The pelvic floor (PF) has become a hot topic in the movement world. Yoga teachers and gurus have been cueing PF engagement for centuries (think: “engage mula bandha” or “lift the pelvic floor”). Unfortunately, PF-related cueing, in the context of yoga, is not always a good idea. As we will discuss in this article, it may be causing more harm than good. Fortunately, now that more of us are hearing about the existence of the PF, the time is ripe for learning more about pelvic health. In this article, we will take a look at all-things PF in order to broaden yogis’ understanding of this oft-discussed and poorly understood region of the body. First, we will provide a general overview of PF function and what can go awry. Then, we will delve into five things you can do to improve your pelvic health in our Practical Guide to Working with the Pelvic Floor.

What is my Pelvic Floor?

The pelvic floor is a group of muscles that line the bottom of the pelvis. There are three layers of muscles that comprise the PF with a more superficial layer, a middle layer, and a deep layer. As illustrated in Figure 1 below, these muscles span four bony landmarks: the tailbone, the pubic bone, and both sit bones (ischial tuberosities). The PF muscles are responsible for a variety of functions including bladder and bowel control, sexual function, giving birth, and even posture and breathing! They are obviously very important to our well-being, so it would be a great idea to learn more about them.

Figure 1. The muscles of the pelvic floor

The PF muscles naturally contract and relax during movement to support the undercarriage of our torso and the organs within.  The wonderful thing about the PF muscles is that they are automatic and anticipatory. They are automatic in that — unlike flexing your biceps — you don’t have to consciously ask them to do anything. Unless you’re dealing with a PF disorder, which I will address below, the pelvic floor muscles know what to do. PF muscle firing is also anticipatory in that these muscles turn on before you have initiated movement. In other words, the PF muscles anticipate movement and the corresponding change to the internal pressure of the pelvic region by contracting [1]. These reasons are why in my previous article here, I detailed why yoga teachers need not ask us to consciously squeeze our nether-regions throughout our entire practice. In fact, it is outside of a yoga teacher’s expertise to cue pelvic floor engagement for reasons I will detail below. The automatic and anticipatory nature of the PF muscles ensure continence during movement and provide support to the overall stability of the pelvis and spine, which we will dive into next!

The Pelvic Floor in Posture and Stability

It is easy to appreciate how the PF works to control our bowels and bladder — it’s right below those organs, directly supporting them. Maintaining continence, however, only begins to scratch the surface of the PF’s full function. The PF is geographically and functionally related to a host of deep hip and spinal support musculature. These muscles work together to provide postural stability to the entire body during movement. The PF is part of a group of muscles known as the intrinsic “reflexive” core, as illustrated in Figure 2. The intrinsic core consists of the PF, the respiratory diaphragm, the transverse abdominis, and the multifidus. This group of muscles forms a boundary around the “core” of the body with the respiratory diaphragm forming the top, the transverse abdominis forming the front and sides, the multifidus along the back, and the PF lining the bottom.

Figure 2. The muscles of the intrinsic “reflexive” core.

As we have seen, the PF is anticipatory: it turns on before movement is initiated. The PF, however, is not the only muscle anticipating your movement — all four muscles in the intrinsic core have anticipatory engagement [2]. This is because the intrinsic unit works as a team to prepare for the changes in pressure that occur during movement that would otherwise wreak havoc on your ability to control your bowels and bladder. For example, if you decide to reach to pick up your phone, your PF starts to prepare for the inevitable change in abdominal pressure before the muscles in your shoulder, arm, and hand begin to coordinate their movement [1]. Studies have shown that people with chronic back pain don’t display this natural anticipatory firing of the intrinsic core [3]. This demonstrates the important role the PF plays with its intrinsic core relatives to facilitate pain-free movement. If a simple motion of the arm requires PF engagement, you can begin to appreciate how hard the PF works throughout complex movements such as walking, running, or even practicing yoga!

How does the Pelvic Floor relate to breathing?

As we saw in the previous section, the PF muscles are functionally related to the respiratory (thoracic) diaphragm. The relationship between the PF and the respiratory diaphragm goes further — they are both major players in breathing. While we often think of the respiratory diaphragm as the breathing muscle, there are also accessory breathing muscles. The PF muscles actually form their own diaphragm — the pelvic diaphragm! As illustrated in Figure 3 below, when you take a breath in, your respiratory diaphragm expands and descends. This movement of the respiratory diaphragm pushes all the organs beneath it in the pelvic cavity downwards. The pelvic diaphragm responds by expanding and descending to receive the organs [1].

