Performance Training and the Pelvic Floor
Performance training: Training (physically in this case) in order to 1- develop specific qualities with the aim of improving the performance of a given task, sport, or occupation, and 2 – counteract the potential downsides of such training, such as injury risk and boredom.
The pelvic floor: A group of muscles and connective structures inside the pelvis which keep the pelvic organs (bladder and part of the bowel in men, plus uterus in women) and openings (urethra, vagina, anus) where they should be. The perineum is the area between the anus and scrotum or vulva, which borders the pelvic floor.
Intra-abdominal pressure: The pressure within the abdominal cavity, created by the interaction between the wall of the abdomen and the internal organs. The abdominal walls are made up of muscles and connective tissue which interact with the pelvic floor muscles and the diaphragm causing intra-abdominal pressure to fluctuate dependant on the phase of breathing and the level of resistance of the abdominal wall. This system coordinates to manage forces and prevent urinary or faecal leakages.
Valsalva manoeuvre: A breathing technique to increase pressure within the abdomen. It is performed by exhaling against a closed airway and is often used by strength athletes when lifting, to stabilise the trunk muscles and protect the spine. Also used by mothers during childbirth, and constipated people.
What does the pelvic floor do?
The pelvic floor muscles are those which support the pelvic organs by stretching from the coccyx to the pubic bone, front to back, and from one sit bone to the other, side to side. When healthy and well-functioning these muscles are barely noticed by the owner as they go about their business. They act a bit like a trampoline, they support the organs sitting on them and they move up and down when they need to, absorbing and distributing forces and helping to keep poo and pee in their respective places. Within the muscles of the pelvic floor are holes through which pass the urethra, anus, and in women* the vagina. The functions of these need little introduction so I’ll keep it brief. When the pelvic floor muscles are contracted, the organs above are lifted and this helps to keep the various openings closed, whilst relaxing them allows conscious control of peeing and pooing. As well as involvement in erectile function in men and sexual sensation in women, the pelvic floor also supports baby during pregnancy.
What makes them weak?
There are a number of things thought to impact the strength and function of the pelvic floor muscles, probably the most well-known of these, at least for women, being pregnancy and childbirth. However, some other factors can affect both men and women notably heavy lifting and high impact exercise or activity. Other factors which may be relevant, sometimes, to active and athletic populations include age, chronic coughing, and straining on the loo. The good news though, especially if you are experiencing leakage when exercising, is that the muscles of the pelvic floor can be controlled and trained in much the same way as any other skeletal muscle.
What happens if they don’t function as they should?
Most commonly, stress urinary incontinence (SUI) which is leakage of urine when doing activities which place sudden increased pressure on the bladder and urethra. This doesn’t have to be anything as intense as lifting weights or plyometric exercise, it can happen with a sneeze or cough. The other kind of urinary incontinence is known as urge incontinence, that is the sudden and intense urge to pee which is often followed by involuntary release of urine. Sometimes both types of incontinence can occur together. The hormonal changes of the menopause can also affect bladder control in women, and the muscles of the pelvic floor themselves can become weaker, making it all the more important to resolve any problems sooner rather than later.
The muscles of the pelvic floor don’t function alone, they are part of a system of support which behaves in a similar way to a piston and also includes the diaphragm, obliques, and lower back muscles. As the diaphragm contracts and lowers away from the ribs, when you take a breath, the pressure in the abdomen increases and the other muscles in the system need to relax and the pelvic floor also lowers accordingly, to prevent excessive stress on the organs. When the diaphragm relaxes and moves up towards the ribs on the exhale, the pelvic floor also moves up. Like a piston see. The Valsalva is a move to deliberately contract all the muscles to increase intra-abdominal pressure, as there are occasions when this is a good thing. Ideally, the pelvic floor will be strong enough to maintain support when you do this.
In athletic and active populations, weakness, chronic tension, or generally poor functioning of the pelvic floor can result in leakage when training or participating in sport. Contraction of the abdominal muscles without proper appreciation of the pelvic floor may put pressure, especially abrupt pressure on the bladder or urethra, and can cause loss of urine as the bladder drops and the urethra is forced open. Generally, the impact from landing after a jump, constantly oscillating forces from running, or bracing the trunk to perform movements such as lifting, twisting, or anticipating a collision will be enough stress on a poorly functioning pelvic floor to cause leakage. Intensity and frequency of these stressors are associated to the increased risk of SUI. High impact sports like basketball, trampolining, or CrossFit place a lot of stress on the pelvic floor muscles, and if these activities are carried out several times a week then the risk for SUI increases significantly above that of non-athletic populations. Often, trying to maintain a constant contraction of the pelvic floor muscles to counteract leakage will result in accumulated fatigue of the area and continued weakness. Similarly, holding in the gut by tensing the abdominal muscles is a bad idea.
