Incontinence, Prolapse & Pelvic Floor Health

Pelvic Floor Health.

This is my very first ‘proper’ blog!  I hope you enjoy.

Have you ever heard the rumour that if you sneeze 6 times in a row, you orgasm?  Well guess what, I’ve managed to sneeze 6 times in a row, and man I wish that were true.  The actual results of my sneezing attack were devastating, and have impacted on my quality of life ever since.  Here is my story and what I have learned about pelvic floor health since that day.

FYI: I think all women should read what I’ve written in this article, because 77% of women will have a pelvic organ prolapse at some stage in their lives – and most of them will have incontinence.  The medical world believe that surgery is the only way to deal with prolapse, but once a woman has had surgery (including a hysterectomy) she has a 500% greater chance than the rest of the population to go on and develop a further prolapse.  Prolapses and stress incontinence are largely preventable with the tips I have shared below.

My Story

Early on in my second pregnancy, I had a massive sneezing attack, and managed to sneeze my bladder into a prolapse. This means that now, instead of being in it’s proper position, my bladder bulges into my vagina – and no, it’s not very comfortable! When I got to about 20 weeks pregnant, I was suffering from severe stress incontinence. I was wetting myself 5 times a day. A sneeze, a cough, a laugh, anything – and I would need to go and change my clothes again. I was at the stage I could not leave the house as I never knew when I would wet myself again. You have no idea how seriously depressing it is wetting yourself that many times a day.

I always did my pelvic floor exercises (Kegals to all you Americans reading this), but they never seemed to make an ounce of difference. And to tell you the truth, it never made sense to me that as soon as a woman has a baby, all of sudden she needs to do these unnatural exercises, just so that her body would work the way it was meant to, and made to. It didn’t make sense that we are made to give birth, but then not made to be able to function normally after. It wasn’t fair. So, I decided to do some research, and found out that the common teachings of doing pelvic floor exercises are not actually as valuable as we are made to think they are! They are not the answer to all pelvic health issues – and for many women, they actually cause more issues.

With the research and exercises that I am going to share, I went from wetting myself 5 times a day, to 0 times a day instantly. And this, was as I went through second and third trimester, with more and more weight from baby in my pelvis.

Illustration 1: Vesalius's Incorrect Pelvic Orientation (5). Can you imagine walking with this pelvic structure?!

History

Many medical professionals today have an incorrect vision in their heads of the layout of a female pelvis.  In the early 1500s the first medical artist drew pictures that became universally accepted medical depiction of the female pelvic orientation. The artist actually drew this incorrectly, as he mounted the vertebrae on a vertical iron rod, thereby losing the curves of the lower back & sacrum, and the orientation of the rest of the pelvis became distorted.(1) This was the beginning of picturing the female pelvis as a ‘bowl’ with a ‘floor’.(1) These inaccurate illustrations persisted unnoticed in medical literature until the 1950s, and ‘then were largely ignored for another 30 years, before correct pelvic alignment began to appear in medical textbooks'(2). Even in 1993 two university professors tried to draw professional attention to the issue. “A persistent error in many anatomical textbooks used today presents a modified view of the pelvis as the ‘front view’ and a nearly accurate front view as a ‘view from above’. No definite conclusion can be reached concerning the reason(s) for the remarkably long persistence of this error”. (3) Most textbooks still get the illustrations of pelvic alignment wrong. (4)

Illustration 2: Male pelvis (left) and female pelvis (right). Notice the difference with the bottom of the spine, and how flat the underside of the female spine is. (6)

Anatomy

The correct alignment of the pelvis has the pelvic opening (our girly bits), actually at the back of the pelvis, rather than straight down (see illustration 3). The following information is from Larry Goodman’s A Husband’s Guide to Prolapse (4), as he explains it so clearly.

“The reality is that women are horizontal creatures from the waist down and vertical creatures from the waist up. The male spine configuration is somewhat different, but the pronounced lumbar curve is part of the definite shape of a woman.” We are different to men – we are supposed to have curves with our belly & bottom!

Illustration 3: Pelvic Anatomy (7) Notice how the pelvic organs aren't in a 'bowl', but are on more of an angle, leaning over the pelvic bone.

So where does everything go?