Figure 3. Movement of the thoracic diaphragm and the pelvic floor during respiration.

During your exhale, your PF naturally contracts and lifts. In fact, the PF co-contracts with the transverse abdominis — the deep abdominal muscle we looked at above. This is why we often move, lift, push, or pull during our exhale — we take advantage of the natural bracing of the core that happens on the exhale. In geekier terms, we use our exhale during the most difficult part of the movement: the concentric portion. This is when your muscles are contracting while they shorten their length. Think of a squat. As you lower down, your glutes and quads are working eccentrically — they are firing while they lengthen to allow you to lower down. When you rise, your glutes and quads work concentrically to shorten their length and allow you to press back up against the force of gravity. Interestingly, when we move into backbends in yoga, we often reverse this pattern. Think about lifting up into baby cobra, bridge pose, or upward-facing dog — we lift on the inhale! There is nothing wrong with this reversal — but next time you are moving into your backbend, be bold, give it a try on the exhale! Notice if you are able to extend into your backbend using your muscles instead of any momentum gained from the inhale filling the chest.

Pelvic Floor Disorders — Beyond Kegels

PF disorders are alarmingly common. According to some conservative estimates, 1 in 4 women experiences some form of pelvic floor disorder [4]. These estimates also increase with age. While men have PF disorders too, the unfortunate truth is that women deal with the lion’s share of PF disorders. This is unsurprising given the trauma the PF endures during pregnancy and childbirth. Some countries, like France, recognize how childbirth interferes with PF function and give all women postpartum pelvic floor physiotherapy. The bad news for men — because PF rehabilitation and awareness are usually synonymous with women’s health, the male PF is even more marginalized and often left unrecognized.

PF disorders usually manifest as mild to moderate urinary leakage but can also include gas and fecal incontinence, sexual dysfunction, and pelvic pain [5], [6]. When things really start to go awry, leakage from the bowels and bladder becomes much more severe, and some people experience organ prolapse, where the pelvic organs droop down from their natural position and push against the walls of surrounding structures. Some women experience prolapsed organs pushing through their vagina. Aside from the physical discomfort, you can imagine seeing one of your internal organs peeking out from your vagina is not a pleasant experience! And while men don’t need to worry about organs peeking out from the first opening, they do need to worry about the backdoor! Men and women can both experience rectal prolapse where the rectum protrudes from the anus.

Kegels — or isolated PF muscle contractions — have become a one-stop shop for preventing and treating PF disorders. This is unfortunate because, while there is certainly a time and a place for Kegels (particularly under the supervision of a clinical therapist), they have some major downsides. The downsides of Kegels are very important to understand because they pretty much sum up everything we have discussed about PF function in this article.

The first major downside to Kegels is that they simplify PF function and disorders. They give the impression that a healthy PF needs to be strong and beefy. In fact, it is not necessarily a good idea to pump the PF like iron. The very architecture of the PF, down to the individual muscle fibres, is vastly different from, say, the six-pack muscles or the biceps. The PF muscles are supposed to be pliable and responsive to pressure changes (think: intra-abdominal pressure that increases on the inhale and decreases on the exhale). The PF is happiest when it can shorten and lengthen, when it can contain and receive, and when it can respond and relax. Many people with a PF disorder have what is known as an overactive PF disorder [7]. Very simply, their problem lies in their inability to relax their PF. Kegels would, therefore, do more harm than good for these folks [8], [9]. Instead, they would benefit from the opposite of Kegels: reverse Kegels! Read more below in our Practical Guide to Working with the PF.

