Physiotherapy for Bladder Control

The Bladder

The bladder is a balloon shaped muscle, which stores urine. First sensation to empty the bladder should be at approximately 200mls. It should be possible to hold the urine comfortably to 350mls without having a strong urge to pass urine. The capacity of the bladder should be around 500mls. You should be able to walk to the toilet simply with a feeling of fullness and not feel like you have to run to get there with fear that you might leak.

As the bladder fills to capacity, it gives a sensation to pass urine. By tightening your pelvic floor muscles you should be able to delay the urge and postpone emptying the bladder until it is convenient. It is normal to empty your bladder 5-7 times in the day and once at night. There are a few different types of problems that can happen with the pelvic floor:

• Stress incontinence - this is loss of urine related to physical exertion e.g. cough and sneeze or activities of daily living or exercise.
  Download information on stress urinary incontinence
• Urgency - this is an increased sense of urge in the bladder often at low volumes of filling and related to triggers such as seeing the hall door or the toilet door.
  Download information on overactive bladder
• Urge incontinence - this is the urgency at low volumes of filling as above but this time not quite making it to the toilet in time.
• Frequency - this is going to the toilet too often i.e. more than the maximum of eight times in a 24 hour period.

PDF Infographic Download

What Every Women Should Know About Her Bladder

Where are the Pelvic Floor Muscles?

The pelvic floor muscles support the pelvic organs i.e. the bladder, uterus and rectum. These muscles should react automatically to close the bladder outlet when you cough or sneeze. During childbirth, muscles can be damaged and become ineffective resulting in loss of control at the bladder outlet. It is important to know that this can happen even if a woman hasn't given birth vaginally. In the diagram below, the pelvic floor muscles are in pink and can be shown to support the rectum, the uterus and the bladder.

The Pelvic Floor Exercise (Pelvic Floor Elevator)

Every one is different and needs an exercise programme to suit their individual needs. However, this is a good way to activate your muscles as you imagine your pelvic floor is like a lift and try to take the lift up and down to different floors.

• Sit comfortably on an upright chair, knees slightly apart.
• Breathe in deeply and then all the way out.
• Take the lift to the first floor by gently lifting your back passage up and forwards towards your bladder (be careful not to brace your tummy)
• As soon as you have tightened - resume normal breathing while you hold.
• Keep holding for 5 secs and build up to 10 secs.
• Release the muscle completely.
• Breathe in deeply and then all the way out.
• Take the lift to the second floor by contracting your back passage and water passage , as above.
• As soon as you have tightened - resume normal breathing while you hold.
• Next time contract the muscles and take the lift to the third floor.
• Repeat to each floor holding each repetition up to 10 seconds.
• Correct breathing and the ability to release the muscle COMPLETELY to the basement during the programme is very important.

In order to control the bladder and stop accidents you must increase the strength and endurance of the muscles.

• Aim to squeeze harder to take the lift higher.
• Aim to squeeze longer to hold the lift longer at each floor.
• Count how long you can hold for and how many times you can repeat the squeezes. This will enable you to know that you are increasing your exercise programme and improving your strength.
• Aim to hold for 10 seconds and do 10 repetitions as a guide.
• Include a set of fast squeezes in each set of exercises; tighten quickly and release quickly and repeat 10 times - this is to target your fast muscle fibres that will stop you from leaking when you cough)
• Do 10 of your 10 second holds and 10 of your fast contractions three times per day.
• Record your programme to see your progress. The Squeezy Ap is a good way to do this.

Once you have mastered these exercises use them when you need them. Practice holding the muscle and coughing to prevent a leak. This is called 'The Knack'.

Hold While You Cough 'The Knack'

Try to pull up your pelvic floor BEFORE you cough so that it is protected and giving support from below. This is called 'The Knack'. The knack is the most important technique for you to use if you are coughing.

Activities, such as coughing or sneezing increase the intraabdominal pressure, and therefore the downwards pressure on the pelvic floor. Ongoing episodes of coughing may lead to an exacerbation of leakage of urine (stress incontinence), a feeling of heaviness in the vaginal passage (related to prolapse) or lack of control of wind from the back passage. This will be particularly challenging for an already weakened pelvic floor. Many factors contribute to this weakened pelvic floor including child birth, menopausal changes, ongoing heavy lifting and chronic straining to pass a bowel movement.

The first challenge is to connect with your pelvic floor muscles and see if you can feel them working.

• Sit in an upright position with your rib cage over your pelvis and the weight equally distributed through both sit bones.
• Breathe normally. Focus on the muscles connecting from your back passage upwards and forwards to your bladder.
• Just before you cough pull up your pelvic floor muscles. It is the timing of this contraction that is important.

