Pelvic floor issues are on the rise. I am seeing that in my practice more than ever before and I am surprised to hear so many people know the term. This blog will be answering the commonly asked questions and myths about pelvic floor dysfunction and the one true solution to it all.
While surgery and medication are 2 of the options for treatment of some of the symptoms and signs of pelvic floor dysfunction, the focus here is on the non-medicine and non-surgical approach. While male incontinence and female incontinence are widely inflicting many, you are not doomed to live with pelvic floor dysfunction. In fact, regardless of urinary incontinence or fecal incontinence, it is more than likely that it is the pelvic floor that is weak.
But what is the pelvic floor? This blog will answer the most commonly asked and logical questions related to pelvic floor dysfunction.
Surgery is always left for those cases that are simply not within the scope of the non-surgical realm and I will post my podcast interview with a Pelvic Reconstructive Surgeon when it becomes available. The images below are intended to give an overall understanding of the internal organ arrangement in the pelvic inlet. While I don’t want to make an anatomist out of you, you ought to understand some basic structures.
Female pelvic anatomy laying down (https://www.ncbi.nlm.nih.gov)
Male pelvic anatomy standing up (https://teachmeanatomy.info/)
What Do the Pelvic Floor and Related structures Look Like?
In order to fully understand the pelvic floor, I am going to use a simple analogy and refer to it periodically! You will also need to understand other structures involved in pelvic floor dysfunction. ALL of these structures have to be addressed in order to fully resolve the issue. The issue we have is that we are NOT addressing all of these parts and are doing a half-hearted job taking care of the problem. Pelvic floor weakness and dysfunction affect people on many levels including social, psychological, physical, and emotional levels… and no, medicine is not the solution!
If your whole abdominal cavity was a paper bag with a cover: the top cover is the abdominal diaphragm, the sides are the oblique muscles of the abdominal muscles, the front is the rectus abdominus, the back is the back muscles and the bottom is the pelvic diaphragm which is just above the pelvic floor.
Imagine the bottom of the bag is like a bowl with the inside lining of the bowl being the muscles of the pelvic floor while the outside are the muscles connecting the genitals to the anus and sphincters. The hip muscles, meaning the muscles that make your hip joint (where your legs get connected to the pelvis) flex and extend, turn in and turn out, lift up to the side, make your knee straight and bend, all make the corners of this bag.
Pelvis Anatomy:
Now, let’s talk about your pelvis, the bottom of which is the pelvic floor or the bowl in our analogy. Your pelvis has 3 main parts to it:
- Two halves called ilium get connected to a triangular shaped bone called sacrum in the back (the end of the sacrum, away from the spine is the tail bone btw)
- and the front of these two halves form the pubic bone where the genitals are on the surface of.
When we walk, the sacrum and one half of the ilium move in opposite directions. That means when you put a foot forward, the ilium flexes on the right while the sacrum extends. Why am I talking about walking? Because you don’t have to have urinary or fecal incontinence to have a weak pelvic floor dysfunction and you need to be aware of it to fix it sooner than later.
You don’t have to be old to have pelvic floor weakness and dysfunction. Unfortunately, we are prematurely having issues with the pelvic floor because we have a sedentary lifestyle. Do you realize that people who are in their 40s now and younger have been sitting down, playing video games, and using computers almost all of their lives? That is many many years to get a weak pelvic floor.
Now the same people go to the gym to work out (best case scenario and assuming they are trying to be more active), the same weak muscles including the pelvic floor muscles now have to go beyond the ordinary to perform challenging moves! This is like beating a dead horse to get it run faster!!
You have no idea how many patients I see with the so-called ordinary back, hip, or lower extremity pain that have the weak pelvic floor because it could not endure the challenge the person put them through at what appeared to be an ordinary workout session. Imagine those who do marathons or cross-fit!
Take the time to become familiar with the bony structure names of the pelvis AND pay close attention to the muscles that are involved in the pelvis region. Every single one of these muscles plays a role in the health of the pelvic floor even though more than likely up to this point, you thought the pelvic floor was an independent issue!
Pelvis bones (courtesy of https://orthoinfo.aaos.org/)
Pelvis ligaments (Back) impacting the floor
Pelvis ligaments (Front) impacting pelvic floor
Pelvic floor outside showing anus and bottom shaft of penis
Front of the abdomen= “front of the bag”
Oblique muscles of the abdomen= “side of the bag”
Lower back, pelvis and hip muscles are involved in pelvic floor integrity
What Are the Symptoms of Pelvic Floor Dysfunction?
While incontinence CAN BE a sign of pelvic floor dysfunction, there are many other signs that point in the direction of pelvic floor weakness. By now you understand what the pelvic looks like, what structures (bones and muscles) are involved in holding its integrity. The nerves that go to the muscles in the area come from the lower back and sacrum so any interference with the function of those nerves may lead to an issue at the end organ, being the bladder, ureter (the tube that connects the kidneys to the bladder), and urethra (connecting the bladder to the outside world). In case of fecal incontinence, the nerves going to the muscles and the sphincter that assist in defecation (discharge of feces) all come from the lower back area as well.