The second major downside to Kegels is that they aren’t very functional. When walking, or planking, or performing deadlifts, the PF muscles should not need to be consciously activated in order to provide the necessary support to the pelvic organs and nearby hip and spine structures. Yes, for some people who have lost the mind-muscle connection to the PF, Kegel-like exercises can help them re-learn how to contract their PF. However, these should be done under the supervision of a specialist who is trained to assess the correctness of the contraction. This is because people who perform Kegels on their own too often fail to do them properly and end up straining their bowel muscles or recruiting other muscles along the way [8]. Don’t take it from me; take it from Chapter 6 of Kari Bø’s informative book “Evidence-based Physical Therapy for the Pelvic Floor”[6]:

If patients are straining instead of performing a correct contraction, the training [of the PF] may permanently stretch, weaken and harm the contractile ability of the PF. In addition, straining may stretch the connective tissue of fasciae and ligaments, thereby potentially increasing the risk of development of pelvic organ prolapse. Proper assessment of ability to contract the PF and feedback on performance is therefore mandatory.

The message for us yogis and yoga teachers out there: unless you also happen to be a pelvic floor physiotherapist, please stop telling your students to lift their PFs or engage their mula bandhas! More to the point, the goal of a therapist asking a client to do Kegel-like exercises is to eventually help the person not have to think about contracting their PF while moving — those of us without PF disorders do not have to think about it. 

Even if you are not yet experiencing the PF disorder symptoms I mentioned above (urine leakage, pelvic pain, etc.), it’s a good idea to find some preventative measures and perhaps improve your overall pelvic health before things go awry. And if you are beginning to see some minor symptoms, act now before things get worse. While a little urinary leakage during a sneeze may seem inconsequential, this is already indicative that the PF is not living up to its functional standards. Don’t wait until you are dealing with an organ prolapse to begin to think about your PF health. The next and last section of this article is designed to help you improve your overall pelvic health.

A Practical Guide to Working with Your Pelvic Floor

1. Have a nourishing movement practice

As we learned in this article, the PF muscles are part of your deep core. When they are functioning optimally, they are proactive by being anticipatory. The PF muscles anticipate movement and respond to help maintain continence, support the pelvic organs, and assist nearby muscles in their mutual goal of managing intra-abdominal pressure, posture, and overall stability. As such, your entire movement practice — from walking, to planking, to deadlifting — simultaneously works the PF. Engaging in exercises that specifically target hip and low spine musculature such as squats and deadlifts are a great addition to your movement practice. Exercises that require functional core stability while also using your limbs, such as bird-dogs and dead bugs, as I am demonstrating below, are also great for working the PF. Further, exercises that also require balance while stabilizing the pelvis and low spine are a great addition to your nourishing movement practice, as demonstrated in the single-leg deep squat below. The options, however, are endless. Move often and in a variety of ways and your PF will be happy. 

Bird-dogs: Come onto all-fours and find a table-top position with shoulders over wrists and hips over knees. Reach one arm out in front of you and the opposite leg behind you. Try to lift the back leg using your glute and hamstring strength and avoid overarching your low spine. Stay reaching on your inhale and use your exhale to draw your elbow and knee together under your torso.

Dead-bugs: Lie on your back, bend your knees, and lift your lower legs, so they are parallel to the mat. Bring your hands onto your thighs. On an inhale, reach an arm overhead and the same leg out long on the mat so that your entire leg is hovering above the mat. Keep your spine neutral throughout the movement. Think about isolating this movement so that only the reaching arm and leg are moving. On your exhale, draw your hand and leg back to the start position. You can also try this exercise with the opposite arm and leg reaching.

Bird-dogs (left) and Dead-bugs (right)

Single-leg deep squat: Please note, this exercise requires the prerequisite ability to perform a deep squat with a neutral spine. This exercise can be adapted to suit a large range of levels. Start in a deep squat with your hands planted behind your hips to support your weight. Come onto the ball of one foot to test the waters of your balance first. Then lift your foot and extend your leg out long in front of you. Keep your pelvis steady throughout the movement and try to isolate the movement to the floating leg. You can up-level this movement by bringing your hands closer to your hips and tenting your fingertips so that they are holding less of your body weight, as demonstrated below. You can up-level beyond this point by removing your hands entirely and either keeping them at prayer or reaching them out in front for balance.

Single-leg deep squat

2. Reverse Kegels and diaphragmatic breathing

PF muscles need to be strengthened and lengthened. A PF that is under constant tension may appear to be strong, but when push comes to shove and you jump/cough/sneeze/laugh, if your PF muscles have been working hard to stay under tension all day, they will fail from exhaustion when they actually need to contract. Reverse-Kegels and diaphragmatic breathing with visualization can help us learn to relax down there.