“To understand prolapse, we need to understand where the internal organs are supposed to be. Let’s start at the back and work our way forward. The tailbone is the base of the sacral spine, a series of fused vertebrae that form the top of the pelvic opening. While the sacral spine slopes down on the posterior or back side of the body, on the interior of the pelvis, the sacral spine is virtually parallel with the ground.”

“In front of the tailbone is the anus then the perineum.”

“Moving forward, next is the vagina, which in normal anatomy of a standing woman is a flattened, airless tube. The vagina, urethra and clitoris are surrounded by the labia majora and minora which constitute the vulva. Just in front of the vulva is the pubic bone which is the bottom of the pelvic opening and which supports the pelvic organs like the straps of a saddle. Tucked up above the pelvic bone and next to the front abdominal wall is the bladder. The uterus, a fist-sized muscular organ, is situated above the bladder. The uterine opening, or cervix, is at the top of the vagina and when in proper position, the uterus folds over the vagina like a crimp in a hose.”

What is prolapse, and what does it matter?

Prolapse occurs when the bladder, uterus, rectum or small bowel gradually, or sometimes suddenly fall into the vaginal canal. Sometimes these organs even bulge out of the vagina. Prolapse is incredibly common. 77%, or 3 out of every 4 women will have some level of prolapse in their lives, and 1 in 9 women will seek out and undergo surgery for prolapse (this is not counting surgeries purely for incontinence).

Illustration 4: Progressive cystocele or bladder prolapse from normal on the left, to a stage 2 prolapse on the right (8) You can see in each picture, from left to right, the pelvic bone, the bladder (and urethra), and the vagina.

Once a woman has undergone prolapse surgery, her risk of developing further prolapse is 500% greater than the general population. Prolapse surgeries have a 30-50% repeat surgery rate. 40+% of post surgery women have some level of incontinence, and 10% suffer from fecal incontinence. (9) In summary, pelvic organ surgery is largely experimental, and highly unsuccessful.

If you want to see a photo of a prolapse, do an internet search for one.  I have purposefully not included a photo here, as, to be honest, they really are quite gross to look at.

Also, if you’ve ever been told you have a ‘tipped uterus’, this is an early sign of a prolapse in the making.  I wish my doctor had told me what a tipped uterus meant, so I could have prevented my prolapse and all the stress and discomfort it has caused.

Causes of Incontinence and Prolapse

Basically both incontinence and prolapse are caused by the same factors. Posture, pregnancy & birth, clothing, diet, and even the way we breathe all impacts on our pelvic health. But believe it or not, the biggest factor of all, is posture.

Pregnancy & Birth
Pregnancy and birth impact on pelvic health in a few different ways. Pregnancy itself puts a lot of strain on the bladder, so many women, despite having a c-section will have incontinence and prolapse issues. In fact, pregnancy and birth may well just ‘speed things along’ when it comes to pelvic issues. (10)

Birth itself can damage pelvic health when women are forced into unnatural positions during labour, or are forced / encouraged to ‘push’ when they don’t feel the urge. In fact, “maternal injury is considered by much of the medical establishment to be an inevitable outcome of vaginal delivery and demonstrably little effort has been made to separate truly natural birth from interventionist hospital strategies when considering outcomes.” C-sections are probably more damaging than ‘unnatural’ vaginal births, as they are actually cutting the uterus off it’s attachments to the bladder, removing it from the woman’s body to perform stitches, then putting it back in the mother. “This yields anything but prevention from prolapse and incontinence. It has been estimated that seven to nine women would have to deliver by caesarean to prevent one woman from having a disorder of pelvic organ support.”(11) So, the best thing to do in pregnancy and birth is to go as natural as possible, and follow the body’s leads, rather than listening to outside influences, who don’t necessarily know what is going on inside you.

