Pelvic floor and bladder health information and exercises for exercise teachers Functions of the Pelvic Floor The pelvic floor is the inferior and integral component of the abdominal wall. As such it forms an outlet for the pelvis for urination, defecation, enabling emptying of the bladder and bowel, and enables vaginal opening for childbirth. Contraction of the muscles enables the continence of urine and faeces. The pelvic floor also counteracts changes in abdominal pressure caused by coughing, sneezing, nose blowing, forced expiration and vomiting. Reflex activity enables rapid action when required. The conscious contraction of the pelvic floor can improve sexual enjoyment during penetrative sex. On the downside, some women experience involuntary excessive contraction of the pelvic floor prior to or during penetrative sex, prohibiting sexual intercourse, or making it very painful. This usually requires referral to specialist psychosexual services. A strong pelvic floor is also instrumental in preventing a ‘prolapse’. The muscles also support the contents of the pelvis and abdomen. Pelvic floor exercises are therefore a vital component of any fitness programme. Perhaps because results are not immediately evident, this area has, until recently, received comparatively little attention. One inhibiting factor for teachers may be the concept of naming the vagina, urethra and anus in a generally acceptable manner, and so the language and atmosphere for including the pelvic floor in a programme of exercise can make all the difference.

1. page 8 f i t p r o
Anatomy
The superficial pelvic floor muscles comprise the ‘figure
of eight’ muscles supporting the sphincters, and those
attaching the ‘figure of eight’ to the pelvis. Individually
they are ischio-cavernosus, transverse perineal, the
perineal body, bulbo-cavernosus, and the urethral and
anal sphincters
Deep Pelvic Floor Muscles
Deep pelvic floor muscles are collectively known as
Levator Ani. The origin of levator ani is the spine of
ischium and tendinous arch of the obturator fascia.
Their insertion is in the coccyx, the perineal body and
the fibres of muscle on the opposite side. The action of
the levator ani is to constrict the rectum and the vagina.
The individual levator ani muscles are the
ilio-coccygeus, ischio-coccygeus, pubo- coccygeus,
pubo-rectalis and the coccygeus. The coccygeus
muscle has its origin in the spine of the ischium
and it’s insertion in the sacrum and coccyx. The
action of the coccygeus is to pull the coccyx forwards
after defecation.
the pelvic floor & bladder:
a review
report: Barbara Hastings-Asatourian
Pelvic Floor Muscles (Viewed from below)
These are more clearly visible
when separated into two layers:
i.e. the muscles of the
Superficial and Deep Pelvic Floor.
Levator Ani Muscles (Viewed from below)

2. f i t p r o page 9
Functions of the Pelvic Floor
The pelvic floor is the inferior and integral component of the abdominal wall.
As such it forms an outlet for the pelvis for urination, defecation, enabling
emptying of the bladder and bowel, and enables vaginal opening for
childbirth. Contraction of the muscles enables the continence of urine
and faeces. The pelvic floor also counteracts changes in abdominal
pressure caused by coughing, sneezing, nose blowing, forced expiration
and vomiting. Reflex activity enables rapid action when required. The
conscious contraction of the pelvic floor can improve sexual enjoyment
during penetrative sex. On the downside, some women experience
involuntary excessive contraction of the pelvic floor prior to or during
penetrative sex, prohibiting sexual intercourse, or making it very painful.
This usually requires referral to specialist psychosexual services. A strong
pelvic floor is also instrumental in preventing a ‘prolapse’. The muscles also
support the contents of the pelvis and abdomen.
Pelvic floor exercises are therefore a vital component of any fitness
programme. Perhaps because results are not immediately evident,
this area has, until recently, received comparatively little attention. One
inhibiting factor for teachers may be the concept of naming the vagina,
urethra and anus in a generally acceptable manner, and so the language
and atmosphere for including the pelvic floor in a programme of exercise
can make all the difference.
A word of caution: all that goes wrong with the urinary system does not originate in the pelvic floor.
Advice offered therefore needs to be considered in that context (Overstall and Castleden 1998)
The Bladder
The bladder is made up of three layers of smooth muscle called the
detrusor. The urethra comprises both smooth and striated muscle.
The smooth muscle is continuous with the detrusor. The first striated muscle
fibres are slow twitch and are involved in maintaining continence at rest.
