Pelvic floor dysfunction

The pelvic floor is a group of muscles that supports the bottom of the pelvis like a hammock. It extends from the pubic bone at the front to the tailbone at the back, supporting the bladder, uterus (prostate in men), and rectum from below. It also opens and closes the passages through which urine and stool leave the body.

The pelvic floor does not work alone. It teams up with the diaphragm, the transversus abdominis deep in the abdomen, and the deep lower-back muscles to regulate intra-abdominal pressure and support the trunk from within. It moves with breathing: as you inhale, the diaphragm descends and the pelvic floor lowers slightly; as you exhale, they rise together.

Rather than the name of a single disease, this is a broad term covering various conditions in which the pelvic floor does not perform its roles properly. These can broadly be divided into two patterns.

• Insufficient supporting strength — Urine leaks when pressure is placed on the abdomen, such as when coughing, sneezing, running, or jumping rope, or there is a heavy, dragging sensation in the lower abdomen.
• Excessive tightness that does not release — There may be a persistent pulling sensation in the lower abdomen and perineum, a urine stream that does not feel free-flowing, or a feeling of having to strain during bowel movements. For details, see Pelvic floor overactivity.

Both patterns can occur in the same person. So rather than deciding in advance that your pelvic floor is “weak” or “strong,” the first step is to look at what discomfort you are experiencing now.

During pregnancy, the weight of the growing uterus continually loads the pelvic floor, and during vaginal birth, the pelvic floor muscles and nerves stretch considerably. This is why the pelvic floor comes up so often in discussions after pregnancy and childbirth. However, even after similar birth experiences, recovery rates vary from person to person. Lack of sleep, positions used while caring for a baby, and changes in the abdominal wall (Diastasis recti) can also play a part.

Urinary incontinence means involuntary urine leakage. People often search for it using phrases such as “a little comes out when I cough” or “I think I leak when I run.” There are two main types.

• Stress urinary incontinence — Urine leaks when pressure is suddenly placed on the abdomen, such as during coughing, sneezing, laughing, or jumping. It is explained as occurring when the pelvic floor cannot adequately support the pressure at that moment.
• Urgency urinary incontinence — A sudden urge to urinate is followed by leakage before reaching the toilet. This is more closely related to the bladder reacting sensitively.

Many people first experience it after childbirth, and symptoms may return in middle age or later. Pelvic floor muscle training is widely recognized as a first-line approach to managing stress urinary incontinence. Management differs depending on the type, so keeping a record of when urine leakage occurs can help during a consultation.

Kegel exercises often come to mind first when thinking about pelvic floor care. These exercises were introduced in the 1940s by American obstetrician-gynecologist Arnold Kegel to restore the pelvic floor weakened after childbirth. This makes it easy to assume that “the more you tighten the pelvic floor, the better,” but releasing tension is just as important as tightening these muscles.

Like other muscles, they need to contract strongly and then relax completely to do their job. If tension does not release in everyday life, they can tire easily, and the relaxation needed for urination or bowel movements may become difficult. Practicing contraction, full relaxation, and movement coordinated with breathing is therefore more balanced than repeatedly tightening alone.

Coordinating with breathing is an easy way to understand the movement. As you inhale, create a sense of the bottom of the pelvis gently widening and lowering; as you exhale, gently lift it upward. At first, avoid using maximum effort and focus on clearly letting go after contracting. It is also important to check that only the pelvic floor is moving, without tightening the buttocks, thighs, or abdomen.

• Urine leaks when you cough, sneeze, run, or lift heavy objects.
• A heavy, dragging sensation in the lower abdomen or vaginal area becomes worse toward evening.
• You feel the need to urinate but have trouble doing so, or feel that your bladder has not emptied completely afterward.
• There is a constant pulling sensation in the perineum, or sitting for long periods is uncomfortable.
• You have to strain a lot during bowel movements.

• Start with breathing. Lie in a comfortable position and breathe, getting used to the feeling of the bottom of the pelvis gently opening as you inhale and lightly rising as you exhale.
• Pair tightening exercises with relaxation. After tightening for a few seconds, allow at least that much time to fully release the tension.
• Try to reduce constipation. Repeatedly straining hard during bowel movements places cumulative stress on the pelvic floor. Pay attention to fluids and dietary fiber; many people find using a footstool while on the toilet more comfortable.
• Try exhaling as you lift heavy objects. Holding your breath and straining causes a sudden rise in intra-abdominal pressure.
• Build up gradually after childbirth. Start with walking, and feel free to delay higher-impact activities such as running or jumping depending on how your body is doing. For detailed criteria, see Postpartum return-to-exercise criteria.

• Difficulty controlling urine or stool interferes with daily life.
• A persistent sensation that something is descending into the vaginal area.
• A sudden worsening of lower abdominal or perineal pain after childbirth.
• Blood in the urine or pain during urination.
• No change after several weeks of self-management.

In these situations, consulting a healthcare professional who specializes in the pelvic floor or a pelvic floor physical therapist can help you find an approach suited to your condition. See Pelvic floor physical therapy for information about the assessments and training involved.