It`s easy to see how important this muscle is and yet, amazingly

A STRONG
PELVIC
FLOOR
HOW NURS ES CAN SPRE AD THE WOR D
T
he pelvic floor contains muscles that
support continence, sexual functioning,
childbirth and more. Yet, few people even
know these muscles exist or how important they are
to overall health and well-being. This article explains in
detail the anatomy, functions and importance of the pelvic floor musculature (PFM) and how nurses can educate
and empower women of all ages about its important role
in many aspects of their health and well-being. Accompanying this article is a patient education page with
specific instructions on how to exercise the PFM.
Kelli Berzuk, BMR-PT, CAFCI,
Melb Physiotherapist
PGCertPhysio(Cnt&PlvFlr Rehab)-Uni
Female pelvis illustration: Peter Cull
/ Photo Researchers, Inc.
Anatomy and Functions of the PFM
In the pelvis, there are muscles that when healthy
and strong, silently do their job, allowing us to go
about our lives and activities without interruption
(see Box 1 for functions of the PFM). Anatomically,
this area of musculature can be considered a sling
that attaches at the coccyx, posteriorly, and into the
pubic bones, anteriorly, forming the base of the pelvis. The term PFM refers to the deeper layer known
as the pelvic diaphragm, as well as the more superficial layer, the urogenital diaphragm.
The pelvic diaphragm, also referred to as the levator ani muscle, consists of three muscles: the pubococcygeus muscle that assists the urinary sphincter,
the ileococcygeus muscle that is responsible for supporting the vagina and the puborectalis muscle that
assists the anal sphincter. The pelvic diaphragm is a
striated muscle and attaches to the arcuate tendon as
well as the anterior, posterior and lateral aspects of
the lower pelvis and sacrum.
The urogenital diaphragm is often called the perineum and is responsible for supporting the pelvic organs and assisting in sexual function. This diaphragm
consists of the transverse perineal, bulbospongiosus
and ischiocavernosus muscles. The urogenital diaphragm, like the pelvic diaphragm, consists of striated muscle that attaches to the symphysis pubis, pubic
rami, perineal body and ischial tuberosities.
The urogenital diaphragm interdigitates via fascia and connective tissue with the pelvic diaphragm
and, therefore, as a unit, constitutes the PFM. The
diaphragms are further connected via the external
Box 1
Functions of the PFM
Supports pelvic organs
Involved in sexual sensation and satisfaction
Aids in childbirth
Supports proper closure of urethral and anal
sphincters
urinary sphincter embedded in the urogenital diaphragm and crossing to the pelvic diaphragm. The
muscles of the PFM, as well as the external urinary
and anal sphincters, are innervated by the voluntary
nervous system from S2 and S3 nerve roots via the
pudendal nerves, allowing contraction and relaxation of this striated muscle. The smooth muscle of
the bladder and urethra, bowel and rectum, and internal urinary and anal sphincters are innervated by
the autonomic nervous system via nerve roots from
T11, T12, L1, S2, S3, and S4.
The PFM wraps around the urethral and rectal
openings in both women and men, and the vagina in
women. If you picture its position proximity, and integration with the internal pelvic organs, we begin to
see the functions it must sustain. The PFM holds the
great responsibility of preventing urinary and fecal
leakage, increasing sexual satisfaction and supporting internal organs. A weakened or injured PFM may
no longer effectively close off the urethral and rectal
openings, and urinary and fecal incontinence may
result. Laxity or weakness in the PFM may lead to
a decrease in sexual sensation and appreciation, and
weakness or injury to the PFM can allow the pelvic
organs, such as the bladder, uterus, rectum and intestines, to fall downward instead of supporting them
in their proper positions.
It’s easy to see how important this muscle is and
yet, amazingly, most people do absolutely nothing
to ensure its good health. The PFM is an extremely
underrated and often neglected area of the body, but,
fortunately, it’s also quite resilient and forgiving. It’s
often injured as a result of pregnancy, vaginal delivery, the strain of chronic coughing or chronic constipation, or being overweight. However, it generally
only requires a small amount of consideration and
proper exercise for this muscle to respond positively (see accompanying Patient Page for step-by-step
instructions on how to exercise the PFM). The following sections discuss the functions of the PFM in
greater detail.