The second striated muscle is the peri-urethral part of levator ani, which is
separated from the external urethral sphincter. These are fast twitch and are
involved in maintaining continence under stress. The mucosa of the urethra
is lined by epithelium (skin cells). The structure of these epithelial cells is
under the influence of oestrogen, and therefore changes throughout the
lifecycle, particularly peri- and post-menopausally. Women approaching
or experiencing the effects of the menopause may find it reassuring that
their fitness leader is concerned about optimizing the function of the whole
body, including the bladder and urethra at this time.
Sometimes the problem is chronic urinary infection. But sometimes
apparently urinary symptoms are in fact caused by vaginal or cervical
infection. Some people have detrusor instability, others lose all bladder
control after illness or injury (reflex bladder). People on diuretics (‘water
tablets’) often complain of urge incontinence, and those who take too much
caffeine, fizzy drinks and alcohol may get bladder irritation. Whilst the role of
the fitness leader is not to diagnose, try to fix or assume any role for which
they have insufficient training, there is still essentially practical advice the
fitness leader could give at appropriate times that might save discomfort
later. Urine tests carried out via the General Practitioner or NHS walk in clinic
will quickly determine whether the problem is infection. Advice regarding
sufficient fluid intake and avoidance of irritants for re-hydration can prevent
considerable discomfort and complication. Demonstrating knowledge of the
options available reinforces that the problem is important and should be
taken seriously by early referral. Invariably, the earlier the treatment, the
more likely it is to be successful.
Stress incontinence
There are several proposed
theories of stress incontinence
(Monger and Phillips, 2000):
1. Bladder Neck Hypermobility,
where the neck of the bladder
falls below the pelvic floor
2. Intrinsic Sphincter Deficiency,
reduced urethral tone caused
by neuromuscular or vascular
insufficiency, for example from
reduced oestrogen levels,
radiotherapy or surgery.
3. Mid-urethral support:
the hammock hypothesis
Pubo-urethral ligaments support
the pelvic fascia, which forms
an aponeurotic plate over the
urethra. These ligaments
become continuous with the
ligaments of the clitoris. The
endopelvic fascia forms a
fibrous band running from the
pubis to the ischial spine.
When there is a rise in
intra-abdominal pressure,
continence is maintained by
compression of the urethra
against the anterior vaginal wall
and its endo-pelvic fascia.
This is attached to the levator
ani muscles. The levator ani
muscles have slow-twitch fibres
to maintain constant tone. At
rest levator ani contract
constantly, relaxing only during
emptying of the bowel and
bladder. This keeps the bladder
neck in position at rest.
Stress incontinence is brought
on by apparently unrelated
expulsive actions such as
coughing, sneezing and
laughing. It is only true stress
incontinence if its origin is in
a weakened or damaged pelvic
floor, and therefore affects
people physically, emotionally,
socially and sexually.
Barbara Hastings-Asatourian has had 26 years of experience since
first achieving her Bachelor of Nursing from Manchester University.
It’s now 21 years since she qualified as a midwife at Tameside
General Hospital, nearly 10 years since she gained her teaching
certificate from Huddersfield and began to work in Higher Education
teaching nurses, and 5 years since she achieved her M.Sc. from
Salford. Having since become a qualified exercise teacher, she has
been teaching ‘Heart and Soul’ her own holistic balance of aerobic
activity, mind/body conditioning and deep relaxation techniques.

3. possible. This is not impossible as
the exercises can be performed
anywhere and in any position:
standing, sitting, lying, at work,
during leisure time or during sex.
Regular pelvic floor exercises as
described above over a period of
several weeks after childbirth
should begin to have a positive
effect in weeks. In the event of little
or no improvement referral to a
physiotherapist may be required
and the addition of vaginal weights
or cones may then be taught
(Versi and Christmas 1998).
If there is no improvement referral
to urodynamics may then follow,
to assess if this is true stress
incontinence or detrusor muscle
instability (Overstall & Castleden
1998). Detrusor instability responds
to drug treatment, rather than pelvic
floor exercises. Sometimes
biofeedback at a specialist unit,
using video helps women to
identify and isolate contractions.
Imaging techniques (ultrasound
and MRI scanning) have also
helped understanding.
