26. So far I’ve been managing reasonably well, although it slowly has been getting worse. I’m peri-menopausal, still having irregular periods. Since my last period 4 weeks ago, I have needed to wear a pad every day, and I’ve started “dripping” when going for walks, and that’s getting worse. There isn’t an accident as such, it’s more like a drop with each step. So all I notice is my pad slowly getting wet, and after about 20 minutes of walking, it’s drenched. Do you have any suggestions?

Mary O’Dwyer: With less oestrogen the urethral sphincter and the urethra itself lose some of their natural ability to close, hence the drip effect! For some immediate benefit, try a Contiform device that slips in under the bladder neck to help the problem. A WH physio can fit and show you how to use this as its best to take it in and out as needed. http://contiforminternational.com Also have your thoraco/lumbar spine checked and start regular yoga stretching to release spinal and buttock muscle tension as stiffness/tightness impacts the continence mechanism. Reduce your sitting times, this is the enemy of our PFM strength, keep on the move. Ask your physio to show you some strengthening exercise for the Gluteus medius muscles in the hips as research shows strengthening them improves PFM strength. eg: side clams and side walking with theraband around your ankles (start slowly).

Please also note this article highlighting that vit C and calcium supplements can be real culprits with the drip /stress loss. If it’s the case then it is important to up the dietary intake of both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3085565

Can doing pelvic floor exercises stimulate a fibroid?

Question cont.: I’ve spent the last ten months getting symptoms under control using herbs to balance my hormones, but since doing my exercises every day have noticed occasional mild discomfort in the area of my uterus.

Kati Janssens: Pelvic floor muscle training can move fibroids, as the uterus rises up with pelvic floor contractions. This is safe. The only time pelvic floor muscle training would not be recommended -or with lower intensity- if bleeding is experienced. This would be dependent on the location of the fibroid.

Pelvic floor muscle training is indicated with more emphasis is a fibroid or fibroids are present due to the increased weight of the uterus, therefore extra load on the pelvic floor.

I have no awareness that pelvic floor muscle training would stimulate fibroids to grow.

Mary O’Dwyer: Kathi has summed up in her reply the recommendation to your inquiry. You may also benefit from some visceral abdominal massage, but not with any regular masseuse, it needs to be with a practitioner who specialises in this type of treatment.

Case History: bowel movement issue after childbirth

Question cont.: Im 41 and have had 2 wonderful girls – vaginal completely natural births and quite quick – now 5yr and 21mth.Particularly since the births i’ve noticed that at times when having a bowel movement – it’s like its trying to come through my perineum…and I have to hold my hand there to provide a barrier / fixed support and the “movement” tends to redirect itself out the correct passage and from anus.Now would this be a WEAK PF that is not supportive for the rectum, bowel etc? Or totally unrelated and not worth worrying over?I did have slight haemorrhoids after the births. Now I would say I notice erratically / irregularly some small protrusions after a bowel movement – no pain / bleeding..but curious if all this is related to PF???

Mary O’Dwyer: So the feeling of the bowel coming through the perineum (better with support) perfectly describes a tear in the recto vaginal supports, causing a back wall prolapse.Due to a tear in the supports, the bowel descends into the back vaginal which is why light pressure over the back wall lets the bowel empty more easily. The issue is more the tear rather than ‘a weak PF”.PFM exercise helps reduce a front wall prolapse (stress incontinence) but won’t reduce the back wall prolapse.Having said that PFM strength provides support for the back wall.Your symptoms are all related to birth strain/damage to the supporting ligaments and fascia that support the bladder, vagina and bowel.I would advise to continue with Kathi’s excellent exercise program to regain and build ongoing PFM strength. Also advise a PFM and prolapse assessment with a WH physiotherapist so you have a better handle on your pelvic floor. Lots of education regarding lifestyle is important: keep poos as soft as possible to avoid straining, low impact exercise, STOP heavy lifting for life, Treat chest and sneezing infections quickly as these actions can injure the PF.

Could you explain the urge incontinence opposed to sneezing or coughing?

Mary O’Dwyer: Urge loss happens when the bladder repeatedly contracts and these contractions overwhelm sphincter control. Urge loss happens for many reasons, a major one being infection, irritable bladder, interstitial cystitis. Research shows the bladder bacteria in women with urge loss is different from those with no urge loss.
Some women are sensitive to caffeine, tomatoes, spicy foods etc and it’s easy to google a list of these foods to start an elimination trial. Age is another factor post menopause and using a vaginal oestrogen cream may help settle urge in some women.
As these are only some of the causes, please consider consulting a urogynaecologist to uncover the reason for your urgency issues.

Some women benefit from stronger PFMs to help control urgency. The evidence shows stronger PFMs are more effective in controlling stress incontinence. Many women have a combination of both stress and urgency.
Just looking at the muscles role in urgency: some women have overactive muscles, making it difficult to effectively relax (related to infection, pain, emotions, scarring or trigger points). This leaves the muscles weaker and less effective to contract and overcome the urge. Tightening PFMs contracts the voluntary urethral sphincters to close the urethra.

If tightness is causing urgency, learning to fully release the PFMs prior to contracting is essential.

Kati: There is list of common bladder irritants under the Discreetly Fit Blog that you may wish to explore. It can also be helpful to keep in tune with the capacity of your bladder, with the target of a 10-15 seconds flow.

f you have developed the habit of emptying your bladder often to avoid leakage it is possible that the capacity of your bladder reduced. As a result would need to go to the loo often, however it is a frequency issue.

To ensure that this is not the case check the volume of urine that exits the bladder each time (10-15sec).

The good news is that this study has found that pelvic floor muscle training can improve the symptoms of urgency incontinence, so keep up your training.