Supportive Function
Kelli Berzuk BMR-PT, CAFCI, PGCertPhysio(Cnt&PlvFlr
Rehab)-Uni Melb Physiotherapist, is the director and physiotherapist at IPPC-Incontinence & Pelvic Pain Clinic in
Winnipeg, Manitoba, Canada. She is the author of the book
I Laughed So Hard I Peed My Pants! A Woman’s Essential
Guide for Improved Bladder Control.
DOI: 10.1111/j.1751-486X.2007.00118.x
56
In 2004, a study in the Netherlands found that 40 percent of the general female population ages 45 to 85
had significant pelvic organ prolapse (POP) (Sliekerten Hove, Vierhout, Bloembergen, & Schoenmaker,
2004). For some women, POP may result in simply a
mild pressure on their perineum resembling a familiar
sensation often noted during pregnancy or prior to
© 2007, AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
Volume 11
Issue 1
It’s easy to see how important this muscle is and yet,
amazingly, most people do absolutely nothing to
ensure its good health.
menstruation, whereas others report significant low
back pain, pain with intercourse or difficulty with
heavy lifts or prolonged standing. POP often interferes with complete bladder and bowel emptying as
the organs are unable to function maximally. This
may lead to urinary tract infection or constipation.
The Dutch study also noted that the presence of POP
is related to poor pelvic floor coordination and that
this is likely to be the cause of the prolapse (Sliekerten Hove et al., 2004).
There’s an analogy that often helps patients understand the role of the PFM in prevention of POP as well
as in stopping the progression of an already present
prolapse. Think of a boat floating in water and being
tied up onto docks on either side. When the water
level is high, the ropes will be slack with no tension
placed on them; however, as the water level drops, the
ropes become taut and must bear the weight of the
boat. If the water level continues to remain low, the
tension on the ropes will build and stretch the ropes.
The ropes may even snap. Now think of the boat as a
bladder or vagina (the prolapsing pelvic organ), and
the ropes would be the connective tissue or endopelvic fascia. The water represents the PFM. When this
area is strong and healthy, it will support the pelvic
organs and reduce the tension on the connective tissue. An unhealthy and weakened PFM won’t support
the pelvic organs effectively, and strain on the connective tissue will lead to a downward plunge of the
organ and, over time, significant POP.
Sexual Function
Bulbospongiosus and ischiocavernosus muscles of
the urogenital diaphragm assist clitoral stimulation,
while the pubococcygeus sits deeper in the PFM,
within the pelvic diaphragm, and is important for
vaginal sensation. When the PFM is healthy, it leads
to an improvement in sexual function by increasing
sexual sensation, appreciation and satisfaction. The
healthier the muscle and the more active it is, the
better its blood flow and oxygen delivery, thereby increasing sensation and awareness of the area.
February
March 2007
It’s important to understand that all muscles require
good strength, but to be healthy, a muscle also must
have the ability to properly relax. A healthy PFM will
be able to relax during intercourse as well as contract
effectively when appropriate in order to heighten the
sexual experience, often for both partners.
Muscle spasm in the PFM can cause intense pelvic
pain. Just as we hold our tension in our neck and shoulder muscles and myofascial pain syndromes can result,
so can the PFM develop tightness, muscle spasm and
trigger points with active pain referral patterns. This
can cause devastating effects on sexual function. According to the International Pelvic Pain Society (IPPS),
chronic pelvic pain (CPP) is one of the most commonly reported medical problems reported by women, and
90 percent of CPP patients have pain with intercourse
(IPPS, 2006). In patients with CPP, assessment and
treatment of the PFM should not be overlooked, as
hypertonus of the PFM may produce or exacerbate
vaginal, bladder and rectal pain disorders.
