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Uptight and Personal – The Hypertonic Pelvic Floor

Men, as we all know, have a lot to answer for.

We also know that they are often just trying to do the right thing. Arnold Kegel has changed many a woman’s life for the better, by introducing pelvic floor exercises, or ‘Kegels’, to his practice as a gynaecologist.

These repetitive, conscious contractions are, according to the best clinical research evidence we have, the most effective non-surgical treatment for pelvic floor weakness, incontinence and prolapse. The NICE guidelines state that performing Kegels daily, 3 sets of ten contractions, can produce significant improvements in pelvic floor control of urinary incontinence in around 3 months, providing they are supervised and taught by a qualified Pelvic Health Physiotherapist.

But despite the best of intentions, Kegels unfortunately haven’t managed to ‘eliminate incontinence once and for all’: sometimes, believe it or not, Kegels can actually make symptoms worse.

I’ve always found it a bit odd that a man has had such an impact on women’s health, but I guess that’s just a sign of the times, and there’s no doubting Arnold’s input has been invaluable. What I suppose is odder is that we ladies still often avoid our own lady bits with a potent mix of embarrassment, shame, fear and British practicality. That’s a sign of times gone by, and something I’d love to change. How wonderful it would be if we all accepted and cared for our pelvic floor for what it is – just another group of muscles.

That’s not to say they are not hugely intimate places, to be honoured and protected, but it is to say they have a lifelong job to do… and they get tired, just like the rest of our muscles.

A Girl Like You

The following scenario is increasingly common, and it is emerging that women, really young women, without any children, are suffering too. So we can’t blame the kids this time either…

A busy lady called Emma works full time in quite a stressful but rewarding job, and enjoys running in her spare time. She also has recently joined a Crossfit group, and loves going trampolining with her nieces. Her partner has just moved in to her house, and aside from a few rows about space and possessions things are settling down ok. Though strangely she is having the following symptoms:

  • leaking urine towards the end of a run or on trampolining
  • achieving orgasm less often and less intensely
  • sometimes sex is a bit dry and a bit painful
  • occasional aching in her vaginal area the day after crossfit
  • headaches and generalised anxiety when work is busy
  • the appearance of haemorrhoids which flare up when she’s stressed, but no constipation

She’s naturally alarmed by the incontinence and has been dutifully doing her Kegels for 3 months now. But the symptoms are not changing – in fact it’s happening more often: for the first time ever the other day she leaked urine when she sneezed. She’s not told anyone about her problem, and is continuing to have intercourse with her partner as she doesn’t want her symptoms to affect her relationship.

Any of these sound familiar?

Woman with menopause hot flush

You’d get points for assuming, just like Emma, that she has a weak pelvic floor that needs strengthening to cope with her high level and impact activities. You’d be forgiven for taking matters into your own hands and cracking on with the Kegels – after all, nobody wants to admit their bladder is giving up on them!

But there are other clues in the symptoms that are crying out a different story:

stress… anxiety… busy… pain… aching… pressure…

Apply these symptoms to your neck and shoulders. What happens? Every hand in the room shoots up: The muscles would get tight, knotty and painful! We all, men, women, people, accept that this is how muscles behave when we are stressed, physically AND emotionally. Why not our pelvic floor..?

If you are doing Kegels and they are not working, yes it’s possible that you might not be doing them correctly. But consider the option that it could be the opposite – that these poor muscles are working like mad, and when we go on a trampoline or for a long run after a long day to ‘de-stress’ they simply cannot work any harder and fail just at the moment you need them most.

And how do mums describe their day-to-day? Amid the hilarity and joy of little ones in your life, here’s that undercurrent again: stress… anxiety… busy… pain… aching… pressure…

What’s Going On?

Quite simply, we hold tension in our bodies, and the pelvic floor is often the place we hold emotional tension. Often the release of orgasm is both physical and emotional, as the pelvic muscles experience a spontaneous relaxation. The mind-body connection is not to be underestimated – in fact often when ladies shyly ask me whether it’s all in their heads, I say “Yes, of course it is!” All muscle movement, tension and behaviour starts in the brain, so don’t ignore this component of the issue. If there’s something bothering you, it is likely contributing to your symptoms.

On a physical level, these symptoms describe a high-tone pelvic floor – termed ‘Hypertonic’ – essentially muscles that are contracted and don’t want to let go.

In a healthy system, the pelvic floor muscles work constantly throughout the day. They ease and ‘give’ on our inhale, and contract naturally on our exhale, creating a gentle push and pull in tandem with the diaphragm, massaging the organs and helping gut motility and fluid movement in the lower body. When the pelvic floor is tight and restricted in its movements, it often results in occasional constipation, haemorrhoids, and aches and pains, again just like any other over-worked muscle of the body.

Add to this picture any trauma from childbirth, such as Episiotomy, tearing, neo-natal illness, post natal depression, and you can imagine how these factors further contribute to the physical and emotional load of the pelvic floor, and the mind, perpetuating the cycle.

