Why do athletes frequently suffer from pelvic floor weakness?

Certain sports predispose themselves to more likeliness of pelvic floor wear and tear such as gymnastics, running, tennis, and basketball, to name a few, because the activity directs downward pressure on the pelvic floor. Athletes work their bodies to peak performance and the pelvic floor is just another muscle that could potentially be injured.  Our pelvic floor muscles are as thin as our facial muscles, and in high performance sports the pelvic floor muscles are needed to hold the abdominal contents. If activity overworks the muscles, the connective tissue can then be lengthened which can lead to prolapses, where the abdominal contents push downwards and affect the optimal emptying of urinary or fecal contents.

At SynergiePT, we can recommend techniques to combat the weakness often caused by high intensity activities.  Pessaries, which are soft, flexible, non-surgical devices placed in the vagina, can help support the bladder, vagina, uterus, and/or rectum, which can maintain  the integrity of the pelvic floor while participating in these sports.  Unfortunately, not all orthopedic therapists are comfortable treating pelvic floor disorders, and may not offer pelvic floor therapy as a solution. But as the initial sports injury progresses to a higher degree of dysfunction, treatment to the pelvic floor is really essential. At SynergiePT we address, without shame or shyness, your whole fitness and body awareness, which includes your pelvic floor, for ultimate wellness and high performance training.

What types of issues do you see with triathletes?

Julie Guthrie PT, DPT, OCS is a triathlete and brings a unique understanding of the pelvic floor issues that can result from training and performance. She has worked with athletes who push themselves hard, which sometimes causes pelvic floor weakness resulting in incontinence. Unfortunately, our culture is still unwilling to talk openly about incontinence, but as physical therapists we see this symptom all the time, and we can help athletes train effectively without causing the pelvic floor to weaken and leak.

Is a baseline evaluation recommended for athletes?

Yes, getting a baseline evaluation and occasional checkups to identify changes is optimal. There should be no shame in having this area of the body examined and assessed. The pelvic floor area is made of tissues and muscles, similar to so many other parts of the body. But because the pelvic area is hidden under clothing, or somehow considered taboo to discuss, patients tend to arrive at physical therapy because they are experiencing problematic symptoms, like incontinence, and their embarrassment has held them back from seeing treatment earlier. If any symptoms of pelvic pain or pelvic disorder occur - such as urine leakage or frequency, loss of control of gas, or prolapse -  a pelvic floor evaluation should be performed. Sometimes an external look at the alignment of the tailbone can help us correct your pain or discomfort during sports.

What is pelvic floor therapy? 

Pelvic floor therapy is physical therapy for men and women who are suffering from disorders of the pelvic floor. These disorders can include bladder, bowel, sexual function, and pelvic pain as well as musculoskeletal or nerve injuries to the pelvic floor. A pelvic floor therapist is an orthopedic therapist who has had special training in the anatomy and physiology of the pelvis and how its contents (internal organs) relate to posture and everyday functions. At SynergiePT we help patients restore function where there has been a disruption in the pelvic floor and reconnect proper alignment to improve quality of life and return to physical activities.

What can cause a weak pelvic floor? 

Pelvic floor weakness can happen to men and to women, and can come from the simplest activity -- from just sitting on a hard chair each day to sitting on a bike seat for a hundred-mile ride.  Any sustained stretch to the pelvic floor can cause weakness. Sudden trauma, such as a fall onto the hip, can also cause pelvic floor weakness. Weakness can also be the result of increased internal pressure, which can occur from straining too hard for a bowel movement or prolonged coughing due to illness.  Some women experience a weak pelvic floor postpartum, but other causes include inactivity, sitting for long periods of time, or changes in weight, which can change the functionality of the muscles in the pelvic floor. In some cases, pelvic weakness is a consequence of muscle strain and stress on the connective tissues, frequently seen in gymnasts, runners, basketball and volleyball players. 

What is prolapse, and how it is treated with physical therapy?

Your pelvis contains several organs in a tight space -- your bladder, cervix, intestines, rectum, urethra, uterus, and vagina. When the muscles and tissue that hold everything in place get stretched out, weakened, or torn, some of your body parts can drop down from their normal position, and can protrude from the pelvis. This is called prolapse. In our practice, we have helped treat mild prolapse with pelvic floor strengthening routines. 

How would I know that I have pelvic floor weakness?

Incontinence is typically the first symptom of pelvic floor weakness, either in the form of urinary or fecal leakage, or urgency, which can be very stressful for a woman or man to manage.  If you feel leakage of urine when you laugh or cough that may be a sign that something might be out of sync. Having to go to the bathroom frequently or not being able to hold back an urge to pee or poop is a potential pelvic floor problem. Other symptoms include tailbone pain, pain with intercourse, any sort of vaginal pain, or vulvovaginal pain. Some women during pregnancy will feel what is called “London Bridge is falling down” or will be told that their organs are falling into their vagina. This condition is known as a mild prolapse which may subside after pregnancy but we recommend a consultation after delivery to be sure the pelvic floor muscles return to their original length.

Men may experience scrotal pain and sit-bone pain, which sometimes is exacerbated by bike riding or other sports. 

How do you use physical therapy to treat a weak pelvic floor?