The problem may need to be
resolved by uro-gynaecological
surgery (Versi and Christmas 1998),
for example if there is a ‘prolapse’,
and if there is a weakness of the
vaginal walls (rectocoele or
cystocoele). Recovery from surgery
may be another area where
knowledge, information and a
planned approach to collaborative
care will improve the quality of
clients’ recovery period.
Finally the ‘information giving’ role
for the fitness industry can be
optimised through the gathering of
resources such as self help groups,
library resources, and web sites.
This information can be posted on
walls, noticeboards and Web sites,
for maximum exposure. Three
have been included below for
future reference.
References &
Organisations
The Continence Foundation has a telephone
help-line (020 7831 9831) which provides
information, leaflets, videos and a support
network. Their Web site address is:
www.continencefoundation.org.uk
For a detailed reference and recommended
reading list, send requests to Michelle
Roberts, Publishing Manager at the
Fitpro office.
page 10 f i t p r o
Causes
•Hormonal changes (menstrual cycle,
pregnancy, menopause)
•Pregnancy and childbirth (a long labour,
instrumental delivery e.g. forceps)
•Prolonged immobility, where
muscles are inactive and wastage occurs.
•Obesity, (leading to an increase in pressure
on the abdomen and its contents)
Stress incontinence caused by pregnancy
and childbirth
Surveys carried out over the last 10 years (Mori 1993, Mayne 1995, Marshall
1996 cited in Woodham 1998) are in agreement that about a quarter of new
mothers suffer from stress incontinence in the first 3 months of their baby’s
life, for some (estimated at 15%) this continues well into the first year.
Approximately 4% of new mothers suffer from faecal incontinence.
True stress incontinence benefits from pelvic floor exercises, when they are
performed regularly. The following is a routine that could be incorporated
into any exercise programme. A simple leaflet of this information with
diagrams will provide reinforcement to aid compliance with a regular
daily programme.
A Basic Pelvic Floor Exercise Routine
• Sit, stand or lie with legs slightly apart.
• Try to avoid clenching buttocks and thighs together as the pelvic floor
requires isolating from the gluteal and adductor muscles (Isolation takes practice and
may not happen at first).
• Try to relax the abdominal muscles at first, to feel the difference between superficial and
deep contractions.
• Breathe in to prepare, then breathe out to begin contracting.
• Pull up and close the urethra (front passage for urine)
• Extend this contraction to include the vagina (middle passage) breathing normally, not
holding the breath.
• Extend this contraction to include the anal sphincter (back passage). Breathing normally,
not holding the breath.
• Then relax.
• Alternatively, start by contracting back to front, to help isolate the sphincter muscles
from behind.
Using Visualisation Techniques
1.The Lift Visualising the pelvic floor on two levels, pull further upwards to the second floor
to engage the deeper pelvic floor muscles. Then relax.
2.The Flower Visualise the openings of the pelvic floor like flowers influenced by sunlight.
Imagine the pelvic floor tightening up like the head of a daisy at night, and then relax like
a flower opening in the midday sun.
To engage both fast and slow twitch fibres the routine should include slow
and fast rhythmic contractions. Play with the timing. Do 5 slow then 10 fast.
Build up the number and frequency, and then build into daily routine
(for life). Practise with different terminology until it becomes both comfortable
and fun.
Kitzinger (1978) describes several other variations of Pelvic Floor Exercises
for pregnancy and childbirth, Robinson et al (2000) provide three
visualization ideas to facilitate the process. Older literature may suggest
practising whilst passing urine, but this is no longer recommended as a
regular strengthening activity, since it may cause urinary reflux.It can,
however, be used occasionally in order to identify the pelvic floor.
Performing Pelvic Floor Exercises
The exercises above are sometimes referred to as Kegel exercises, after
the Californian doctor who described them. They are not useful if only
performed occasionally. They need to become part of life to ensure
maintenance of tone, preferably several times daily, as frequently as
•Obesity, (leading to an increase in
pressure on the abdomen and
it’s contents)
•Actions that cause persistent pressure
such as coughing (i.e., uncontrolled
asthma or chronic bronchitis)
or constipation.
•Occupations or leisure activities that
cause persistent pressure (e.g. athletics,
parachuting, standing work, heavy lifting)