Pelvic floor problems, such as urinary or faecal incontinence and pelvic organ prolapse can occur throughout the lifespan, but are more common at certain life stages. There are also certain lifestyle factors and associated health problems which may increase your risk further. You are more at risk of pelvic floor problems if you are:
- Pregnant, or have ever had a baby
- Currently or previously experiencing the menopause
- An athlete with high training volumes particularly as a trampolinist or gymnast
- A man who has undergone surgery for prostate cancer
- A woman who has undergone gynaecological surgery such as a hysterectomy
You are at greater risk if you are:
- Overweight, obese (body max index over 25)
- Regularly lifting heavy weights at the gym or work
- Straining when you use your bowels- such as with constipation
- Coughing or sneezing often, which may be due to smoking, or respiratory disorders like asthma or hay fever
- Currently or previously experiencing back or pelvic pain
Although some of these risk factors are out of your control, many are modifiable, which means along with the help of your physiotherapist or health professional, you can make a plan of action to either change these risk factors or do other things to offset your risk. For example, evidence supports the role of pelvic floor muscle training, supervised by a physiotherapist trained in pelvic floor muscle rehabilitation, in reducing the symptoms of prolapse.
Pelvic floor risk factors
Pregnancy and childbirth
During pregnancy your body undergoes rapid and significant physical, emotional and hormonal changes. Your growing uterus expands twenty to thirty times its original size, your upper back increases its curve, your abdominals lengthen, the pelvic girdle widens and your blood volume increases. All these changes can impact your pelvic organs, pelvic floor and put you at risk for developing a pelvic floor disorder such as urinary incontinence. Many people don’t realise that the risk for many pelvic floor disorders later in life is similar whether you underwent a vaginal or caesarean delivery. This means it is important to undergo a full postnatal evaluation with a trained physiotherapist to identify any issues early, irrespective of the mode of delivery. The best time to have this done is around 6-8 weeks postpartum, however it is never too late to have an evaluation done.
The menopause
Menopause is another time of great hormonal change in a woman’s life and this can also impact the development of a pelvic floor disorder. As we age all the muscles of the body weaken, including those that support the pelvic organs- the pelvic floor. This can impact control of your bladder and bowel. In addition, it is common to experience abdominal weight gain which may also put further strain on the structures supporting the pelvic organs. The good news is these pelvic floor muscles, along with the other muscles in the body can be trained and strengthened to counteract these changes. Sometimes weakness in your legs, hips and trunk may result in overload of your pelvic floor, so addressing your body as a whole is an essential part of this process.
Another significant change at this time is the reduction in circulating levels of oestrogen. Oestrogen is a hormone that is responsible for maintaining strength and elasticity of the vagina, urethra and supporting tissues. It also has a big role in regulating pH and blood flow of the vaginal and vulval tissues, which may also impact the development of a pelvic floor disorder. A pelvic physiotherapist can work alongside your GP or gynaecologist to individualize the treatment plan for your specific needs.
High training volumes/high impact
Any kind of repetitive downward force on the pelvic floor and pelvic organs has the potential to increase the risk of pelvic floor problems. This can be the case for you if you participate in high intensity exercise such as gymnastics, trampolining, netball, running, boot-camp style training or high intensity interval type regimes. Most commonly these activities will uncover underlying weaknesses or issues associated with other risk factors (such as childbirth), but they may contribute to the development of these disorders in some individuals. It is important to remember that although bladder leakage is common in some of these sports, it is never normal and you can do something about it!
Following prostate surgery
If you or someone you know has undergone prostate surgery, chances are you have had to deal with urinary leakage. This is because the muscles that help to keep the urine in the bladder can become damaged or lose coordination due to their close proximity to the surgical site. In addition, the signals to and from the bladder to the brain may be interrupted by the use of a catheter (which drains the urine from the bladder into a bag during the early phase of recovery) and this signalling process often needs to be relearnt. Understandably this can be highly distressing and lead to anxiety and social isolation. The good news is, learning how to control your pelvic floor muscles can speed up the recovery process and prevent these symptoms from becoming persistent. Seek help from a pelvic health physiotherapist before your surgery to learn how to correctly contract and relax these muscles and receive guidance on a rehabilitation plan to help with your recovery.