Lie in a supported supine butterfly pose or extended child’s pose, as demonstrated below. These poses are great for learning to relax the PF because the muscles are in their lengthened position. Bring your awareness to the lowest part of your pelvis — the space around your man or lady bits. If you can’t imagine that area or have a hard time orienting your mind there, simply bring your awareness to your groin, abdomen, and inner thighs.

Extended child’s pose and supported supine butterfly pose

Visualize the movement of your respiratory diaphragm and PF as you breathe (refer back Figure 3). As you breathe in, watch your lungs fill, and abdomen respond and expand. Feel, or visualize, your PF moving downward. When you breathe out, watch the diaphragm lift as the lungs empty, and your abdomen follows. Feel, or visualize, the PF responding by moving back up.

Once you are comfortable with diaphragmatic breathing and visualization of the natural rhythm of the PF, you are ready to try a reverse-Kegel! Take a breath in first and watch your PF descend. On your exhale employ a gentle contraction of the PF: women, think about using your vagina to lift a lentil; and men, as Garret Neil (aka Dr. Yogi Gare) likes to tell his clients, “pull the turtle head in.” If you feel your abdominal muscles or glute muscles straining along the way, you have gone too far. When you inhale again, let this tension go and visualize your PF fully relaxing. If reverse-kegels are not making any sense in your body, stick with the diaphragmatic breath work until you feel a strong mind-body connection with this oft-neglected area. If you continue to struggle with this and suspect you may have a PF disorder, consult a pelvic floor physiotherapist.

3. Squat to Eliminate

Humans have evolved to eliminate their bowels in the squatting position. This is because of the function of — you guessed it — the PF! With the advent of toilets, we are now accustomed to pooping while seated. As illustrated in Figure 4 below, when we squat, our colon “unkinks” from the grip of the PF muscle puborectalis. The puborectalis helps ensure that the anal sphincter stays closed. With this in mind, you can imagine how a PF disorder might result in fecal incontinence. Pooping in a sitting position is not optimal because the puborectalis kinks the colon and therefore requires said pooper to strain in order to defecate. Indeed, studies show that people strain less and have an easier time eliminating in the squatting position [10], [11]. And for those of us who sit to pee, it’s also a good idea to squat for that too! The PF controls the closure of both the anal and urethral sphincters. Squatting is an optimal position for the PF muscles to lengthen and thus release their grip on the pipe closures.

Figure 4. Relationship between puborectalis muscle and the colon in a seated versus squatting position.

Thanks to the Squatty Potty, it has never been easier to bring yourself into the squatting position and continue to have the luxury of using a toilet. The squatty potty is really just a glorified footstool that allows you to raise your feet bringing your hips into flexion and mimicking the squat position.

Squatty potty

4. Bathroom meditation

In our distraction driven society, we are very unlikely to be fully present while toileting — anyone bring their phone with them while they go? Or even grab some reading material? Think again. Shelly Prosko, a physiotherapist and pelvic floor educator, has come up with a 6-stage toilet meditation protocol which you can read all about here. As we have learned, many people have a hard time relaxing their PF muscles. This is problematic when it comes to bathrooming where we need to relax in order to release our pipe closures! If you have given steps 2 and 3 a try — you are diaphragmatic breathing, practicing reverse-Kegels, and using a squatty potty — take the next step and meditate on the toilet! Shelly’s protocol will help you release any distractions you bring with you into the loo and help focus on the task at hand when nature calls.

Bathroom meditation

5. Inform yourself

Unfortunately, the PF region has historically been neglected by the medical system because of the way it compartmentalizes the pelvic region and fails to look at it as a whole. As you can see in Figure 5, pelvic health is not tackled holistically in our medical system. Instead, the pelvic region is compartmentalized into three different medical specialties — colorectal surgeons and gastroenterologists, urologists, and gynaecologists [6].

Figure 5. How the pelvic region is compartmentalized in the medical system [6].

The good news is pelvic floor physiotherapists and educators are coming to the rescue. They specialize in this area of the body and have techniques for addressing all manner of PF disorders from minor to major. Even if you don’t need to see a specialist, it’s great to better inform yourself about your pelvic health. And since you’ve made it this far in the article, congratulations! You are well on your way!