This will help to support the neck of the bladder so that you do not leak, the pelvic organs do not descend and you do not pass wind. All of these take practice but once mastered, should become an automatic reaction to help protect your pelvic floor with coughing or sneezing. If you feel that you cannot control the downwards force, try to support your perineal area with counter pressure from your hand or a small towel roll as you cough.

Repeated coughing can be very tiring, not very effective in clearing your chest and can put downwards strain on the pelvic floor. If you have a chronic respiratory condition or have recently developed a cough please use the techniques above every time.

The Abdominal Muscles (Transversus Abdominis )

The deep muscles of your abdomen support your spine and pelvic floor. These supporting muscles provide a "girdle of strength" around your pelvis and work for long periods of time.

They work most effectively when the pelvis is held in the natural 'neutral' position. To be more effective in doing your exercises aim to find this neutral position. Imagine a compass on your lower abdomen, the navel is north and pubic bone is south. Your pelvic bones are east and west. In neutral, the line between the pubic and pelvic bones remains horizontal. Start your exercise with your pelvis in this position whether you are lying, sitting or standing.

• The abdominal muscles are easiest to find in side lying with the tummy relaxed. Check your pelvis is in neutral whether in lying, sitting or standing.
• Slowly and gently draw in the lower abdominal muscles as if bringing your tummy button towards your spine or think of bringing your hip bones together or pulling your lower tummy away from the zip of your trousers. Don't brace or force your tummy and don't move the spine or pelvis.
• Keep breathing and hold the muscle for at least 10 seconds. Using this abdominal muscle can help you find your pelvic floor muscle. It is not easy to find the pelvic floor muscles and it can take a lot of time and concentration.

NB Bracing the tummy is incorrect; this technique is gentle and slow and the tummy should not bulge out. This slow contraction of the deep abdominal muscle will help a pelvic floor contraction but bracing and forcing will not. It is important to know that over-holding of the abdominal muscles can be part of the problem with bladder overactivity. It is important to release the abdominal muscles as well to ensure correct activation.

Posture

When your posture is correct you will look and feel better. It also enables you to improve the control over the pelvic floor for longer periods of time e.g. when out for a walk.

• Hold your head up but not your chin.
• Lift your breast bone and keep your neck long.
• Breathe down low.
• Keep your pelvis in the neutral position.
• Keep your knees straight, not locked.
• Keep your weight back a little towards your heels.

Bladder Retraining for Urgency or Urge Incontinence

For people who have problems making it to the toilet in time, simple bladder retraining can improve your symptoms. Urge incontinence is due to over-activity of the bladder muscle or nerves. It gives a sensation of urgency to pass urine and you may not reach the toilet in time. Having to get up more than once a night is common.

An average person can hold 400 to 500mls of fluid and passes urine five to eight times in a 24 hour period. When you have a problem with urgency it is usually due to a disturbance in the reflexes of the bladder or reduced bladder size. The bladder gives off strong messages that it wants to empty and you find it difficult to stop the reflex, the bladder squeezes and the pelvic floor is not strong enough to resist it.

To retrain your bladder, when you feel the urge to go to the toilet during the day try and hold on for a few minutes longer than you normally would before passing urine. Try not to rush to the toilet at the point when your urge is strongest (see diagram). Use the techniques below to practice holding. It can be very difficult at first and seem impossible.

What To Do:

• Stand still or sit down. Sitting and leaning forward is best.
• Press on your pelvic floor muscles underneath and hold the pressure for as long as it takes for the urge to subside.
• If you can't sit - stand up on your toes for a long as it takes for the contraction to subside (this helps settle the reflexes).
• Breathe in a regular pattern.
• Don't brace your stomach.
• Tighten your pelvic floor muscles gently.
• Think of something else other than the toilet - distract yourself, Give yourself a small task to do e.g. check your text messages.
• When the urge subsides you can then walk calmly to the toilet.

Urge Curve

Points To Remember

• Don't go to the toilet "just in case". Learn to take control of your bladder and have confidence.
• Use your muscles when you need them and exercise them regularly.
• The more control you need, the harder you must squeeze - but don't brace!
• Drink 1.5 litres of water a day.
• Avoid large quantities of alcohol, avoid tea and coffee, fizzy drinks and alcohol.
• Watch your weight; being overweight can put a further strain on your muscles.
• Avoid constipation and straining by taking extra fibre in your diet.
• It may take up to 3-5 months to train the muscles and as much as a year.
• Improvements can happen much sooner ie as soon as you change your habits.
• You can always insert two fingers into the vagina to see if you are doing the exercise correctly and for the male press your fingers on the perineum behind the scrotum.
• Keep up your exercises for life - use it or lose it!

Medication

If the urge is too severe then talk to your doctor about medication. You should practice these techniques in conjunction with the drug therapy. Bladder retraining may also be used for someone who has an over stretched bladder.