Breathing
Breathing impacts on our pelvic health. Every breath that we take should create a downward and outward force from our diaphragm, pushing out our (relaxed) abdominal wall. With each natural inhalation, the respiratory diaphragm pulls forward on the lumbar spine, which forces the pelvic organs into the abdominal cavity. However, many people have reversed this, and pull their abdominal muscles in with each breath, and use their upper chest and neck muscles to lift their ribcages. Over time, this abnormal habit of breathing ends up dislodging the pelvic organs from their natural position. (12)

Diet
Along with abnormal breathing habits, our diet plays a role in our pelvic health. If you think about it logically, everything you eat ends up coming out through the pelvic area, and different foods have an impact on our internal organs. We all know what it’s like when we eat too much bread, or cheese, or when we have too much fruit, but how many of us have experimented with our diets, to see if what we are eating is really the best food for us? How does cutting out certain foods from your diet, impact on the way your body feels and operates? I know mine feels worse, the more processed the foods are in my diet.

Clothing
Clothing also impacts on our pelvic health. As discussed earlier, our natural posture is that our bellies are curved out. So many clothes today are designed to suck or squish our tummies into unnatural flat positions – thereby pushing our pelvic organs also into unnatural positions. They have to go somewhere – and if they can’t go forward and into your abdominal cavity, then they will go the other way – down and possibly out your vagina. Since I’ve cut certain tight pairs of jeans (below the belly maternity jeans are shocking!!), and a few other items out of my wardrobe, my prolapse and incontinence has improved.

Pelvic Floor Exercises (Kegals)
Traditional pelvic floor exercises are also to blame for many women’s pelvic support issues! These traditional exercises were based on the inaccurate depiction of women’s organs. When you do the flexing up of your ‘pelvic floor’, all you are actually doing is tightening the vaginal, urethral and rectal sphincters, not making any particular muscle stronger. Tighter, yes, shorter, yes, but not stronger.

Illustration 5: Creation of the hammock effect through bad posture and ineffective, if not damaging exercise (13) Compare this picture to the healthy pelvis shown earlier. You can see how much easier it is for pelvic organs to fall into a prolapse!

But worse than that, every time you do these pelvic floor exercises, you may be causing your pelvic floor muscles, or pelvic diaphragm, to slacken off. By exercising these muscles in isolation, away from the glutes (bottom) and hamstrings (backs of the thighs), you might very well be causing “slack in the pelvic floor due to the fact that the sacrum [large bone at base of spine] is moving anterior [forward], into the bowl of the pelvis. Because the pelvic floor muscles attach from the coccyx [very bottom of spine] to the pubic bone, the closer these bony attachments get, the more slack in the pelvic floor (the pelvic floor becomes a hammock)”(14) This is the opposite of what you are aiming for, as what you really want is your pelvic floor to be more ‘trampoline’ or ‘drum skin’ like, instead of ‘hammock’ like.

The following information on traditional pelvic floor exercises comes from an interview with Katy Bowman on Mamma Sweat’s website (15). “Kegals [Pelvic floor exercises] attempt to strengthen the pelvic floor, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to Pelvic Floor Disfunction (PFD). Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the PF is beginning to weaken. Deep, regular squats (pictured in hunter-gathering mama) create the posterior [backwards] pull on the sacrum. Peeing like this in the shower is a great daily practice, as is relaxing the pelvic floor muscles to make sure that you’re not squeezing the bathroom muscle closers too tight. Just close them enough…An easier way to say this is: Weak glutes + too many Kegels = PFD.”

“The Kegel keeps making the PF tighter and tighter (and weaker and weaker)[tight is not necessarily strong]. The short term benefits are masking the long term detriments. Ditch the kegels and add two to three squat sessions throughout the day (anywhere). The glutes strengthen and as a result, they pull the sacrum back, stretching the PF from a hammock to a trampoline. Viola! You can still practice opening and closing your PF in real-time situations, but you don’t have to approach it like a weight-lifting session or anything. It doesn’t need to be on the To Do list”

When you don’t exercise your glutes, you allow the bones of the pelvis to collapse into themselves. “The squat is the most effective and natural glute strengthener–using the full range of motion and your body weight. It is entirely more effective than any gym machine or contrived exercise. The hunter-gathering folks squat multiple times a day (or at least once in the morning), so they had a nice routine down over a lifetime. Doing this four to five times a day, every day of your pregnancy will improve the delivery as well!”