More Resources

This article has been nothing short of a doozy. It’s amazing how a region of the body so seemingly insignificant can produce so much discussion! We have seen how the PF has a host of important responsibilities beyond continence and sexual function. The PF anticipates your every movement and responds to every breath by helping stabilize your overall structure. Given how hard they work for us, we should honour our PFs and seek professional help when things aren’t working up to their functional standards. For more information about the PF and pelvic health, check out the following resources:

  • Shelly Prosko is a physiotherapist, yoga teacher, and educator with a very informative blog that you can find here: physioyoga.ca. Shelly writes extensively about the PF and has dedicated an entire blog post for PF resources which you can check out here.
  • Katy Bowman is a powerhouse producer of fantastic information about all things movement. While she isn’t specifically a pelvic floor educator, she discusses the PF throughout her work, including her website nutritiousmovement.com, podcast, and many books. Her book “Diastasis Recti” is a great place to start for those interested in the biomechanical forces at play in the pelvic region.
  • If you are looking to delve deeper into the nitty gritty details of the anatomy of the PF, check out Physiopedia’s Pelvic Floor Anatomy hereYou can learn about the individual muscles that comprise the three layers of the PF. Scroll to the bottom to find two awesome videos that detail the anatomy of the PF using 3D visuals.
  • For podcast listeners extraordinaire, Francesca Cervero’s podcast “The Mentor Sessions” episode 25 titled “Yoga and the Pelvic Floor with Guest Teacher Diana Zotos” posted May 14, 2018 is definitely worth a listen. Diana Zotos is a yoga teacher and physiotherapist and does an excellent job discussing the pelvic floor from a whole body perspective.
  • For the academically inclined readers looking for a scholarly text, check out the book I cited throughout this article, Evidence-based physical therapy for the pelvic floor: bridging science and clinical practice (reference number 6, below).

 

References

[1]       P. W. Hodges, R. Sapsford, and L. H. M. Pengel, “Postural and respiratory functions of the pelvic floor muscles,” Neurourol. Urodyn., vol. 26, no. 3, pp. 362–371, May 2007.

[2]       J. Key, “‘The core’: Understanding it, and retraining its dysfunction,” J. Bodyw. Mov. Ther., vol. 17, no. 4, pp. 541–559, Oct. 2013.

[3]       P. Hodges, “Changes in motor planning of feedforward postural responses of the trunk muscles in low back pain,” Exp. Brain Res., vol. 141, no. 2, pp. 261–266, Nov. 2001.

[4]       I. Nygaard et al., “Prevalence of Symptomatic Pelvic Floor Disorders in US Women,” JAMA, vol. 300, no. 11, p. 1311, Sep. 2008.

[5]       C. Achtari and P. L. Dwyer, “Sexual function and pelvic floor disorders,” Best Pract. Res. Clin. Obstet. Gynaecol., vol. 19, no. 6, pp. 993–1008, Dec. 2005.

[6]       K. Bø, B. Berghmans, S. Mørkved, and M. Van Kampen, Evidence-based physical therapy for the pelvic floor : bridging science and clinical practice. Edinburgh: Churchill Livingstone, 2007.

[7]       A. Padoa and T. Y. Rosenbaum, The Overactive Pelvic Floor. Cham: Springer International Publishing, 2016.

[8]       M. P. FitzGerald and R. Kotarinos, “Rehabilitation of the short pelvic floor. I: Background and patient evaluation,” Int. Urogynecol. J. Pelvic Floor Dysfunct., vol. 14, no. 4, pp. 261–268, Oct. 2003.

[9]       M. P. FitzGerald and R. Kotarinos, “Rehabilitation of the short pelvic floor. II: Treatment of the patient with the short pelvic floor,” Int. Urogynecol. J. Pelvic Floor Dysfunct., vol. 14, no. 4, pp. 269–275, Oct. 2003.

[10]     R. M. Modi et al., “Implementation of a Defecation Posture Modification Device,” J. Clin. Gastroenterol., vol. 53, no. 3, pp. 216–219, Mar. 2019.

[11]     D. Sikirov, “Comparison of straining during defecation in three positions: results and implications for human health.,” Dig. Dis. Sci., vol. 48, no. 7, pp. 1201–5, Jul. 2003.

Edited by Jaimee Hoefert

Illustrations by Ksenia Sapunkova


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