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Nursing for Women’s Health
57
Childbirth
The PFM also plays an integral role during childbirth. The healthier the PFM, the more able it will
be to assist in vaginal delivery instead of hindering
progression. When this muscle is strengthened and
prepared for pregnancy and delivery, it will not only
decrease the likelihood of being injured in the process but will also assist in a smooth and safe delivery.
A healthy muscle is better able to support the weight
of the fetus during the pregnancy and then aids in
turning the baby’s head during the birth. Finally, a
healthy muscle is able to fully relax when the baby is
ready to emerge, rather than fighting the final stages
of delivery.
Most women do very little, if anything, to prepare
their PFM for the stresses of pregnancy and delivery,
When the PFM is healthy,
it leads to an improvement
in sexual function by
increasing sexual sensation,
appreciation and satisfaction.
and are unprepared for the resulting impairments to
the muscle, which are often noted in the postpartum
period. People would fully understand that a marathon runner would experience injury if she ran the
race with unprepared muscles. Yet women are often
surprised to experience PFM injury following vaginal
delivery when this muscle has not been strengthened
for this exhausting and demanding workout, often
the biggest challenge it will ever face. This muscle
was meant to carry and deliver babies; however, it
needs consideration both pre- and postpartum for
preparation and rehabilitation. Some women falsely
believe that PFM-strengthening exercises may prolong vaginal labor, but research does not support
this. In fact, a Norwegian study found that there was
even a slight decrease in the second stage of labor
among women intensively training their PFM compared with controls (Morkved & Salvesen, 2004).
Sphincteric Function
Perhaps the most widely acknowledged function of
the PFM is proper closure to the urethral and anal
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Nursing for Women’s Health
sphincters. If the PFM is not strong enough, it will
not effectively close off these openings, and bladder
and/or bowel incontinence (flatus and fecal) may result. The striated muscles of importance for continence include the pelvic and urogenital diaphragms
and the external urethral and anal sphincters. It’s
also important to confirm proper function of the obturator internus and hip adductor muscles as their
insertions include the arcuate tendon and pubic
rami, respectively, and may influence function of the
urogenital and pelvic diaphragms.
According to the National Association For Continence (NAFC), 25 million Americans suffer from urinary incontinence (NAFC, 2006). The Mayo Clinic
estimates that 50 percent of American women experience urinary incontinence at some point in their
lifetime (Mayo Clinic, 2002). As for bowel control, a
household survey revealed that 6.9 percent of adult
women and 7.4 percent of adult men are affected by
minor fecal incontinence in the United States (International Foundation for Functional Gastrointestinal
Disorders, Inc., 2006).
Incontinence is preventable, treatable and often
curable. But because of ubiquitous advertisements
for bladder control products, many women believe
the loss of bladder function is a normal and expected
part of aging. But continence pads are simply a bandage on the problem. While it’s important for patients
to protect themselves and to use continence garments
when necessary, treating the underlying causes of the
incontinence, such as a weakened PFM, is vital.
Many women are unaware that treatment is available or do not seek help due to embarrassment; yet,
most women can be treated and dramatically improve
their situation, often resolving their symptoms.
PFM Weakness Can Affect Teens, Too
Urinary incontinence is not only a problem for adult
women. A study of 144 nulliparous, female athletes
ages 18 to 21 showed that 28 percent experienced
urinary incontinence. The breakdown according to
sport specificity was as follows: 67 percent of gymnasts, 66 percent of basketball players, 50 percent of
tennis players, 42 percent of field hockey players, 10
percent of swimmers, 9 percent of volleyball players, 6 percent of softball players and zero percent of
golfers were incontinent. Interestingly, 40 percent of
the incontinent female athletes reported urine leakage while involved in a high school sport and 17
percent already had problems during a junior high
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Issue 1
Box 2
Benefits of Exercising the PFM
Increased blood flow and oxygen saturation
Development of muscle memory
Improved muscle contraction
Better sphinctal closure
sport (Nygaard, Thompson, Svengalis, & Albright,
1994).