Posture

Illustration 6: This diagram demonstrates how, when the bladder and urethra are displaced, the intra-abdominal pressure created by sneezing, coughing etc, (as demonstrated by the dotted line) is actually forced onto the bladder itself, thereby causing stress incontinence.(17) Image A, is of a healthy pelvis with organs in normal positions. When the woman sneezes, the pressure is forced on her urethra - tightening it and keeping the urine in. In Image B, the bladder is slightly prolapsed, so when the woman sneezes, the area of intra-abdominal pressure (or stress) is actually on the bladder itself. So the pressure forces urine out. This is 'stress incontinence'.

But the biggest day to day factor in pelvic organ support is our posture. Since we were little girls, many women were, and still are, told to suck their tummies in and tuck their bottoms in. Every time a woman does this, she flattens out her lumbar spine, and causes the pelvic floor hammock to form. Walking like this also weakens the glutes, and abdominal muscles. When I first heard that, I was astounded. I thought ‘how can I have weak abdominal muscles when I can make my 17 week pregnant belly look basically flat?’ But really all I was doing was moving, or displacing my abdominal contents up into my respiratory diaphragm, and down into my lower pelvis, kind of through a force – like a vacuum. This is not strength of abdominal muscles – your abdominal muscles aren’t being used at all, and I certainly wasn’t doing my pelvic organs any favours. So if you are sucking and tucking, stop it right now, and remind yourself as often as you possibly can throughout each and every day to STOP! I originally found that I forget about 30 seconds after I’ve ‘relaaaaaxed’ my lower belly, and that I had vacuumed it back in again. Now I’m probably up to about 2-5 minutes before I re-vacuum, it’s such an ingrained habit.

But just because you may not be a sucker and tucker, doesn’t mean you don’t have postural problems! Again, I’m going to quote Larry Goodman (16) “Imagine sitting in your most comfortable chair. How would you characterise the shape of your spine? Probably a ‘C’ or concave shape, looking from the front. Now think about how women and men sat when our cultures were ‘primitive’. Look in any National Geographic magazine for examples. Women sat on the ground, cross legged or with their legs splayed out in front of them. If you look carefully, you’ll notice that it is virtually impossible to sit that way with a ‘C’ shaped spine. To sit that way you have to maintain that strong lumbar curve.”

This lumbar curve is important, as I mentioned earlier, it forces your pelvic organs down into your abdominal cavity, instead of down and out. “So sitting in upholstered chairs, car seats and other comfortable furniture, the lumbar curve flattens out over time. This pulls the organs back from the front of the abdominal wall and they fall into the vaginal space creating bulges in the case of the bladder (cystocele) or rectum (rectocele) or the cervix intruding into the vulva (uterine prolapse).”

Exercises

If you are totally addicted to doing pelvic floor exercises, then the only way to do them properly is to actually sit on the floor. Either have your legs out in front of you, or cross legged, and make sure your lumbar curve is in place. Relax your lower belly, raise your arms above your head (more towards your forehead than the back of your head), lean forward a smidge, and then do your traditional pelvic floor exercises.

To tell you the truth, I can’t be bothered doing that. Not when there are much more effective ways to get healthy pelvic organ support! As you have read, squats are awesome, but again, make sure your lumbar curve is in place.

Also, you can squat over the toilet. Not only is this great exercise, but it also really helps to fully empty the bladder, thereby helping to prevent incontinence. I could never figure out what was meant by ‘squat over the toilet’, so here’s a little picture for you. She’s nearly sitting down, but not quite. Kinda like a hover over the seat. (18)

Stress Incontinence exercise
To deal with stress incontinence, I learnt a pretty neat magic trick. Like I said, I was wetting myself five times a day. But I figured that if the lumbar curve was so important in just general posture, why not try and super exaggerate it when I needed to sneeze / cough etc! So instead of doing the typical tuck-the-bottom-under-while-crossing-my-legs-and-squeezing-those-pelvic-floor-muscles-as-tight-as-I-possibly-could, I did the opposite. I stood with my legs apart, looked up to the ceiling, pushed my butt and boobs out as far as they would go, making my back as curved as possible, and then sneezed. The difference was amazing, and immediate. Instead of all that downward pressure going straight down through my pelvis (and bladder), it was now going straight out my belly! Give it a go now if you want, with a little pretend cough! Like I said, I instantly went from wetting myself 5 times a day when 4 months pregnant, to not at all, to being 9 months pregnant, and it only being very very rarely that I ever suffered stress incontinence. Yay!