Looking at incontinence as the only sign of pelvic floor dysfunction is waiting for a D minus or an F on a report card as a sign to have to study and do some work in a class!!! The best is to be aware of the other subtle and perhaps not so subtle signs and symptoms that are a prelude to the metaphoric F in our example! All activities (or lack of) that impact the affecting structures of the pelvic floor (see the pics above) are fair game in contributing to pelvic floor weakness and dysfunction.
For instance, I wish all those who participate in any sport would get a check-up to see how strong their pelvic floor is. I wish those who get injured playing sports would get checked to assure their pelvic floor was functional. I wish all that visited a podiatrist would get their pelvic floor checked. I wish those who sit a lot during the day would get themselves checked. The list goes on and on.
Isn’t Incontinence the Inability to Hold the Urine Correctly?
No, not necessarily. There is urinary incontinence that has to do with the urine and then there is fecal incontinence that has to do with the fecal matter. Overall, it is a dysfunction of the emptying of the urine and or fecal matter due to either the structures involved or the nerves involved.
Types of Urinary Incontinence are:
1. Stress incontinence: Pelvic floor muscle weakness is the cause, and the reason can be:
-
- sneezing
- exercise
- coughing
- pregnancy
- excess weight
- or medications
Pads, vaginal inserts, pelvic floor exercises, and biofeedback can be used to work on the brain recognizing the signals, although injections and surgery are the common approaches. Read below to see why I think they all serve their purpose but are only part of the answer. You will learn what I consider to be the most comprehensive approach to put an end to it.
2. Urge incontinence: This can be because of nerve irritation or damage to the bladder area (such as multiple sclerosis, diabetes, and stroke). Nerve irritation or damage to other nerves in the body, just like pelvic floor weakness, or aging is more than likely just a decrease in the integrity of the muscles. While some medications can also lead to urge incontinence, I want you to remember that just because you are getting old, does not mean you are doomed. Look around you and you will see there are plenty of older people that are active while there is no shortage of those that just sit and not move. Movement is SO important in overall health.
For Urge incontinence, timed avoiding and bladder training becomes the focus of the treatment which will help some but again, as with Stress incontinence, to me, it is a partial solution.
3. Overflow incontinence: When there is dribbling of the urine flow. This can be due to the pelvic floor muscle weakness (remember, there is more to the pelvic floor muscles than just the muscles of the pelvic floor getting weak on their own), nerve damage, enlarged prostate, tumors, constipation, and once again, medication. The chances of overflow incontinence leading to infection are high because the person with this issue has a hard time getting the full urine out so UTI becomes common there.
4. Functional Incontinence: Involving the hip and pelvic muscles of the pelvic floor: is when due to whatever reason, usually dementia or arthritis, the person can’t make it to the bathroom in time.
Of course remember, you can have more than one type of incontinence and it is easy to start with one but as a result of its chronicity, other factors causing more incontinence to occur.
While medications, electrical stimulation, surgery, and even catheters are used for incontinence, urinary or fecal, the question is the long term efficacy of them. While in some cases there is no choice but surgery, even in surgical cases, post-surgical rehab is very similar to pre-surgical therapy. What is missed the most and certainly not done to the extent that it should be is the biomechanical contribution to pelvic floor dysfunction.
What Causes Pelvic Floor Dysfunction?
As explained above, anything that impacts the nerves to the muscles of the pelvic floor, the colon/lower intestine, reproductive organs, bladder (and its ‘tubings’), the urinary and/or anal sphincters, as well as how the hips, sacroiliac joints, lower back, and mid-back area impact the pelvic floor, the general movement of the body and it’s impact on the pelvic floor and proper breathing based on the biological patterns of breathing (watch this video) are the main focus.
We are seeing a huge rise in pelvic floor dysfunction, as a result of our sedentary lifestyle. Pelvic floor muscles are not an exception to the rule that if you don’t use a muscle it weakens. The muscles on the inside of the pelvic girdle (the Bowl example I used before) are worked out with walking, but we hardly walk.
Then the all of our same weak muscles, resulting from our overall sedentary life, have to ‘perform’ when we go to the gym after work (if that is what we do) or weekend (in case of weekend warriors) or if we work out at home doing what we think are good workouts.
Having the mindset of no pain no gain, enslaving our bodies to make our wishes come true, we become disconnected. Injuries, sports or not, impact our movement and with every pathological pattern of movement, pelvic floor muscle integrity becomes more compromised. With every insult to our body (involuntary or not), the nerve connection to the body parts become compromised. You add these up, no wonder we blame our age to most of our issues that have more to do with our choices than age!
You don’t need to become a doctor to learn the basics of life and that the bases of health are movement, nutrition, and emotional balance. Here, I will be focusing on the impact of movement on the pelvic floor.
How Does Movement Affect the Pelvic Floor?