Bladder Diary

Your doctor, physiotherapist or nurse continence advisor may ask you to fill out a bladder record chart or bladder diary. This is a record of your fluid intake, the amount of fluid passed and episodes of leakage daily. This gives a lot of information about the minimum and the maximum amount of fluid the bladder can hold, types of fluids you are drinking, whether they are irritating the bladder, the number of times you are going to the toilet daily and the different patterns that you have established. This chart will be used to help you and your advisor understand and retrain your bladder.

There is more information available on www.oab.ie and you can download bladder diaries from this website.

Download information on Bladder retraining

Physiotherapy for Bowel Control

The food that we eat passes through the stomach and is digested in the small intestine. Nutrients are absorbed and the remaining waste moves in to the colon. In the colon, water is absorbed and the faeces should become more solid.

When faeces reach the lower part of the bowel - the rectum, there should be a feeling of fullness in the bowel and the urge to pass a bowel motion. This feeling is reliant on the nerves in the rectal area sending a message to the brain.

Our pelvic floor muscles (the puborectalis muscle), and back passage (the anal sphincter muscle), allow us to control where and when we empty our bowels. We need to feel in control of our bowels rather than our bowels in control of us. Normal bowel control depends on many factors including the integrity and strength of the internal (passive) and external (active) sphincter muscles.

The internal anal sphincter is responsible for around 80% of the resting pressure of the back passage. We can compensate for reduced resting pressure by training the active component of the sphincter muscle.

Loss of bowel control is called anal incontinence and is described as the involuntary loss of faeces (faecal incontinence) or wind (flatus incontinence). It is not uncommon for people with anal incontinence to experience some symptoms of urinary incontinence also.

Approximately 1 in 10 people have a problem controlling their bowels. This can affect both men and women and does tend to increase with age.

Symptoms that may be related to anal incontinence are:

• Passive faecal soiling without a sensation of needing to empty the bowel.
• Faecal urgency ie. not able to hold on / having to immediately pass a bowel motion.
• Uncontrolled flatulence (wind).
• Feeling of incomplete bowel evacuation.
• Difficulty wiping / cleaning after a bowel motion.

Causes of anal incontinence are:

• Damage to the pelvic floor muscles, nerves and connective tissue during childbirth.
• An extensive tear in the anal sphincter muscle during childbirth.
• Spinal lesions.
• Neurological disease eg. Multiple Sclerosis.
• Irritable bowel disease causing excessively loose stool.
• If the rectum is blocked with severe constipation this can cause a stretch on the rectal tissue leading to incontinence from around the impacted stool.
• Constipation can cause a loose sphincter due to straining over a long period of time.
• Environmental factors such as limited mobility or access to a toilet.

What To Do If You Are Not In Control Of Your Bowels?

Management of anal incontinence is a team approach and may involve the GP in the first place, a colorectal surgeon, a dietician, a physiotherapist and of course, the patient. The initial physiotherapy visit should involve a detailed history of the nature of the symptoms and possibly completion of a bowel diary. This gives the team an idea of the pattern of your bowels over a period of time. A thorough physical examination should include evaluation of the muscles of the pelvic floor. A specialist clinic may also use anorectal manometry, pudendal nerve testing, defaecating proctograms, colonic transit studies or MRI.

Physiotherapy Management of Anal Incontinence May Include:

• Assessment of the pelvic floor musculature.
• Evaluation of the way you currently empty your bowels and correction as necessary.
• Detailed discussion of bowel habit and lifestyle.
• Education in reasons for anal incontinence.
• Specific pelvic floor exercise program.
• Biofeedback - to show you how you are currently using your muscles and allow you to improve your technique.
• Electrical stimulation - to get the muscles working if they are extremely weak.
• Sensation - improving your awareness of both the contents of your rectum and what your muscles are doing.
• Manual therapy of the pelvic floor muscles or surrounding joints as needed.
• Rectal irrigation

Goals In Bowel Management:

• Hold on for a short time after you feel the first urge to go to the toilet.
• Allow time to get there and remove clothing without any accidental loss of faeces.
• Pass a bowel motion within about a minute of sitting down on the toilet.
• Pass a bowel motion easily and without pain - ideally, you shouldn't be straining on the toilet or struggling to pass a bowel motion which is hard and dry.
• Completely empty your bowel when you pass a motion.

Where Are The Sphincter Muscles?

The back passage, or anus, consists of two rings of muscles, the internal and external sphincter muscles. The internal sphincter muscle should be closed at all times except when you are trying to pass a bowel motion. At this point, it relaxes and allows faeces to enter the top part of the anal canal.

The external anal sphincter muscle is a band of muscle that is under voluntary control ie. we should be able to tighten the external sphincter band to control gas and faeces. The external sphincter muscle must be strong enough to push the bowel motion back up into the rectum to hold until in an appropriate place to defaecate. Control and timing are important. Like any other muscle in the body, it we don't use it, we lose it!

