Your Pelvic Floor Symptoms Might Not Be a Pelvic Floor Problem
When a new client presents into the clinic, a lot of times they have sought me out because of their pelvic floor symptoms. They explain a history of leaking and heaviness at times when doing higher level activities. They googled the symptoms and have decided their core and pelvic floor must be weak following their pregnancy, and they have tried adding kegels and core work into their routine, thinking that will help, but nothing changes.
Then they find me and I will ask them: “What if your pelvic floor isn't the problem, what if that is just where your symptoms are showing up?”
The look of question and shock usually is what is next on their face and then curiosity, wondering how their leaking cannot be a pelvic floor problem? And then begins the sometimes nuanced education of the pelvic floor in our bodies, and what messages it can be telling us.
Sometimes the isolation of pelvic floor therapy has separated how we think of the pelvic floor as a separate entity, rather than how it's working together as a part of a system.
What Is Pressure Management?
What is intra-abdominal pressure (IAP)? I often teach clients to look at our trunk as a canister. We have the diaphragm on top of the canister, on the bottom we have pelvic floor, and supporting the sides we have abdominals and spinal muscles. When we breathe, that canister has to adjust to the pressure. On the inhalation, our diaphragm lengthens, moving down into the abdominal cavity to allow the lungs to fill with air. Our pelvic floor also lengthens, accommodating that change, as well as our belly and back expand.
When we exhale, the opposite happens, diaphragm returns, as well as all the other aspects of the canister. What is moving between the top and bottom are all our guts: think intestines, liver, bladder etc. Specifically things like peristalsis (involuntary movement of the gastrointestinal (GI) system) requires this movement to actually be able move things throughout our GI system.
As the air is moving in and out of our bodies, the canister has to adjust. It has to manage that change in pressure to allow for the body to function well while allowing the air in and out. When things are being managed well we think of the pressure being distributed well throughout the whole canister aka abdominal cavity.
However, sometimes that pressure system can get disrupted. Meaning the pressure gets dumped into areas that are not meant to be managing the overload of pressure, or it's an area that may have had some weakness, but now is just not able to keep up, and that is where your body is showing symptoms. While I am specifically speaking right now on pelvic floor symptoms, this can be the same logic of back, pelvic, hip, and shoulder pain as well.
What Happens When Pressure Isn’t Managed Well
If pressure isn't getting to areas in that body well, sometimes that pressure ends up in a more downward direction on the pelvic floor. And then sometimes, those muscles, due to previous history, may not be as coordinated as they once were, or have a delay in activating when they are needed. And other times, our body (in its sometimes amazing wisdom but unhelpful solution) picks up different habits to help offer a different management strategy such as breath holding or bracing, that doesn't match the requirement long term, overloading the pelvic floor.
And what do people notice? They don't notice the poor pressure management as what is happening, but they notice the urinary leaking, the heaviness feeling, the low back pain, the tightness in the hips, the feeling of a weak core.
Just because those are the symptoms that are felt, it doesn't automatically mean there is a pelvic floor weakness or damage.
Why the Pelvic Floor Gets Blamed
I don't blame anyone for thinking that their pelvic floor is the problem. Especially in a postpartum population, where the pelvic floor obviously had some changes. It's where the symptoms are felt and can sometimes be the most embarrassing functionally with respect to the symptoms. It's easy to think, “I leak, that means I’m weak, I must get it stronger”. But this is where sometimes the limitation of looking at the pelvic floor by itself can really get people stuck. They get the things they think are “weak”, stronger and still have the same problem.
This is the limitation at only looking at the pelvic floor in that area of the body, and not looking at how the pelvic floor is working as part of a system.
Outside of an anatomy context, it's like this: If you had a heatwave going on, and a transformer blows, it's easy to say, “oh that transformer was a problem”. But the reality is, the heat wave is the problem and overloaded the system, and the transformer was just the weak point in the system
Patterns of Poor Pressure Management
There can be many reasons that poor pressure management happens in the body. Sometimes there can be breath holding when performing a task, impacting that pressure on the pelvic floor. Other times it can be a change in pelvic/rib cage stacking position. Even not taking deep enough breaths, not allowing the diaphragm its full length, impacts the pelvic floor's ability to fully lengthen, limiting its ability to sustain a load. Often in a postpartum population, that pelvis and ribcage are accommodating a growing belly, but the body never picks up correctly to go back to where it once was when that space is empty again. And still other times, there can be weakness in other areas of the body, like the abdominal muscles, that isn't supporting the front as much as it could, and therefore, the body then relies on the pelvic floor to carry more than it is prepared for, or just isn't coordinated well with those muscles.
All these different strategies the body is doing impacts where pressure gets re-disrupted to, and can impact the pelvic floor management of the pressure and whether you can remain with or without symptoms.
Pelvic Floor is a part of a team
When speaking about pelvic floor function and purpose in the body, it is important to understand that it is never working in an isolated context. The pelvic floor works in coordination with the diaphragm and transverse abdominal muscles, helping manage the intra-abdominal pressure. This pressure is a necessary thing in our bodies, and is vital for our internal organs to be able to do their job. Our body is going to prioritize this internal movement, and need to manage the pressure. When that pressure is optimal we generally feel like we're moving well, and when it's not, our organs are still getting what they need, but things like leakage and pain may be present.
Treatment
What this means on a treatment side, is shifting the mindset away from “I just need to strengthen my pelvic floor” to understanding our body’s specific pressure strategy, restoring coordination of muscles working together, and integrating breathing with movement.
Some examples of this can be:
When you lift something heavy, exhaling during effort
Learning how to stack ribs over pelvis in sitting, quad, and standing positions
Weight training with good breathing technique and coordination
Gradually building confidence in different positions and adding in more dynamic activities challenging positions when managing pressure
While the impact of leaking and heaviness can be very limiting in a postpartum population, understanding how the system works all together can be very empowering: no matter the severity of the symptoms. Avoiding the activities is not the solution, but rather understanding how to manage the pressure makes approaching the activities can be what allows the ability for someone to return to a previous activity or movement without fear.
The amazing thing about our bodies is the ability to adapt to changes. Most of the time those changes and compensations serve to keep us functional. Even when those changes are not serving us, our bodies still have the amazing capabilities to be taught even different strategies. Sometimes we can figure them out on our own, but other times, we need that support to figure it out.
If you are experiencing symptoms, it doesn't mean something is “wrong” with your pelvic floor, but rather, your body is just indicating it needs a different strategy. And with the right approach, that is something that can change.
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