Reasons to Exercise the PFM
There are several benefits to exercising and strengthening the PFM (see Box 2). First is the increase in
vascularity. Proper blood flow to a muscle promotes
oxygen delivery leading to a healthier, more-fit muscle. Another benefit is the development of muscle
memory. Every time a message is passed from nerve
to muscle, a memory of this occurs. This passage of
information at the neuromuscular junction increases in efficiency with use. This is very important in
producing a fluid and rapid response between the
message being sent, and reaction of muscle contraction. This is a critical factor when we require rapid
response of PFM contraction to sudden increase in
intra-abdominal pressure, such as with a sneeze.
Also, over time, motor unit recruitment increases
with regular exercise. A muscle is made up of many
small motor units. As muscle endurance and strength
improve, a resultant increase in the number of motor
units activated will be noted, as well as firing in a
more coordinated fashion. This is very important in
producing a good quality muscle contraction.
Finally, following months of diligent exercise, the
muscle will produce a bulking effect by producing
an increase in size of muscle fiber diameter. This
translates into an overall hypertrophy of the PFM
and is important especially during the hormonal
changes of menopause. As estrogen production depletes, the diameter of the urethral sphincter opening
will increase and atrophy. Hypertrophy of the PFM,
subsequent to exercise, assists in better closure of
the urethral sphincter. Overall, proper exercise routines produce a more efficient and healthier muscle
contraction.
February
March 2007
It’s important to not only have a PFM with good
quantity strength and endurance, but also to recognize that the subtle improvements in the quality of
the contraction, the speed at which the PFM reacts,
the efficiency with which it fully and effectively closes around the urethral sphincter, and overall coordination of the muscle all work together to support
urethral closure.
Most women do very little,
if anything, to prepare
their PFM for the stresses
of pregnancy and delivery,
and are unprepared for the
resulting impairments
to the muscle.
Implications for Nurses
Familiarity with the PFM and its extremely important functions should convince nurses first of a personal need to exercise this muscle and second to ensure that patients are receiving the information that
they need to understand the role their PFM plays in
their overall health and well-being. The first step is
to identify patients at risk of the consequences of a
weakened PFM (see Box 3).
Nurses who care for women during the prenatal
period have an opportunity to advise women during pregnancy of the new challenges that are being
placed on their perineum and pelvic organs caused
by an increase in weight and hormone-induced
ligament laxity. Nurses can inform these women
Nursing for Women’s Health
59
Box 3
Questions to Ask Patients
Asking patients the following questions can help
identify those at risk for the consequences of a
weakened PFM:
• Do you refrain from laughing wholeheartedly?
• Do you worry about leaking while you laugh?
• Do you cross your legs when you sneeze?
• Do you have trouble holding back gas?
• Do you know the location of every bathroom
around you and in your neighborhood?
• Do you use the bathroom more than nine times
in a day and one time during the night?
• Do you leak urine when you cough, sneeze or
exercise?
• Do you often have a strong urge to void?
• Do you race your children to the bathroom?
• Do you need to reposition yourself on a chair
until the feeling of urgency passes, and then
race to the bathroom?
• Does your bladder seem to be contracting as
you pull up on your driveway or just as you get
your key in the door?
• Would you think twice before jumping on a
trampoline or skipping rope with your children?
• Would you need to run to the bathroom first, or
put on a pad, or would you just tell your kids
that “Mommies don’t jump on trampolines”?
• Do you use the bathroom “just in case” every
time you’re about to leave the house, even if
you just went half an hour ago?
• Have you altered any physical or social activities
because of your bladder?
• Do you just feel that things are not the same
as they used to be, your bladder is more finicky
or your pelvic floor does not feel as toned as it
did before you had your babies?
Patients answering yes to any of these questions
may be experiencing urinary dysfunction or the early
warning signs of a PFM that needs attention and
strengthening.
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Nursing for Women’s Health
about how to avoid problems of POP, sexual dysfunction and pain, and bladder and bowel incontinence
later in life by encouraging them to locate their muscle and begin a healthy exercise routine. At this stage
in life, women notice the many changes that occur
in their bodies and are often very receptive to information regarding the personal transformations they
are witnessing. It’s important to remind them that
if the PFM is strong and healthy going into childbirth, it will be better able to assist in vaginal delivery rather than hinder progression and increase risk
of injury.
