We have all heard this before – “Use it or lose it” – but not always had to think about it.
Pelvic floor function is not on most people’s list of worries, we trust it to be there for us as a part of the core muscle group. When we go for a walk, swim, yoga, Pilates (….choose your workout), we expect that the pelvic floor muscles are automatically reacting to the activity with the support and closure they are designed for. But what happens when we’ve lost it?
What do the Pelvic Floor Muscles do?
First off, we need to understand what the pelvic floor muscles (PFM) actually do. The pelvic floor muscles (PFM) are a sling formed by superficial and deep muscles at the base of the pelvis . They are important in :
◦ Supporting pelvic organs
◦ Bladder control
◦ Bowel control
◦ Sexual function
Strong pelvic floor muscles (PFM) provide a good level of strength and endurance to prevent urinary or bowel accidents, give support to the pelvic organs, and improve sexual function.
How do we lose it?
There are challenges of illness that might stop you from your usual activities at any time in your life. COVID-19 was an additional difficulty with the last 2 months of social isolation and a decrease in activities. To flatten the curve (COVID-19), the physical activity of all of us has been affected in some way. When suddenly physical activity patterns are changed, there will also likely be some changes in the pelvic floor function.
There are studies looking at the effects of not using muscles [2,3,4]. Some of the changes noted:
- Bed rest: (Full body – systemic) insulin sensitivity, changes in muscle mass and strength, arterial stiffness
- 17 to 40% loss in muscle strength and mass after 84 days of bed rest
- 10-12% loss in muscle mass after 17-20 days of bed rest
- 7% loss in muscle mass after 10-day bed rest
- Immobilization (casting or brace) : (Local – peripheral) changes in muscle mass and strength in the immobilized limb, lower limb arterial structure changes
- 23% loss in muscle mass after 2 weeks
- 9% loss in muscle mass after 5 days
- Step reduction (continuing with some activity, with up to 750-1500 steps per day): (Full body – systemic changes) insulin sensitivity, changes in mass and muscle strength
When there are changes to your pelvic floor muscles (PFM), you can face a new onset or increase in :
◦ Incontinence: bladder and/or bowel
◦ The sensation of pelvic heaviness or organ prolapse
◦ Pelvic pain
◦ Changes to overall core stability
How do we get it back?
We have heard about Kegels as THE exercise helping to improve pelvic floor strength and endurance, but it can be hard to do the pelvic floor contractions correctly. We should be able to feel the pelvic floor muscles contract, squeeze and lift without other, unnecessary muscles, contracting. Often there is accidental involvement of the buttocks, inner legs, and holding of one’s breath. A pelvic floor assessment and exercise prescription is the most optimal way of returning to a fully functioning pelvic floor.
Assessment of your pelvic floor muscles (PFM) 
There are different ways of evaluating your pelvic floor muscles and there is not a “gold standard” for the PFM assessment. The examination needs to be geared towards your special needs and level of comfort. The examination needs to look at the ability of the correct muscle contraction as well as evaluate the strength and endurance of the contraction.
- External observation: only partially helpful, as there might be an absence of deep pelvic floor contraction with only superficial muscles working
- Internal vaginal digital palpation: ability to evaluate pelvic floor – PERFECT by Laycock 
- Power – using the Modified Oxford Scale
- Endurance – How long can they hold a maximal voluntary contraction (up to 10sec)
- Repetitions – How many maximal voluntary contractions they hold with a rest between them, up to 10 reps (eg 10 repetitions of a 10-second hold)
- Fast- The number of 1-second maximal voluntary contractions they can perform in a row (up to 10)
- Every Contraction Timed – a reminder to time every contraction
- NOTE: “The advantage of an internal vaginal examination is that as well as the muscle strength, anatomical changes, the symmetry of a contraction, muscle tone as well as any painful areas can also be examined.” 
- Real-Time Ultrasound (RTUS): the ability to visualize a pelvic floor contraction and relaxation (movement of the muscles) without an internal exam when such is contraindicated; does not give information on PF strength.
- MRI: assessing for pelvic floor dysfunction, and lift with a contraction
- EMG: surface electromyography; not reliable in reporting PF strength
- Manometers and Dynamometers: tools for an objective measure of PF strength
- Biofeedback: visualization of PF contraction, relaxation, and resting tone evaluation; non-invasive with surface electrodes or internal with vaginal or rectal probes. It does not give information on PF strength
As we enthusiastically return to the gyms, yoga and Pilates studios, hiking our favourite trails in the parks, as we get stronger with the activity; pay attention to the pelvic floor muscles (PFM). If there is a challenge you noted with the pelvic floor, or you would like to review your presentation, it might be helpful to see a Pelvic Floor Physiotherapist. A consultation with a Pelvic Floor Physio will give the best information about how your body is now and it will allow you to get that strength and fitness back.
- Pelvic Floor Anatomy and Applied Physiology Varuna Raizada, M.D. and Ravinder K. Mittal, M.D. Gastroenterol Clin North Am. 2008 Sep; 37(3): 493–vii.
- Muscle Atrophy Induced by Mechanical Unloading: Mechanisms and Potential Countermeasures Yunfang Gao, Yasir Artat, Huiping Wang, Nandu Goswami Front. Physiol., 20 March 2018 | https://doi.org/10.3389/fphys.2018.00235
- Disease-Induced Skeletal Muscle Atrophy and Fatigue Scott K. Powers, Gordon S. Lynch, Kate T. Murphy, Michael B. Reid, and Inge Zijdewind Med Sci Sports Exerc. 2016 Nov; 48(11): 2307–2319.
- The Impact of Step Reduction on Muscle Health in Aging: Protein and Exercise as Countermeasures Sara Y. Oikawa, Tanya M. Holloway, and Stuart M. Phillips* Front Nutr. 2019; 6: 75.
- Pelvic Floor Muscle Function and Strength: https://www.physio-pedia.com/ Pelvic_Floor_Muscle_Function_and_Strength
Written by: Maryla Podgajny, Pelvic Floor Physiotherapist