What to do about it
In the first instance it may well be advisable to get an assessment by a healthcare practitioner who specialises in pelvic health. Not all pelvic floor problems are caused by muscle weakness, it may be excessive tension from overactive, chronically contracted or spasming muscles. They can be both tight and weak. Pelvic, obstetric, and gynaecological physiotherapists do exist in private practice if you prefer that route to the NHS, if waiting times are long. Expect an internal examination and some simple tests to rule out any serious underlying condition. If you don’t feel that the problem is severe enough to warrant that, or there are no complications like organ prolapse or pain, then you may feel comfortable carrying out strengthening yourself. However, best results tend to be when a strengthening programme is individually tailored and supervised, since there seems to be no consensus on optimal dosage. Like any other strength training programme, it depends on baseline strength and proper execution. For those who take part in sport or exercise, whatever the level, it is recommended to specifically train the pelvic floor to reach or maintain good function and protect from leakage.
How to train the pelvic floor
There has been much good work done on pelvic floor muscle training, which essentially involves contracting the muscles of the pelvic floor and perineum, holding for a number of seconds, then relaxing and repeating. I have put links and references to more complete descriptions and resources at the bottom of this article. The suggestions which follow are a guide only, and remember this article is written in a strength and performance training context.
There are a couple of points to bear in mind as you begin. The position of the pelvis and rib cage has a bearing on the effectiveness of the exercise. I’m not a big fan of blaming posture for all musculoskeletal ills - sustaining any posture for a couple of hours at a time is probably going to hurt whether it’s considered good or bad. Positioning of the pelvis and rib cage is more to do with freedom of breathing and ability to contract the target muscles. Logically though, the muscles of this system need to work in harmony always, whether you’re training, competing, or sitting about watching Netflix with a glass of wine.
Step 1. Identify the right muscles to train
- Place your pelvis into neutral by tilting it back as far as it will go (stick your bum out), and then forwards as far as it will go (tuck your bum under). Halfway between the two is about neutral. Don’t overthink it
- Imagine you’re trying to stop yourself from peeing and/or pooing, you should feel the muscles around the urethra, vagina, and perineum contract
- Squeeze as hard as you can, you should feel your lower abs wanting to get involved by pulling in
- Hold for a few seconds and then relax without pushing out on everything
- Learn the different feeling between tensed and relaxed
- If you lean forward in standing you can contract just the front half of the pelvic floor. Lean back and you can contract just the back half. You’ve just become a little more familiar with your own body. Well done
Step 2. Coordinate with breathing
- Imagine the system working like a piston, when you inhale your pelvic floor needs to relax, on the exhale it contracts
- Practice this with 6-8s holds where you squeeze the pelvic floor muscles as you exhale and relax as you inhale
- Try 2-3 sets of 8-12 reps with a couple of minutes rest in between sets
- If this is too difficult then drop the reps until it’s manageable
- Train every other day, building up slowly to daily if that works for you
Step 3. Progress
- Mix up the position you’re in. Have a go at it standing, sitting, laying down, all fours, walking. Get creative
- You might find some positions harder than others, don’t get disheartened, you’ll get there with practice
- The pelvic floor needs to learn an appropriate contraction force for the task, for example landing from a jump will need a stronger contraction than a casual stroll. When you progress to squat movements and jumping, exhale slightly before contracting the muscles and time it with the lowering or landing. It will take practice, but if you're training these movements anyway you'll get plenty of opportunity.
If you have trouble finding the right muscles, can’t contract them at all, have pain, or any other problems then stop these exercises and seek the help of a pelvic health professional. And as always, if you have any questions please get in touch.
Many thanks for the illustrations go to Willow Findlay at snackpandadesigns
Useful links and resources
*I’m using just male and female gender here for ease of explanation. Pelvic function in relation to non-binary gender athletes is complex and outwith the remit of this article.