Postural exercise
And the other thing you need to exercise, is your posture. This is The Whole Woman^TM Posture (19) as described in Christine Ann Kent’s book Saving the Whole Woman, a book I would highly recommend to every woman.

• Stand with your feet parallel and approximately six inches apart. Distribute your weight evenly between three points on the soles of your feet: below the big toe, below the little toe, and in the center of the heel.

• Do not roll your ankles in or out. Try to hold them directly over your feet

• Straighten your knees but do not allow them to bow back. You may have knees that bend to the inside or outside, but the goal is to retrain them so your kneecaps are pointing straight ahead and positioned directly over your ankles.

• Relax your lower belly. Have a sense of pulling up your abdomen from your last pair of ribs. Gently lift your breasts up instead of pulling your belly in.

• Keep your shoulders pressed down. Do not pull them back squeezing your shoulder blades together, but keep your upper back flat and broad.

• Pull your head up and forward by slightly tucking your chin. Imagine your whole body being drawn up by a string at the crown of your head.

Walking is another form of very effective exercise – as long as you are in The Whole Woman^TM Posture. If you aren’t suffering from prolapse symptoms, you can even run with this posture.

Bad exercises
The trouble with quite a few forms of exercise is that it does not ensure that our bodies are adequately supported, and therefore almost encourages pelvic organs to drop. Yoga and Pilates were created by men, and for men, so there are many poses, like the traditional ‘boat pose’ in yoga and the original core mat program of Pilates that are not good for us. They place the body in an obtuse angle, which stresses the structures of pelvic organ support. Generally, if you think about the angles an exercise puts your body in, you can tell if it is good for you. If your body is at right angles to your legs, it is fine, as are acute angles. But Obtuse angles are unstable and should be avoided, whether it is a yoga or Pilates move, or even just pushing the pram or doing the washing up. Straighten up, or don’t do it – it’s up to you. (20) Also, watch out for these angles when watching television, sitting in the car, or doing any kind of activity. It all has an impact on your pelvic organ positioning.

As I stated earlier, I would highly recommend Christine Ann Kent’s book Saving the Whole Woman. She has lots of fantastic research, pictures and help for women suffering from pelvic organ issues – and it’s all natural! She also has a workout in the book, which helps to reinforce The Whole Woman^TM Posture and other exercises to do for prolapse issues.

Conclusion

We don’t need to be stuck with annoying and / or painful pelvic health issues. And we don’t need surgery to fix them. By changing habits in our lifestyles, and getting healthier through posture, exercise, food, clothing, and just responding to our bodies needs, we can be Whole Women again!

For more information, check out all of the websites listed in my references, they really are great to read, and www.wholewoman.com has a forum attached to it too! Good luck!

And watch the video mentioned in (9), it’s great. 🙂

1. Kent, C., 2006, Saving the Whole Woman: Natural alternatives to surgery for pelvic organ prolapse and urinary incontinence, Bridgeworks Inc., Albuquerque, NM.
2. Kent, Christine, March 22 2010, Why Kegals Don’t Work, http://wholewoman.com/library/?p=104
3. Stromberg, M., Williams, D.,1993, ‘Misrepresentation of the human pelvis’ in Journal of Biocommunications 20:14-28.
4. Goodman, L., July 28 2010, A Husband’s Guide to Prolapse, http://wholewoman.com/library/?p=244
5. Kent, 2006, p84
6. Kent, 2006, p32
7. Kent, 2006, p9
8. Kent, 2006, p34
9. Kent, The Whole Woman Solution to Pelvic Prolapse and Urinary Incontinence http://www.wholewoman.com/pages/theater/theater.html
10. Kent, 2006, p34
11. Mama Sweat, Monday, May 17 2010, Pelvic Floor Party: Kegals are not invited, http://mamasweat.blogspot.com/2010/05/pelvic-floor-party-kegels-are-not.html
12. Kent, 2006, p70
13. Kent, 2006, p10-11
14. Kent, 2006, p85
15. Katy Bowman in Mama Sweat, May 17 2010
16. Goodman, July 28 2010
17. Kent, 2006, p33
18. Kent, 2006, p120
19. Kent, 2006, p125-6
20. Kent, 2006, p171