Following gynaecological surgery
Following a gynaecological surgery there are certain factors which may affect your long term outcome including:
- Straining to empty your bladder or bowel
- Returning to strenuous activities, heavy lifting, and high impact exercise too soon in your recovery
- Poor pelvic floor and abdominal muscle function
Early evaluation from a pelvic physiotherapist can not only optimise your post-operative recovery, but enhance your long term outcomes so that your surgery is as effective as possible and you don’t experience a return of troubling symptoms, or develop new ones.
Overweight and obesity
The prevalence of pelvic floor disorders increases with the degree of being overweight or obese. If you are overweight or obese you are four times more likely to have urinary incontinence and two times more likely to have difficulty controlling bowels. This is thought to be due to a number of reasons including:
- Obesity-related comorbidities
- Diabetic neuropathy
- Damage to pelvic musculature
- Nerve damage and associated conduction abnormalities
- Intervertebral disc herniation
- Chronic increase in intra-abdominal pressure which puts downwards strain on the pelvic organs and pelvic floor
- Damage to pelvic muscles and supports
- Nerve damage (including from diabetes, back injury) and disruption of signals to the pelvic organs and pelvic floor
Weight is a modifiable factor, so weight reduction (surgical and non‐surgical) may be an effective treatment for the management of pelvic floor disorders and this has been shown to be true for urinary incontinence. Some studies suggest even a small amount of weight loss (such as 5%) can have a significant impact on bladder leakage. If you are having difficulty losing weight, offsetting the downwards pressure with pelvic floor training supervised by a physiotherapist trained in pelvic floor muscle rehabilitation may be a good starting point for you.
Straining to use bowels
Chronic straining and/ or constipation can also increase your risk of developing a pelvic floor disorder. This is due to the downwards force that overstrains the pelvic floor and pelvic organs. In general, a healthy bowel routine should consist of regular, soft bowel movements. These bowel movements should occur within a minute or so of sitting on the toilet and they should be easy to pass with no straining required. The bowel movement should be preceded by a comfortable urge to signal that your bowel is ready to be emptied, but you should be able to confidently defer this urge if it is not a convenient time to go. Frequency of bowel movements normally varies from 3 times per day to 3 times per week. If you are having difficulty passing soft bowel movements there are a number of things you can do:
- Modify the consistency with diet, fluid intake, fibre and stool softeners
- Change your posture on the toilet
- Stimulating and timing with the gastro-colic reflex
- Getting enough physical activity
Chronic cough or sneeze
Repetitive downward stress during coughing or sneezing can overstrain the ligaments and muscles that support the bladder and urethra within the pelvis. At times, this is completely unavoidable, however if you have a chronic health condition such as asthma, bronchitis or hayfever ensuring your condition is well managed by a medical professional may be the first step in improving your pelvic floor symptoms. This may involve taking regular medications, avoiding known allergens, quitting smoking or reducing your use.
In addition, learning how to tighten your pelvic floor prior to a cough or sneeze can reduce the total downwards force, thus reducing the strain on the pelvic floor and pelvic organs and reducing bladder leakage. This often needs to be practiced in a range of settings and positions so that you are able to use the technique at the right time. Often a series of coordination exercises will help you get to this point.
Low back and pelvic pain
Studies have shown that up to 95% of women with low back or pelvic pain will also have a pelvic floor disorder. This may be a pelvic organ prolapse, pelvic floor weakness or pelvic floor tenderness. We don’t know exactly why this is the case, or whether one directly causes the other, but what we do know is that it makes sense to address your whole system when we develop a treatment plan.
The bottom line
So as you can see, many of these risk factors are modifiable, which means along with the help of your physiotherapist or health professional, you can do something about them.
Make a time with your pelvic floor physiotherapist to see what you can do about it to either cure or improve your symptoms
Summary
There is strong evidence to support the role of physiotherapists with additional training in women’s and pelvic health to treat a number of conditions across all life stages – from more commonly known pelvic health issues affecting women such as incontinence and prolapse, to pelvic and sexual pain concerns and also for helping children and adolescents with bed wetting or other bladder/bowel control concerns.
We hope the information in this blog has been useful and should always be considered in conjunction with an individual assessment with your physiotherapist and/or other health care provider skilled in the area such as a GP or gynaecologist.
We would love to help you manage your concerns and get you back achieving your goals worry –free!