Physical therapy treatments for pelvic floor disorders are best treated by an internal digit exam to see if the pelvic floor is operating correctly right to left as well as up and down.  Sometimes there is weakness on one side and tension on the opposite side due to less feeling or sensation from muscle and nerve injury. Other times the line of pull needs to be corrected because the patient is performing a lengthening instead of a shortening contraction and the timing of the entire process is off.  Once the internal pelvic floor is evaluated we connect to the outer posture and alignment to be sure the joints move in the new adapted length-tension relationship of the corrected pelvic floor muscle activation pattern. 

What are Kegel exercises?

Kegel exercises are named after Dr. Arnold Kegel who used internal probes and had patients squeeze 100 times a day for a 30 second hold, each time maximally squeezing.  Scientific research has shown that the fatigue index of the muscle is so high and the architecture of the muscle morphology (size, shape, fiber count, length) is such that fatigue occurs after just 5 or 10 contractions for a maximum of 20-second hold, assuming all sensation and coordination is intact.  Performing a “kegel” is the proper term but the prescription Dr. Kegel suggested is not ideal.  

Are Kegel exercises effective at treating pelvic floor weakness?

A lot of women have been advised, sometimes by their physicians, to try Kegel contractions, but about 30% are doing these pelvic floor contractions incorrectly. Use of a “kegel” app may be helpful in reminding you to exercise the muscle briefly and frequently.  But unless you are sure you are performing the exercise correctly (lifting up instead of bearing down) you should not try to teach yourself because you can over-lengthen the muscle and fatigue it to the point of exhaustion which will increase symptoms.

The physical therapists at SynergiePT take the time to explain the anatomy and reasoning for doing these contractions, and ensure that a patient is doing them correctly. The pelvic floor is comprised of fast-twitch and slow-twitch muscle fibers, and these need to be specifically trained (through proper dosing of the contractions, positioning of the body, and properly breathing during the exercise regime) to get optimal results.

What do you advise women who are pregnant? 

Physical therapy is a compulsory treatment postpartum in countries like France, but here in the United States, it’s unlikely that an OB/Gyn will send a patient to pelvic floor therapy postpartum. Ideally, a woman of child-bearing age should be examined by a physical therapist to get a baseline of her pelvic health, with a focus on the core, obliques, abdominals, use of breath, and more. Even midway through a pregnancy is a good time to check for pelvic floor strength and discuss body mechanics. Exercises that activate patterns for pelvic floor contraction and relaxation can help prevent urinary urge incontinence (70% likeliness post delivery) and urinary stress incontinence during pregnancy.  

If you are pregnant, it is a good idea to be evaluated by a Women’s Health specialist to advise on proper posture, as back pain occurs 90% of the time in pregnancy, as well as optimal sleeping positions and labor positions for delivery. 

Can I strengthen my pelvic floor on my own without seeing a physical therapist?

Many patients have tried to “fix” pelvic pain or weakness by signing up for Pilates classes or doing extra core training at their gym. These are external treatments that can certainly play a role in strengthening the pelvic floor. Sometimes a patient will go this route because the idea of speaking to someone personally about pelvic issues is just too uncomfortable and embarrassing, particularly the therapies that involve internal treatments.  

There are a few Kegel apps and lots of YouTube videos, but from our experience a quick visit to the pelvic floor physical therapist is the most effective way to learn how to strengthen your pelvic floor. Verbal instructions alone are not 100% effective and without the kinesthetic connection of what is moving and in which direction, you may be lost or disconnected to your inner core. Consider this: you wouldn’t rely on verbal instruction or a YouTube video to learn how to play tennis, or any sport for that matter. Why is learning pelvic floor muscle connection any different?  

What is the benefit of doing pelvic floor physical therapy as opposed to self treatment?

For a more effective result, we recommend physical therapy for these reasons: 

We can demystify preconceived thoughts about pelvic floor therapy, and provide information about external therapy, behavior re-training and the sometimes intimidating concept of digital/internal assessment of the musculature through a vaginal or rectal entry. This is not a pelvic examination. Rather, these are internal assessments and treatments, always using gloves, that enable access to palpate internal muscles, and these treatments always require prior consent (and a chaperone, if preferred). Internal treatments are not used with our pediatric patients, or with patients in significant pain. 

We can explain anatomical terms and discuss the process of physical therapy, answer your questions, and then provide you with a personalized treatment plan that will address your specific needs and describe the intended outcomes and timeframes.

Do you work with victims of physical abuse, sexual abuse, or emotional abuse, that may have played a role in the development of a pelvic floor disorder? 

According to officers we have spoken to with the Los Angeles Sheriff’s Department, one in four women experience some sort of sexual trauma in their lives. We do work with victims of abuse, and we are sensitive to the trauma and pain that is a consequence of these abusive relationships.  Physical therapy can be very beneficial and can help restore confidence, support the healing process, reduce pain, and develop a strong inner core. Our role as physical therapists is to guide women to reconnect where there has been disruption in their pelvic floor. It may be a multimodality approach with referrals to a certified EMDR therapist or a sex therapist to address PTSD. The role of mind body connection and healing is a process that involves layers of problem solving.  We focus on creating new neural pathways to diminish recurrence of injury from trauma.