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The pelvic floor: can Kegel exercises be counterproductive?

The main reasons for seeing a pelvic floor specialist are urinary incontinence problems, discomfort during sexual intercourse or scar pain after childbirth. Thanks to a change in mentality due to cultural growth, access to information and their wish to be healthy, more and more women turn to their physiotherapist to solve their pelvic floor problems. They are nonconformist women who seek to improve the quality of their life.

To find out more about this topic, that is relatively unknown to a large part of our society, we have interviewed Maria Carmen Carrillo Leal. She is a specialised physiotherapist in pelviperineology (pelvic floor rehabilitation) and director of the CIFIP, the first centre in Alicante (Spain) that is specialised in pelvi-perineal rehabilitation.

What exactly is the pelvic floor and where is it located?

The pelvic floor is the set of muscles and fascial tissue found in the lower part of the pelvis and supports the pelvic visceral organs, anal canal, vagina and urethra. Therefore, it plays a key role in urination, defecation, sexual relations and is part of the birth canal.

Physiotherapists call it the pelvic diaphragm or perineum since it is not a flat, rigid floor but a set of muscles and ligaments in the shape of a vault that supports the viscera.

What pathologies can the pelvic floor present?

The pathologies related to the pelvic floor can be divided into two main groups. On the one hand, all those related to the weakness of the pelvic floor muscles, such as urinary incontinency, prolapse, diastasis or distal constipation. On the other hand, those that are related to the excessive tone of the perineal musculature.

The perineum, like any other muscle in the body, can contract. These contractions can cause pain during sexual relations, pain from sitting on the coccyx or pain from abdominal scars (caesarean section) or perineal scars (episiotomy).

The appearance of any symptom is an alarm signal that a woman should visit a specialist, no matter how minor the issues seem.

How can it affect daily life?

The quality of life of these patients gets worse. Many women avoid certain exercises because of the fear of urinary incontinence. Others avoid drinking liquids when they leave the house or find the exact location of public toilets on their route.

In those cases where pain affects sexual relations, the symptoms might also affect the relationship with the partner. Or when abdominal diastasis occurs, the belly does not regain its shape and firmness. The woman feels like her body is not what it used to be, which can lead to insecurity.

In my experience, I can say that all the women that come to my consult have one thing in common: they have a nonconformist mentality. I love it when I ask them about their objectives for coming to pelvic floor rehabilitation and they respond: “I want to be myself again and feel good”.

How can the pelvic floor be treated before, during and after the pregnancy?

The pregnancy is the perfect moment to prevent all possible pelvic floor dysfunctions.

Ideally, a pelvic-abdominal assessment by a physiotherapist should be performed after the first trimester. From that moment on, if any dysfunction is found, work will be done to maintain the body’s well-being and to avoid urinary incontinence, diastasis, pains such as sciatica, low back pain or costal pain. If everything is satisfactory in this assessment, it is recommended to do exercises adapted to the pregnancy.

After giving birth, the focus is re-education. This means that if the mother doesn’t have urine leakage, scar pain or pain during sexual intercourse, a plan can be made to recover the abdominal and perineal muscle.

If one of these alarm signals appears, rehabilitation should be carried out.

What physical activities are recommended to improve the pelvic floor?

Every person should be able to execute any type of exercise, because exercising is healthy. The key is to know how to do this exercise.

There are sports that are less harmful, such as hypopressive exercises, which are highly recommended during postpartum.

There are other exercises that are considered impact exercises, such as running or weight lifting. From my point of view, the importance lies in whether the exercise is done in a hyperpressive and therefore harmful way. The best way to work is to work on the abdominal-pelvic synergy. Thus, in addition to training, it also helps to strengthen the perineal muscle.

I recommend carrying out an individual assessment by a physiotherapist to check the correct functioning of the pelvic floor and the transverse of the abdomen.

What is the abdominal-pelvic synergy?

The abdominal-pelvic synergy is the involuntary contraction of the deep musculature, pelvic floor and deep transverse abdomen. Before coughing, sneezing or jumping, this musculature contracts. There are three population groups that can lose this synergy: people with lower back pain, abdominal surgeries and pregnant women.

Therefore, it is essential to re-educate this synergy before the woman returns to high-intensity sports. In the classes that we offer in our centre, this is our objective.

Do you think there is a change in mentality in today’s society regarding the treatment of the pelvic floor?

Without a doubt. Cultural growth, access to information and their wish to be healthy have a great influence on this change. The patients that come to my practice are very different, both in mentality as in the physical symptoms they experience.

Is the use of pelvic floor strengthening materials (Kegel balls) and the well-known Kegel exercises recommended for everyone?

In physiotherapy, we avoid generalising treatments and universal norms. As we discussed before, ideally an individual assessment is carried out to see if the use of Kegel balls is appropriate for the specific patient.

A simple example: if a woman inserts a Kegel ball and it falls out again, this shows that she should not use this again before rehabilitation. Similarly, for women experiencing pelvic pain, the pubococcygeus muscle contraction exercises (Kegel exercises) would be contradicted and it is recommended to see a professional.

How do you see the future of specialised perineal physiotherapy?

I am grateful for this question and I hope to read this interview in a few years’ time and see that the answer is a reality.

In my opinion, there should be specialised centres for pelvic floors where anyone, man or woman, can go to consult their doubts or symptoms and where they are attended from a multidisciplinary approach. Health professionals complement each other, and the patient benefits from the joint vision and the teamwork.

Above all, I firmly believe that health professionals accompany the patient when the symptoms appear, but it is the patient herself that should make the decision to start the process towards getting better and to make her own decisions.