During delivery nurses are often the patient’s advocate. It’s important to take note of what a patient’s
pelvic floor is doing and to remind women to relax
this muscle during the end stages of delivery. It may
be beneficial to use perineal massage to further relax
this muscle. When a woman has been strengthening
her PFM prepartum, she’ll be that much more aware
and able to relax this muscle at will.
Nurses who care for women in the postpartum
period can remind them that following vaginal
delivery, exercises should begin very gradually and
gently to improve blood flow to the region and improve oxygen delivery and healing to the traumatized
tissues. Some women may need a reminder to maintain this exercise regime as their lives will be busier
than ever before. Nurses have the benefit of knowing how much damage their pelvic floor sustained
during the labor, for example, if forceps were necessary or if significant tearing occurred. Even though
new moms are exhausted and rarely thinking about
themselves at this point, nurses can offer them a
gift by taking the time to discuss the injury and
trauma their PFM endured and its need for proper
rehabilitation.
Neglecting this muscle may not present immediate problems with pelvic floor function; however, the
next cold with intense coughing, the next baby, the
subsequent years of straining with chronic constipation or even the hormonal changes of menopause
may be the final straw. Women need to be impressed
with the knowledge that incontinence, POP and sexual pain and dysfunction are very real and extremely
common and that caring for this muscle now is an
investment that may prevent them from ever knowing these problems.
At our clinic, we hear women ask repeatedly why
they weren’t warned to exercise this muscle after
Volume 11
Issue 1
they had their babies, especially those who had difficult deliveries. Women who had planned cesarean
sections with no labor sometimes feel that they’ve
avoided trauma to their PFM and muscle rehabilitation is not required. This is not necessarily the case,
as we see PFM dysfunction in nulliparous women
and also because their PFM carried the weight of
their baby throughout the pregnancy.
Information about a healthy pelvic floor is important for women of all ages and for the nurses who
care for them. And it’s never too late. Even when
women have finished family planning or have never
experienced pregnancy, pelvic floor strengthening
remains very important. We know that the hormonal changes of menopause bring about another challenge to bladder control, and women need to be proactive in fighting this battle. I’ve had the great pleasure of working with many elderly women who have
often suffered with urinary incontinence for decades.
Simple diet and lifestyle alterations combined with a
proper PFM-strengthening program made significant
improvements for women of all ages and all stages of
bladder dysfunction.
Get the Facts
American Physical Therapy Association (APTA)
1-800-999-APTA
http://www.apta.org
Canadian Continence Foundation
1-800-265-9575
http://www.continence-fdn.ca
I Laughed So Hard I Peed My Pants! A Woman’s
Essential Guide for Improved Bladder Control
http://www.ilaughedsohard.com
International Continence Society (ICS)
http://www.icsoffice.org
IPPC Incontinence & Pelvic Pain Clinic (Canada)
(204) 982-9178
Conclusions
Knowledge is power, and motivation can bring about
amazing changes. Please help to spread the word to
the women in your life—your patients, your mothers, your daughters, your sisters and your friends.
Make sure they’re aware of the importance of a
healthy PFM and what they can do to ensure its good
health. NWH
References
International Foundation for Functional Gastrointestinal
Disorders, Inc. (2006). Prevalence of bowel incontinence.
Retrieved April 24, 2006, from http://www.aboutincontinence.org/prevalence.html
Morkved, S., & Salvesen, K. A. (2004). Does pelvic floor
muscle training during pregnancy have an effect on labour?
Neurourology and Urodynamics, 23(5/6), 410–411.
