Get the Pelvic Floor Back in Action - A Physical Therapist's Insight Into Rehabilitating Pelvic Dysfunction

The lack of pelvic floor muscle control is often a common denominator among several types of pelvic dysfunction. Learning to contract and relax the pelvic floor muscles can help resolve many conditions. In later sections, including ‘Building the Kegel Strength from Zero to Hero’, ‘Stress Urinary Incontinence Rehabilitation Is Not “Just Kegeling”’, and ‘Patients with Stress Urinary Incontinence Trudged into My Care, but with Rehabilitation, They Danced Out’, I will discuss the functional gains with specific scenarios I have treated. For now, I will provide an overview of this holy muscle contraction known as the ‘Kegel’.

Contraction of healthy pelvic floor muscles results in stopping the urine stream. The contraction also engages in defecation prevention as well as intercourse. The pelvic floor muscles act to close the orifices of the perineum, or undersurface of the pelvic cavity.

When voluntarily and consciously contracting the pelvic floor, or Kegeling, we can often feel the contraction of the posterior (rear) muscles first, and the anterior (front) muscles second. The muscles seem to relax in the reverse order. The anterior muscles normally release first, the posterior muscles second. I speculate that the order of contracting and relaxing is a reason I have seen numerous cases of urinary incontinence instead of fecal incontinence. It appears to take more effort to contract the anterior muscles than to contract the posterior. It also seems more difficult to hold onto the contraction of the anterior muscles. Hence, between urinary and fecal control, urinary control appears to be the more difficult task, and the lack thereof has been the issue I have treated more frequently.

In the grand scheme of urinary control, the pelvic floor musculature ordinarily boasts 3 functional elements:

1. An automatic contraction responds to sensing urine in the bladder.

2. A voluntary contraction combats a strong, building urge to urinate, and prevents or halts an undesired urine stream.

3. A release of the muscle contraction allows for voiding when appropriate.2

We, as children, normally develop an automatic response to urinary urgency, which draws on the pelvic floor muscles to counter urine flow. The pelvic floor muscles can also be automatically called upon to stabilize the lumbar and pelvic regions to resist perturbation.2 As we develop, we usually acquire pelvic floor muscle strength and agility from these automatic responses instead of from conscious contractions of these muscles. This differs from how we usually build muscles in other parts of the body. As children, we normally learn how to lift with our biceps, write and grasp with our hand muscles, and climb over a crib or fence using muscles in the legs and arms, and in the torso. These conscious actions can actively train the arm, leg, and torso muscles to perform specific functions and simultaneously build the muscles’ strength and agility. Throughout our lives we can continue to consciously use these muscles and build their strength and agility with daily chores and exercise. We are normally well aware of these muscles especially when we lift, squat and jump. In contrast, we usually do not consciously train the pelvic floor to contract. As children, we are normally coaxed to find a restroom instead of soiling our undies! And, in due time, we seem to ignite the automatic response to control our urine flow successfully on a regular basis. Problems can arise, however, if the automatic responses are not enough to keep the pelvic floor muscles strong, or the muscles are over-strained or traumatized…then, a conscious effort to exercise the pelvic floor muscles may need to kick in!

 

 

Our first successes at controlling urine flow can be compared to taking our first steps. Contracting the pelvic floor and walking are both automatic acts. Walking can even be thought of as a reflex: As the leading limb propagates forward, a stretch is applied to the hip flexor muscles of the trailing limb, and the hip flexors respond by contracting. The hip flexors’ reflexive contraction lifts the trailing leg and moves it forward. Forward momentum is generated as we walk, and with successive steps we can repeatedly and reflexively “catch” ourselves from falling flat on our faces! We can tell ourselves to start moving, but, in healthy scenarios, we do not have to think about the actual walking motion. We can, however, actively control how fast our legs move. For example, normally if we are in a hurry, we can deliberately move our legs quickly. Similarly, in healthy scenarios, when the urine level rises above the half way mark in the bladder, we normally do not have to think about contracting of our pelvic floor muscles to keep our urine from flowing. In normal situations, we can automatically contract our pelvic floor muscles to “catch” our urine and prevent leaking. And, like forcing our legs to walk quickly when in a hurry, we can voluntarily force the contraction of the pelvic floor muscles when needed… But, we still may not know exactly where we are contracting, or how the pelvic floor muscles actually work! Despite not knowing exactly how or where we are contracting, we can still ordinarily tell ourselves to hold the pelvic floor muscles with everything they’ve got, as when the bladder feels like it is about to burst!! Therefore, in less extreme scenarios, the pelvic floor contraction is normally automatic, but when the bladder’s detrusor is putting up a grand fight, a stronger, more cognizant contraction of the pelvic floor can be pulled into battle.

If we never actively or consciously set out to strengthen the pelvic floor muscles the first time around, “retraining” of the pelvic floor contraction is practically a misnomer. I prefer to tell patients that we are training the muscles to re-engage in countering urine flow and stabilizing the lumbar and pelvic regions, and training to release the contraction of muscles that may have become excessively tense and painful. Training the pelvic floor to contract is similar to teaching a patient to walk, since both acts were initially automatic responses. In fact, I often hear from patients, “This is like learning how to walk!” Grasping the concept of contracting a muscle we never had to think about can be very challenging! Initially such training is highly cerebral, and a concentrated effort is needed to contract the pelvic floor. With time, the response to the call for continence takes less and less of a conscious effort, and becomes more cerebellar if you will. With therapy, as I will explain in later sections, including ‘Acquiring a Resting Tone in the Pelvic Floor Muscles’, an extremely strong hold of the pelvic floor can ultimately be achieved for those emergency situations, a moderately strong baseline hold can be achieved for normal urges, and both can become automatic once again.

 

It is important to note that there are two muscles involved with incontinence that we cannot control directly: The detrusor muscle lining the bladder and the internal sphincter muscle where the proximal urethra meets the bladder. In normal situations, as the bladder fills with urine, the detrusor muscle is stretched. A stretch reflex occurs and the detrusor muscle contracts thereby pushing urine against the internal sphincter. The sphincter opens, urine proceeds through the urethra and voiding occurs.6

Though we cannot directly contract and relax the bladder’s detrusor and the internal sphincter, we can control these smooth muscles indirectly via a feedback loop. Normally, contraction of the pelvic floor muscles sends a message to the brain’s micturition center to halt voiding. From the brain, a message is sent to the stop the detrusor’s contraction and to close the internal sphincter at the bladder’s urethral opening. The relaxation of the pelvic floor muscles has the opposite effect. Without contraction of the pelvic floor, there is no a message to stop the contraction of the bladder. The bladder’s detrusor muscle contracts when the bladder is moderately full and the internal sphincter opens. Therefore, although we are not directly contracting and relaxing the bladder’s detrusor muscle or the internal sphincter around the urethra, we can control these muscles indirectly with a strong contraction or with relaxation of the pelvic floor. Under ordinary circumstances, a message to stop voiding is sent with a strong pelvic floor contraction, and the lack thereof results in reflexive voiding.8,9 (See Figure 5a.)

 

 

Figure 5a. Illustration of the pelvic floor’s feedback loop to the brain’s micturition center and bladder.

The contraction of the pelvic floor muscles (bottom right) sends the message to the micturition center of the brain (upper left), which then signals the bladder (mid right) to stop contracting.

 

 

When the muscles of the pelvic floor are weak or are fatigued, their contractions may not provide adequate feedback to stop urine from flowing uncontrollably. On the other hand, an inability to relax the pelvic...