What Can I Do?

It seems for so many of us women, this is the hardest thing to do: RELAX. Life is too busy, too much fun, too stressful, when do we get time to relax? And shouldn’t we be getting tighter, stronger, fitter, in any spare time we have?

So the best news is, you have the opportunity, 16 times a minute, to relax your pelvic floor. As you breathe IN, your diaphragm flattens, sucking air into your lungs. As the diaphragm moves downwards, the pelvic floor ‘gives’ a little to allow for the abdominal contents to move away from the lungs as they are pressed downwards.
So, breathe in.

Allow your tummy to inflate like a balloon. Feel a very slight descent in your undercarriage. Feel it all move gently upwards again as you breathe out.
Congratulations – you’ve just given your pelvic floor a very welcome break.

If you have a moment longer, the yoga poses below are wonderful for letting your mind settle for a moment, to reconnect with your hard-working body, and start to feel your pelvic floor move naturally.

Great positions for starting to feel your pelvic floor movement, in combination with the breath:

Happy Baby Pose

You can make this more manageable by putting a towel across your feet and holding each end, gently pulling your feet towards you within your comfortable range of movement. You might want to put a pillow or two under you – whatever makes you feel comfortable! And don’t worry about the odd ‘trump’ – this is a sign that your pelvic floor is relaxing!

Deep Squat Pose

Ok, this can be a tough one to achieve, not many of us are this bendy. But you can easily modify the pose to get a lovely stretch in our inner thighs, hips and lower back, as well as really allowing the pelvic floor to open. Simply pop a rolled up towel, some cushions or some books underneath your heels, and sit deep into the position, keeping your weight back. It’s in poses like this that you often suddenly start to feel what I’m going on about – that gentle movement up and downwards.

Child’s Pose

The easiest one of all – and wonderfully relaxing, and even emotionally releasing. Again you can rest a pillow underneath you if the position bothers your knees. Keep your knees wider than your hips and breathe deeply into your tummy to really feel the benefits.

What About Pain? Getting Hands On

Feelings of tightness, soreness or pain during or after sex are all symptoms of a tight, or ‘high tone’ pelvic floor. The poses above can really help, but sometimes a more hands-on approach is useful to address these higher-level issues.

The first thing to do really is to have a look. Pain in the genitals can come from a number of causes so a decent look at your lady bits will reveal any visually sore, itchy, flaky or otherwise unhappy-looking tissue. For any visual signs, itching or smelly or unusual discharge (for you – everyone’s is different!), these are things to discuss with your GP.

Tight pelvic floor muscles can develop tender spots, or ‘trigger points’ in them, again just like any other muscle. These might be found on just one side, near the entrance or deeper inside – everyone’s different and each of our pelvic floor has a unique story to tell.

To self assess your own pelvic floor, take ten minutes to lie down and have a feel around. If you slide a finger inside your vagina, and press gently on the walls at the sides and back, you should feel a gentle give, as the tissues and the muscles supporting them relax under your pressure. Again, you can imagine if you were feeling someone’s shoulders. Are they soft, supple, yielding? Or hard, resistant, unable to relax? A key place to assess pelvic floor tension is your perineum – the back wall of the vagina. This is typically more muscular than the sides of the vaginal walls, and when you do a Kegel, you should feel this lift forwards and upwards. It should release backwards if you give it some pressure with your fingers as you breathe out. Ladies with tight pelvic floors will experience quite a firm resistance to pressure and not much distance gained when the muscles do give in to a stretching force.

To release tension and trigger points, you can to an extent do self massage to the muscles, either using your own finger or a vibrator if you have one. Vibration has actually recently been shown to interrupt the pain signals to the brain so can be useful in calming down chronic pain from tension. The key principles are to work within your pain-free range, whilst expecting some uncomfortable sensation from tissues already tender. These should feel measureably eased after a ten minute massage session – if you feel massage is making it worse then please stop.

How do I Know It’s Helping?

Ideally, once you ‘meet’ your pelvic floor and get to know its habits, behaviours and limits, you will start to feel better and more in control as you change small daily habits to help it cope. You’ll be able to feel it move during the day just by bringing your mind to it, and by breathing deeply.

The key thing to do is monitor your symptoms. Perhaps give yourself a massage before going for a run. Or get into the habit of doing the above yoga poses in the evenings, and see how your pelvic floor copes with activity the following day.

Further Information and Resources

If you are worried, unsure or otherwise needing more information it really is best to make an appointment with a Women’s Pelvic Health Physiotherapist.
These specialists can teach you self massage and trigger point release techniques, and talk you through how your symptoms are or aren’t connected.

Crucially, we can identify any other issues you might not have considered, and help create a plan tailored to your individual experience and symptoms. Women suffer for years with pain, discomfort and incontinence but these issues can be genuinely simple to solve.