International Pelvic Pain Society. (2006). Chronic pelvic pain:
A patient education booklet. Retrieved May 13, 2006, from
http://www.pelvicpain.org/patientbooklet.asp
National Association For Continence (NAFC). (2006). National Association For Continence (NAFC) Web site home
page. Retrieved May 16, 2006, from http://www.nafc.org/
Mayo Clinic. (2002). What is urinary Incontinence? Retrieved
June 9, 2002, from http://www.mayoclinic.com/findinformation/conditioncenters/invoke.cfm?objectid = 256654C2-9
Nygaard, I. E., Thompson, F. L., Svengalis, S. L., & Albright,
J. P. (1994). Urinary incontinence in elite nulliparous athletes. Obstetrics and Gynecology, 84(2), 183–187.
Morin, M., Bourbonnais, D., Gravel, D., Dumoulin, C., &
Lemieux, M-C. (2004). Pelvic floor muscle function in continent and stress urinary incontinent women using dynamometric measurements. Neurourology and Urodynamics,
23(7), 668–674.
Slieker-ten Hove, M. C. P., Vierhout, M., Bloembergen, H., &
Schoenmaker, G. (2004). Distribution of pelvic organ prolapse (POP) in the general population: Prevalence, severity,
etiology and relation with the function of the pelvic floor muscles. Neurourology and Urodynamics, 23(5/6), 401–402.
February
March 2007
Nursing for Women’s Health
61
Exercises for
a Strong Pelvic Floor
Patient
Page
a
A strong pelvic floor is integral to continence, childbirth, and sexual satisfaction. Exercises to strengthen the pelvic floor
muscles (PFM) involve isolating, contracting, holding, and releasing these muscles.
Step 1: Positioning
• When first starting out, do your exercises while lying on your back with your knees bent, supported with pillows. It’s
important to take the time to develop a proper technique, and lying down in a quiet room will help you to focus on
contracting the correct muscle. Lying down will also make your exercises easier since you won’t have to work against
the pull of gravity and the weight of your pelvic organs that rest on the PFM.
• Once you’re comfortable with your exercises in a lying position and need to challenge your muscle further, progress
to sitting (sometimes it helps to use a hard chair), then to standing, and finally to exercising while walking.
Step 2: Isolating Your PFM
• Begin by isolating the PFM. To do so, relax your stomach (abdominals), bum cheeks (gluteal muscles), and legs (hip
adductors) as much as possible so that you’re sure it’s the PFM that you’re contracting. Your body should not move
when you contract your PFM.
• Pull “up and in” with your pelvic floor. Imagine that you’re trying to stop urinating or are holding in gas while
standing in a crowded elevator.
• It’s fine to occasionally try to “stop your pee” while voiding on the toilet so that you can see if you’re isolating the
correct muscle. (Note: This should only be done as a test; routinely stopping and starting urine flow while voiding
can lead to serious problems, including increased risk for urinary tract infections). You may want to practice this
once a week, first to help locate the PFM, and later to note an increase in muscle strength when you’re able to hold
back the urine flow more easily.
Step 3: Contracting and Releasing
• Contract the PFM and hold for 5 seconds, then rest for 10 seconds. Repeat 5 times. Now contract the PFM for
1 second and relax for 1 second. Repeat 5 times. (Contracting for different lengths of time works the different
muscle fibers found in the PFM). This is considered 1 set of exercise and should take you approximately 1 minute to
complete. Try to complete 10 sets each day.
Helpful Tips
• Don’t forget to breathe! Counting out loud might help.
• It’s normal for your PFM to fatigue quickly. That’s why
these exercises incorporate twice as much rest time
for each contraction.
• Spread your sets throughout the day and don’t try
to contract an already exhausted muscle. Try to do
3 sets in the morning, 4 sets in the afternoon and 3
sets in the evening. Remember, it’s better to do fewer
exercises properly than to do more improperly.
• Incorporate your PFM exercises into your regular
day-to-day activities, so that the exercises are less
intrusive to your busy lifestyle. This also ensures that
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the PFM is able to work in all positions and can hold
the bladder shut when you need it to.
• If you’re pregnant or considering becoming pregnant,
develop good PFM exercise habits prior to delivery.
This ensures that your PFM will be healthy and strong
and will assist, rather than hinder, your delivery. Plus,
if you’re familiar with your PFM, you’ll be able to
gently contract the PFM after birth to promote better
blood flow and healing in this area. And if you’re
already doing exercises regularly before the birth of
your baby, it will be that much easier to continue after
you bring your baby home.
Volume 11
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