In the pictures above and the paper bag example I used, you can see how so many parts of our body, including the internal organs impact the floor of our torso. What I want you to pay attention to is that not every movement is based on the ‘factory designed’ patterns we are born with. Since I don’t want to digress from the subject of the pelvic floor, and pelvic floor dysfunction, I urge you to read my page on Functional Movement and watch the video below on postural neurology.
Both of these are the core to the concept of movement and its impact on the pelvic floor. Anything that impacts your movement and pushes it from the biological (factory designed way) of movement to the pathological patterns of movement leads you to first weakness then full-blown dysfunction of the pelvic floor. If the bottom of the ‘bag’ is not strong, it does not matter how strong the sides are, how great of quality the bag content is, all will be unstable and subject to falling apart.
Does Pelvic Floor Manual Therapy Work?
As I explained before, there are muscles on the inside of the pelvic girdle that are weak in the case of pelvic floor dysfunction. When a trained physical therapist specialized in pelvic floor treatment, manually addresses those areas, there is certainly an increased benefit in most cases. The problem is how long it lasts. Additionally, most people feel uncomfortable as this procedure is addressing the anus and genitals.
Manual therapy of the pelvic floor in most cases is to be repeated over time and used in conjunction with biofeedback and other devices. It is a great way to address the inside of the pelvis after surgery just as massage helps with tense muscles. Expecting massage to get rid of lower back issues powered by other causes is not a good solution as you may have suspected.
Why Are Kegel Exercises Not Enough?
Have you ever seen a tree trunk that was cut off, but the following year, new shoots came off of its cut off trunk? That is the story with kegel exercises. If you think doing kegels is going to make your pelvic floor dysfunction go away by itself, you are mistaken. Plus, how many of those can you do a day? Do you do them every day? Do you do them 50 times a day? I am sure the answer is no. If you do them, how strong are the ‘holds’?
Those with pelvic floor dysfunction not only don’t do the kegel exercises often, but the power behind their ‘hold’ is not much. The only true machine I have seen that does a great job of stimulating the action of kegel muscles is the Emsella. At 400 kegels a minute, no-one can match its performance; there is no intrusion of privacy BUT Emsella by itself does not take care of the job either.
Pelvic Floor Dysfunction and Emsella Chair
… Then What is the Best Solution to Pelvic Floor Dysfunction?
What if, you were educated on the basics of the pelvic floor, similar to having the manual for the operation of any machine? Then learn about biological breathing because with it comes safeguarding the integrity of the lower back, torso, and hips in movement (watch this video), use Emsella to strengthen the actual floor of the ‘bag’ (see the top of the page in bold), start movement poses that allow the whole body to move based on the concepts of Developmental movements (make sure you don’t skip this), assure proper brain-body connection in posture and balance based on the concepts of postural neurology, and then address the proper nutrition to strengthen your muscles and nerves, choose a lifestyle that incorporates this routine, move throughout the day, use proper ergonomics, and establish eating habits to assure the problem does not come back. Does this seem too involved and unattainable?
…and the answer is
NOT at all. While the 400-kegel-a-min Emsella machine is not covered by any insurance plans (they pay for the surgery but not this machine and in most cases, pelvic floor therapists don’t accept insurance), It does an amazing job strengthening the actual bottom of the ‘bag’ portion in the case of pelvic floor dysfunction. A quick search shows there are not too many places that have the machine and while the price tag more than likely plays a role, they are owned by urogynecologists, and a few med-spas (pelvic floor strength plays a role in sexual pleasures too). These doctors are medical doctors that are trained in their specialty to either prescribe meds, do surgery or refer out for therapy. Their actual expertise is not in movement and biomechanics.
Being a licensed doctor of chiropractic with a specialty in Postural Neurology and Functional Movement, I look at what it takes to move and balance correctly with all of my patients and not just the ones with extreme pelvic floor dysfunction, such as incontinence. As said before, while in most incontinence cases pelvic floor issues are heavy contributors, not every pelvic floor issue comes with incontinence!
Any doctor specializing in biomechanics using the concepts of developmental kinesiology with an Emsella machine should be able to help you with your weak pelvic floor and its associated symptoms.
If you think kegel exercises to the level of fixing the weak pelvic floor are easy to do, if you think you are too old for pelvic floor muscle work, if you think you had a baby and the damage is done, if you think you don’t have incontinence so you don’t have a pelvic floor issue, if you are a man and think you don’t have a pelvic floor, if you think your insurance does not pay so you can’t afford the proper care, if you think you have to be rich to have the effective care, you are mistaken!
The effective treatment does not break the bank, it does require your commitment, your determination, your cooperation with what you need to do and avoid doing, and not giving up. But then again, this is what it takes to effectively address anything in life and not just a stronger pelvic floor; you deserve to enjoy life instead of being defined by your limitations. Every time a partial treatment is done, only a partial solution is achieved and as such, it won’t last long.
If despite your efforts you still experience pelvic floor dysfunction, I am here to help.
Dr. Shakib