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Do you have weak pelvic floor muscles from cancer or cancer treatment? Guest physiotherapist Dr Esther Lim explains some of the common side effects of weak pelvic floor muscles, and shares a few simple pelvic floor exercises you can try at home.

Patients with weak pelvic floor muscles as a result of cancer or cancer treatment may experience side effects such as accidental urine leakage when they cough, sneeze, jump or run. They may even leak urine when bending forward to pick something up.

This type of urinary leakage is also called stress urinary incontinence (SUI). When patients experience SUI, it is a strong indication that there is weakness in the pelvic floor muscles. As the condition worsens, patients may stop exercising all together and even limit socialising for fear of accidental urine leakage.

Fortunately, there are ways patients can relieve symptoms, reduce discomfort, and improve their quality of life.

Pelvic floor rehabilitation

Pelvic floor rehabilitation is more than just ‘Kegels’. It is an individualised assessment of the patient’s core and pelvic stability, and how they relate to functional activities.

Part of rehabilitation includes an in-depth review of bladder and bowel habits, as well as sexual health. Special tests specific to the pelvic floor, hip and pelvis will be performed to further determine areas that need extra help. With that, the clinician will craft a unique treatment plan that includes the patient’s own rehabilitation goals.

Typical goals for patients undergoing pelvic floor rehabilitation include:

• Normalising bladder urgency, frequency and leaking
• Getting patients to perform functional tasks without symptoms
• Relieving constipation
• Getting patients to have sex without pain, and even achieve an orgasm

In my opinion, the number one goal of pelvic floor rehabilitation is awareness—these are muscle and bodily functions that are ‘out of sight’ and therefore ‘out of mind’.

Pelvic floor exercises: 3 things to know before you start

Patients with weak pelvic floor can strengthen their pelvic floor muscles with simple exercises that can be done at home.

Before starting these exercises, there are 3 things to know:

• Where
  

  Patients need to know where their pelvic floor muscles are. As simple as it sounds, most people do not know where their pelvic floor muscles are, and have no idea that they interact with it daily when they urinate or pass motion.

  Knowing where your pelvic floor muscles are is important as many patients have a hard time isolating the group of muscles. When asked to activate their pelvic floor muscles, many patients tend to activate every other muscle but the pelvic floor.

  As a pelvic health physiotherapist, I use visual tools such as a pelvic model, coloured diagrams, and even videos to orient my patients to their own anatomy. Since the pelvic floor muscles attach to boney and easily palpable landmarks such as the pubic symphysis in front, and the coccyx or the tailbone at the back, I sometimes start by getting patients to feel these landmarks with their fingers. Usually, patients can almost immediately discover that their pelvic floor is not a small muscle.

• What
  

  The pelvic floor plays a key role in everyday functions, such as:

  • Sexual function (maintaining an erection, achieving an orgasm)
  • Bowel and bladder function
  • Supporting your pelvic organs
  • Forming the base of your deep core muscles

  A pelvic floor muscle contraction can feel like a ‘squeeze’ or a ‘lift’. For females, this can feel like a tightening of the back, middle and front passage, as if stopping the flow of urine. For males, this can feel like a shortening of the penis, a lifting of the scrotum, and then closing of the back passage, as if stopping the flow of urine.

• Practise, practise, practise!
  

  It is important to practise your exercises with a trained professional such as a pelvic health physiotherapist. This is to correct common mistakes such as breath-holding, or using other muscles such as hip adductors, gluteal and abdominal muscles instead of the pelvic floor muscle itself.

  Keep in mind that 30% of women with pelvic floor dysfunction are not able to perform exercises correctly despite individual instruction¹. This shows that a ‘Kegel’ is notoriously difficult to master. It is therefore strongly recommended that you be evaluated by a trained professional.

Simple exercises to try at home

Pelvic floor muscles are made up of two types of muscle fibres: (1) 66% slow twitch, and (2) 34% fast twitch². Slow twitch fibres provide resting tone and thus support the pelvic organs. Fast twitch fibres are turned on with a sudden increase in intra-abdominal pressure, such as when you cough or sneeze. Exercising both slow and fast twitch fibres are required to strengthen the pelvic floor.

Endurance exercises - to improve strength and endurance

• Position: Lie on your back with your knees bent, or lie on your side. Make sure you are comfortable and relaxed so that you can focus on connecting with your pelvic floor muscles.
• Technique: Contract your pelvic floor muscles as if you are trying to stop the flow of urine or wind. Hold for 1-5 seconds.
• Relax for 5 seconds.
• Repeat 10 times.

Quick contractions - to improve power

• Position: Lie on your back with your knees bent, or lie on your side.
• Technique: Contract your pelvic floor muscles as if you are trying to stop the flow of urine, or wind as tightly as if you are trying to pick up a blueberry.
• Perform 10 of these maximal contractions as quickly as you can.

For beginners, I always start by getting them to lie down on their backs with their knees bent. In this position, the pelvic floor muscles do not have to work against gravity to contract.

A quick Google search of ‘Kegels’ or ‘pelvic floor exercises’ may yield pictures of women performing a bridge. I would advise against these exercises as they do not target the pelvic floor directly. Typically, I would only prescribe this exercise together with other hip exercises if the patient is struggling to isolate the pelvic floor.

How often to exercise your pelvic floor muscles

Patients can start exercises as often as 30 repetitions a day. That can mean 10 in the morning, 10 in the afternoon and 10 in the evening, or 30 in one go but with adequate rest between sets of 10 repetitions.

For certain patients, I may increase this to 60 repetitions a day. It depends on the individual and their condition.

Once symptoms subside, we can then talk about a tapering programme and also discuss how to incorporate pelvic floor exercises into their daily lives.

Pelvic floor exercises are not a quick fix solution to weak pelvic floor. It takes at least 6–8 weeks for muscles to increase hypertrophy or thicken. It may sometimes take up to 6 months of daily practice to see results. Even if you feel that the exercises are not helping, stay the course and keep up with your exercises.

¹ _{Bø, K., Larsen, S., Oseid, S., Kvarstein, B., Hagen, R., & Jørgensen, J. (1988). Knowledge about and ability to correct pelvic floor muscle exercises in women with urinary stress incontinence. Neurourol Urodyn, 7(3), 261-2.}

² _{Dimpfl, T., Jaeger, C., Mueller-Felber, W., Anthuber, C., Hirsch, A., Brandmaier, R., & Schuessler, B.(1998). Myogenic changes of the levator ani muscle in premenopausal women: the impact of vaginal delivery and age. Neurourology and urodynamics, 17(3), 197–205.https://doi.org/10.1002/(sici)1520-6777(1998)17:3<197::aid-nau4>3.0.co;2-8}