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Understanding the solution

Pelvic floor exercises are the NICE recommended treatment for stress incontinence. If you understand how your pelvic floor works, you will understand what you are aiming to change through your exercises. This will give you a clearer physical focus when you exercise and a clearer mental focus when you need to stay motivated, and your pelvic floor exercises will be more effective.

3 key jobs

Your pelvic floor has 3 key jobs to do.

Support - Your pelvic floor must hold everything in place, firmly but gently, 24 x 7 x 365. Everything is all of your abdominal organs, including your urinary organs, your bladder and your urethra.

Keep things in - Your pelvic floor has 3 holes in it, to allow things to pass out of (or into) your body: your urethra (urine), your rectum (stools) and your vagina (babies and penises). As well as supporting these openings, your pelvic floor is responsible for keeping them closed to prevent leaks.

Let things out - Those 3 holes are there for a purpose, as importantly as keeping them firmly closed, it is essential that you can also open them at will, to allow them to do their job.

3 key functions

The HUG

The hug is your pelvic floor's natural state. It supports your pelvic organs (preventing prolapse) and holds them closed (preventing leaks).

If completely relaxing your pelvic floor is counted as 0% and the strongest short strong squeeze possible for use in emergencies is 100%, then the hug starts at about 20%. This is enough to hold your urethra closed, when your bladder is not under pressure; from when you have just emptied it until it starts to fill up. This is a healthy pelvic floor's "resting tone".

As your bladder fills, the pressure builds. External factors, such as movement, affect the pressure too - to perform its basic function, your hug needs to be able to increase in strength to 30, 40, 50, 60 or even 70%, when you're busting and running up the stairs to the loo without letting everything go.

Your need to be able bring that pressue on gently and release incrementally, not letting it fade away to nothing but releasing it with control. Your squeeze should always match the pressure that it needs to hold in.

The KNACK

There are occasions, such as when we cough or sneeze, run or jump, when the pelvic floor has to be able to do a very fast, very strong contraction to counteract a sudden and extreme increase in pressure.

This is the knack, a very strong emergency squeeze (100%) that only needs to last for a few seconds at a time. But it may need to be repeated a number of times in succession, enough for your 3 sneezes or a bout of coughing.

The knack is associated with earlier symptoms of stress incontinence. Most sufferers will be aware of leaks caused by these sudden increases in pressure, before they are affected by more consistent, lower level leakage.

Orgasm

Orgasms are triggered by pelvic floor contractions - a stronger pelvic floor gives you a better orgasm.

4 key attributes

Your pelvic floor has to do these jobs all of the time and in every circumstance. This includes coping with sudden, intense periods of demand (cough, sneeze, jump), slower build-ups in pressure (a full bowel, bladder or a baby) and changes in environment (such as child-bearing, child-birth and menopause). To do this, it needs 4 key attributes.

Endurance - it needs great stamina, as it needs to be able to work all of the time, without ever switching off.

Control - it needs to work at the appropriate level: too little and it doesn't do its job; too much and it will get tired.

Reaction - it must be able to react very quickly, when called upon. A sneeze won't wait.

Flexibility - it must be able to relax and stretch to allow things to pass through, as and when you want them to.

2 types of muscle

As you may be aware, there are 2 types of muscle throughout your body, designed to perform 2 different functions.

You have slow twitch muscle, which is designed to work at lower levels of intensity, but are expected to work all day. And you have fast twitch muscle, which works at high intensity, but is only expected to work for a short period of time. 

Your pelvic floor is made up of BOTH of these sorts of muscle, as it needs to be effective in 2 different ways: the slow twitch muscle provides sphincter and pelvic support, while the fast twitch muscles tighten quickly on demand to interrupt your urinary stream and when you orgasm.

The pelvic floor is made up of about 70% slow twitch and 30% fast twitch muscle fibres. Pelvic floor exercises need to work on both types of muscle.

3 types of exercise

Pelvic floor exercises are designed to correctly condition and strengthen both types of muscle. This can't be done with one single activity, there are 3 exercises that you need to do. These involve contracting, or squeezing, your pelvic floor muscles at with differing amounts of intensity, for different periods of time.

Long squeeze - 10 seconds plus at 60% of your maximum squeeze.

Short squeeze - 2 - 5 seconds at 80% of your maximum squeeze.

Snap - 1 second at 100% of your maximum squeeze.

4 keys to success

Dr Arnold Kegel was a gynecologist, who single handedly put pelvic floor muscle training on the map. He did not invent pelvic floor exercises, but, through his extensive research and clinical activity, he clearly identified their need and their benefits, defined how they should be done and popularised their use. His impact on their practice is most clearly shown by the wide adoption of the term Kegel Exercises.

Kegel identified 4 essential elements for successful pelvic floor exercises.

Feedback - First, you need to know that you are exercising the right muscles. As many as 50% of women doing unsupervised PFMT (for example, following brief instructions on a leaflet or handout) are squeezing the wrong muscles! Secondly, without feedback it is very difficult to know whether your efforts are effective - if you know that they are, you will be motivated to continue.

Education - All muscle activity is managed by messages passing between brain and muscle. When you learn new skills, you are initially clumsy, having to think about what you do as you attempt to make your muscles do what you want them to. Over time and with practice, these movements become quicker and more accurate, until you can perform even highly complex tasks without active thought (in fact, thinking about them often slows you down!). The first step in rehabilitating your pelvic floor is to learn how to control it, so that, in time, it can work effectively without your concious input.

Resistance - Squeezing against resistance challenges your muscles to work harder, escalating their strength and endurance. A basic principle of muscle physiology states that muscles respond in direct proportion to the demands placed on them.

Progressive intensity - As your pelvic floor gets stronger and fitter, it needs to work harder to continue to improve. Increasing the intensity of your exercise over time is the key to increasing your muscles strength and endurance.

Next: How to do pelvic floor exercises

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