Updated: Oct 12
I am continually fascinated with ways to improve your pelvic floor – mainly because of the number of women (predominantly) and men who ask advice on help with stress leaks, prolapses and prostate problems.
Whilst I am no medical person, the interventions an exercise instructor can provide will help support (excuse the pun) this area with conditioning that will improve the muscle before and after any surgery.
My first recollection of teaching pelvic floor was in London, sometime in the 90’s, on a YMCA course for what I think was then called “Gym Instructor for the over 50’s” – which now seems like a bonkers idea that your fitness drastically changes at the age of 50. I remember being quite embarrassed and shy teaching this – especially as, at the time, we were coached to teach it in a sitting position, on the floor with the whole class looking at you, and you looking directly at people who were trying to find and connect to the floor – even more so, as these were keen young students who wanted to teach an older population.
One reason most of us start to think about working the pelvic floor is when it causes problems.
Weakness in the pelvic floor can lead to stress incontinence and prolapse of the internal organs such the bladder, rectum, uterus, or prostate - and if you have had a hip replacement, a baby, prostate cancer, a baby, menopause or hysterectomy, the chances are that you need to pay a little more attention to the hidden, but important muscles of the pelvic floor. Pelvic Floor weakness can often be the cause for an individuals to stop doing exercise, but exercise we must, and here we discuss the role of Pilates in pelvic floor health.
Stress incontinence occurs when the floor does not contract quickly enough to hold the bladder in place and small leakages can occur – the “stress” can be a cough, laughing, sneezing, running, or even just rolling over in bed. Urge incontinence on the other hand relates to the muscle that squeezes the bladder to empty when we go to the loo – and this happens when we start to think about going to the loo or even enter the bathroom – that is to say you can start the weeing process before you get to the loo….. You can have both of these of course. Finally, the dribble is like the leaky tap where the tissue of the urethra (tube from bladder to wee) becomes “lax” due to the ageing process. Incontinence[i] is common in women, and generally, under-reported. It tends to have a stigma connected to it, and it affects quality of life.
Alongside weakness of muscle tissue, some people may have a “hypertonic” or overactive pelvic floor, where the muscle is under contraction, but not necessarily strong. This can often happen following scarring due to childbirth or surgical operation. There can be many reasons as to why the pelvic floor reacts in this way, but the need to include relaxation and stretch is key to improving this situation. An overactive pelvic floor can present as pain on going to the toilet, sexual function, and lower back pain. This is a complex issue that needs to be addressed professionally, but awareness that this might also be the case is worth considering when planning your exercise programme. Stretches such as happy baby or progressive muscle relaxation help.
The good news is that pelvic floor training helps, Price (2010) found a 70% improvement in stress, urge and mixed incontinence following a structured 12-week programme. This type of exercise is very specific to the control of the urethra muscles to ensure that they close/shut the opening until we are ready to go to the loo. Be aware though, that Pilates is here to help support the work of specific pelvic floor training - direct Pelvic Floor Activation (PFA) is required to make improvements to incontinence effective. We understand through the current research, that it is more difficult to learn and perform your PFA sequence when your posture is out of alignment – and that doing Pilates to improve your posture, reduce the pressure on the PF is of great benefit.
Pilates alongside pelvic activation is indicated by the research to help with a neuro response of the floor, citing the breath control and continuous exercise of the deep abdominals that support and of course, reduce the additional strain on the floor with improved posture. Sometime incontinence is due to the urethra length being shorter, which affects its ability to contract properly - the change in the length of the urethra (tube your urine comes down) is linked to poor posture, or a “slumped” position.
Let’s have a look at some of the findings of how Pilates can help your pelvic floor.
Pilates is an accessible training programme. Pilates often involves the contraction of the deep abdominals that help alleviate the pressure on the vertebral disks and realigned the spinal column; to the lower trapezius to draw the scapular into its correct alignment and not let the back curve forward in kyphosis and finally to work with the pelvic floor to help stabilise the pelvis and improve the tone pelvic floor muscles.
In a paper by Gomes (2017/2016) they found that Pilates was effective as convention PFMS (pelvic floor muscle strength training) systems – and that Pilates used alongside PDMS produced better results. For me, I find that doing a Pilates will also help with improvements to your self-esteem, quality of life, improved core and back strength, improved gait, and balance. You can also walk into a Pilates class with a “bad back”, but have incontinence problems that you do not wish to tell the world. Please tell me though. I will keep it confidential, but can offer additional advice to the whole class on when and how to activate the pelvic floor muscles during Pilates – this applies to men and women. I am no longer embarrassed by this as I was in the 90’s. Please don’t be embarrassed either. There is much to gain. Understanding how to activate the floor is key, as to realising the barriers to exercise for those who have weak pelvic floor and the impact that this has on their fitness, social life, relationships, and self-esteem.