To tackle the urgencies see if you can connect your urgency with a trigger and seek professional help if needed. This write up may also help.

Is there an alternative to the lying down pelvic lift?

Question cont.: I sometimes do my training in places where I’m not able to finish with a pelvic lift (or getting down on hands or knees). I saw that I should be aiming to have the pelvis higher than the heart. Would leaning forward from a standing position to touch my toes be sufficient?

Kati: Yes – you are understanding the dynamics well. Leaning forward from a standing position to touch your toes would create the same impact, permitting you can perform this manoeuvre comfortably. If you skip a pelvic lift here and there is also ok. What happens in the majority of the time is what will make a difference. It is worth noting that the pelvic lift has a special importance for people who experience haemorrhoids.

Managing periods

Question cont.: Just wondering about your thoughts for managing periods. I use pads sometimes, but generally find mentrual cups more convenient & comfortable. I have heard there are concerns about the use of both menstrual cups & tampons because of the continual pressure they place on the vaginal wall. What are your thoughts?

Kati Janssens: I can only speak intuitively on this as I can not find any evidence to back up my recommendation, but I would agree with your suggestion to minimise the use of cups and tampons to a convenient minimum to lessen the pressure on the vaginal walls.

I love dancing. I know it's bad for my pelvic floor but really don't want to stop. Any advice?

Mary O’Dwyer: What type of dancing do you love? How often do you dance? What are the signs of pelvic floor weakness when you dance?

Life is all about enjoying activities we love. I recently loved seeing an 80 year old lady gliding across the dance floor with her older partner!

So rather than stop dancing consider the following modifications:

1. Less jumping or impact, back off the intensity

2. Control movement with smaller steps

3. Wear cushioning shoes or inserts

4. Consider dancing earlier in the day rather than night when your body is tired

5. Use a vaginal internally fitted pessary support

Kati Janssens: I would like to add to Mary’s terrific advice postural awareness. So ensure that your bum is not tucked and you are not sucking in or tensioning your tummy excessively. Also, consider wearing an outfit that is loose around your torso.

What do you think of pessaries

Question cont.: Do pessaries strengthen or weaken the pelvic floor? Are there any times they are good eg. for extra support during strenuous exercise?

Mary O’Dwyer: Think of a pessary as support for a broken vagina. They work effectively in around 60% of women to support the vaginal walls when supporting fascia is torn and pelvic organs descend.

They type of pessary fitted is determined by the type and degree of prolapse. Women are encouraged to learn how to remove and insert the pessary for themselves and have their health care provider check the vaginal walls every 12 weeks.

Many women’s health physiotherapy colleagues advise a pessary for extra support for physically active and sporting women.

Combined with an effective PFM strengthening program, lifestyle changes (avoid bowel straining, heavy lifting, prolonged coughing) and tall posture, they can be an effective non surgical method to control prolapse.

Women have used pessaries since the 19th century and worth a trial to gauge their effectiveness and suitability.

Pelvic floor support during a bad cold/flu

Question cont.: I have had a bad cold with lots of coughing and sneezing. My pelvic floor really took a beating, it usually holds up for a couple of days of coughing, but not a week worth. I was hoping you could comment on protecting the pelvic floor in this sort of situation and recovery, as well as when and how much to train when I’m aware of fatiguing.

Kati Janssens: Prolonged incidents of coughing is indeed one of the biggest pelvic floor trials and as you can feel it the muscles fatigue after a while from working hard counterbalancing the impact of coughing. So, there are two things you can do:

– manage coughing (keep warm, breathe through your nose, cough lollies) and

– help your pelvic floor to cope.

When possible cough and blow your nose lightly. Tip forward to redirect internal pressures from your pelvic floor and – if appropriate – hold onto your pelvic floor with your hands when needed. You may find it helps your pelvic floor if you sit down as well.

As of training your muscles at these times…. I think give it a miss. They already fatigued from working out during coughing attacks, so rest will be more beneficial. Besides people usually don’t feel like doing anything other than recuperating at these times.

Mary O’Dwyer: Prolonged coughing is tough on the pelvic floor and studies of intra-abdominal pressure (IAP) generated during various manoeuvres shows coughing/sneezing causes the highest rise of IAP.

Lifting and holding PFMs prior to and during coughing is essential but I appreciate the muscles fatigue doe to the repeated strong rises of IAP.

Consider being fitted with a Contiform pessary support to help counter the high IAP.

What do you think of laser treatment for strengthening the pelvic floor?

Mary O’Dwyer: Just as facial laser renews the layers of the skin, it can achieve similar results when used vaginally. It can be effective in women with milder incontinence and vaginal wall prolapse and also in post menopausal women who avoid sex due to dryness and pain during intercourse.

Speak with your GP (maybe a female GP working in women’s health) and consult with a gynaecologist who does the procedure.

Bear in mind it’s quite expensive and its use is backed by effective marketing.

My pelvic floor is so weak that I sometimes leak during sex - is there anything I can do about this besides emptying my bladder before sex?

Mary O’Dwyer: What an annoying issue!! Just as laughing, coughing or sneezing can cause urine loss, so can intercourse.

The urine loss can be due to weak PFMs (stress incontinence) or from bladder spasms (urge incontinence).

Treatment options are

1. PFM training – you have this covered with Kathi’s excellent program. Keep repeating the Reform throughout the year. Review any lifestyle factors that aggravate your pelvic floor e.g.: too much abdominal weight, bowel straining, heavy lifting and prolonged coughing.

2. Medication may be advised for urge incontinence. Always seek repeated urine tests preferably with a Urologist to check if urgency is caused by bacteria which is sometimes not detected by standard testing.

3. Surgery to treat stress loss. There can be serious complications with this type of surgery.

Do you have a questions? Get your answer at the