Hein et al in 2020, studied the impact of a 12-week Pilates pelvic floor programme on stress incontinence, and discovered that one of the main elements of Pilates – breath control, helped to improve PF strength. When we breathe out, the TA and PF contract together, whereas when we breathe in, the PF lengthens. Together they improved the Lumbo pelvic stability (pelvis and spine) and help to support the urogenital structures. Following the Pilates intervention, participants improvement in incontinence and increased feelings of confidence.
Nightingale in 2020, found a correlation between transversus strength and PF strength and suggest that PFA is greater when the core is contracted. Brubaker (2008) also showed a significant increase in quality of life and sexual function following a combine Pilates and PF intervention.
In a paper by Siff in 2020, they found that the “swimming” exercise and the Pilates plank showed similar types of PF contraction to the more commonly used Kegel exercises. The paper looked at the contractile power generated to help strengthen the PF with 10 different exercises and concluded that these exercises were great alternatives.
For those of you who find this a problem when running, then postural work can help improve stride length and heel strike, which in turn should help reduce the amount of pressure on the PF during the running phases. Fatigue is often associated with symptoms of stress incontinence, so any work to help reduce fatigue with improved muscular endurance should be encouraged.
Using the “legs” and then the necessary stabilising of the lumbopelvic region has also been found to be of great help for PF dysfunction. Exercise that help to strengthen the hip area – and there are too many to mention here – not only improved incontinence, but also improved sexual experience as the floor also became stronger. Weak hip and thigh muscles have also been linked to increased falls in the elderly, and the connection between having incontinent issues and then falls is documented as a causal link.
Add to this the relationship between stronger abdominal strength leading to improved PF contraction, then we can see that many of the Pilates’s exercises can be of great value to us all. However, I have seen other papers which show that specific PF contractions are still considered to be “superior”, and I would recommend that you do both together. Certainly, working with a trained instructor on how to perform the movement “correctly”, and how to cue the muscles in preparation for loading, alongside learning to control the breath – is key.
Think about ways that you can improve your hip, leg, and abdominal strength to support your pelvic floor.
The menopause has a significant effect on the pelvic floor tissue that can cause increased incontinence that you may find makes you self-conscious, unable to discuss the issue and avoiding exercise with impact.
Incontinence tends to increase during peri-and postmenopausal times due to a variety of complex reasons. Menopause has a direct effect not only on the muscle of the urethra, making the muscle thinner and less able to contract with force, but also on bone density which can lead to greater postural changes. The urinary tract is also affected by thinning of the bladder and urethral linings and possibly cause chronic dysuria (painful wee) and an increased incidence of urinary tract infections. Prolapse of internal organs is more prevalent in menopausal women - in particular cystocele, which is prolapse of the bladder. Rectocele (bowel prolapse), or uterine prolapse (procidentia) can also occur. We know that with specific training, that we are able to increase the strength of both the pelvic floor muscle and closing of the urethra, however, rates of increase vary according to the menopausal stage and women in late menopausal transition and early menopause are least responsive to pelvic floor muscle strength training.
Now, on the whole, I tend to find that women will talk about this. Men*, on the other hand keep fairly quiet. Until it comes to prostate problems. The prostate sits underneath the bladder and wraps around the urethra (tube that carries your urine from the bladder when you wee), and its main job is to make semen. Problems start to happen when it comes to urinating, with slow flow, difficulty starting or finishing, feeling that you haven’t “emptied” properly, having urge or dribble incontinence. Not things people find easy to talk about..
Prostate cancer tends to run in families, and can be other men who have had it, or close family members who have had breast cancer,. It has some links with a high dietary fat in the diet. As well as the symptoms above, you can also experience back or pelvic pain – and often back pain is what brings more men into the Pilates classes. 1 in 8 men in the UK will get prostate cancer in their lifetime, and is one of the most common cancers in males. Often there is increased incontinence problems following surgery for anywhere between 3- 18 months. Having a good strong pelvic floor before the op, and working on this after, makes a difference. Pilates has been shown to be an effective training method to help men deal with this issue.
Things have since moved on. Now, in 2023, I can quite happily teach pelvic floor work to large groups or individuals, with no blushing, far more detail and understanding and, since the menopause, definitely a better understanding. I am about to teach and interactive Pilates and Pelvic Floor course for anyone, with a view to submit to CIMSPA an adapted version for Fitness Professionals. The online course starts on the 20th April 2023, and can be viewed at any time on the private webpage, which is handy if you can’t make the session, or if you want to revisit at any point.
We often wait for this to be an issue before we do anything about it – my advice would be to plan ahead, and keep your floor in good working order, so that as we age, or have other operations that affect the floor, we are in the best health possible. Don’t be shy. x
[i] Peggy Norton, Linda Brubaker, Urinary incontinence in women, The Lancet, Volume 367, Issue 9504,2006,Pages 57-67,ISSN 0140-6736,