External Anal Sphincter Muscle Exercises

• Sit or lie with your knees hip width apart. Think of the circle of the sphincter muscle and try to tighten the circle inwards and upwards as if you were trying to stop yourself passing wind. Do not let your buttocks, thighs, abdominals or even your shoulders move or lift.
• Count how many seconds you can hold it for (aim for 5-10 secs) and then release the muscle fully. Keep breathing as you hold the muscle tight.
• Repeat this 10 times, 3 times during the day.
• Gradually increase how many seconds you can hold the muscle.
• It is also important to recruit the fast muscle fibres - pull up the whole circlular sphincter as tight as possible. Don't bring in your thighs or abdominals and do not hold your breath. Tighten and then release COMPLETELY.
• Repeat 10 times 3 times during the day in addition to the endurance exercise above.

Any pelvic floor muscles can take time to strengthen. It is important to do exercises regularly to build on muscle strength and endurance. It can take 3-5 months before you see results and you may continue to see results over a year.

It is possible to check if this muscle is working by using your finger in the sphincter to feel the squeeze.

If you sit on a rolled up face cloth or small towel when you feel a bowel motion coming, try to hold for a few seconds with your sphincter muscle and then go to the toilet when you are in control of your bowels and your bowels are not in control of you!

If you are uncertain about your exercises or how to do them, please consult a Chartered Physiotherapist specialised in Pelvic Health

Other Defecation Disorders

Anal Incontinence is not the only thing that can go wrong with the bowels. The other common disorders are:

• Anismus - the sphincter muscles are too tight to allow the bowels to empty. There can be pain and bowel movements can be obstructed.
• Haemorrhoids and fissures - these can be acute or present over a long period of time causing pain with defecation.
• Constipation - this requires a multidisciplinary approach. It can lead to pain and haemorrhoids and fissures. It may be related to many factors , including diet and stress, and is often tied in with a tight puborectalis muscle. Breathing can be dysfunctional.
• Rectal prolapse - excessive pushing can cause the rectal tissue to come down.

Downtraining of the pelvic floor muscles is the most important physiotherapy approach with these conditions. A Chartered Physiotherapist can help you to identify whether you have muscles that need to be released rather than strengthened.

Pelvic Pain Women

Chronic Pelvic Pain refers to pain in the lower part of the abdomen, pelvis or pelvic floor. It is pain that has lasted for six months or longer. It can be a symptom of another disease, or a condition in its own right. The cause can often be hard to find. A full multidisciplinary team approach is always required in treatment of chronic pain. This will include any or all of - the gynaecologist, urogynaecologist, colorectal team, urologist, anaesthetist, clinical nurse specialist, dietician, psychologist and physiotherapist. The physiotherapy approach is described with each of the conditions below.

Bladder Pain Syndrome

Bladder Pain Syndrome may include a diagnosis of Interstitial Cystitis. The diagnosis is based on the presence of pain related to the bladder, usually accompanied by frequency and urgency of urine and in the absence of other diseases that could cause the symptoms.

In response to the pain, bladder urgency and frequency, the pelvic floor muscles and abdomen can become tense going into a holding pattern. This tension becomes part of the problem further feeding into the holding patterns and pain cycle.

Physiotherapy will help with calming the muscles, nerves and reflexes associated with this pain and will help with retraining the bladder.

Vaginismus

Vaginismus is described as a condition where the pelvic floor muscles have become so tense that the use of tampons or attempted penetration is very painful or impossible. The reaction or withdrawal from penetration of any kind may be as a result of previous experience of pain. Therefore vaginismus will almost always be as a result of some other underlying condition, as described below.

Hypertonic or Overactive Pelvic Floor

Hypertonic pelvic floor describes the resting position or tone of the pelvic floor muscles. Normal tone in muscles will mean that when squeezing and releasing the pelvic floor there is an ability to feel the activation of the muscles as well as the relaxation. It helps to visualise an elevator; squeeze up to the 6 th floor and release down to the basement.

Usually with hypertonic pelvic floor it is impossible to feel this release. Often the nerves around the entrance to the vagina have become involved in this tension pattern. Physiotherapy treatment will always be to teach methods of relaxation and release of the pelvic floor muscles.

Vulvodynia

When involvement of the superficial tissue and nerves is the main problem, then pain presents as a burning around the vaginal entrance or around the labia. This may be called vulvodynia which simply means pain in the vulval area.

Vestibulodynia describes pain in a specific area of the vaginal entrance called the vestibule, this may be pain in general around the vulva or may be termed provoked vestibulodynia which describes pain on touch only. Typically the skin is very sensitised.

Vestibulodynia may present with or without a hypertonic pelvic floor as previously described. There can be an overlap between the two. Vulval pain can persist even though the tone in the muscles is no longer high. This means that the 'elevator' is working better with control from the 6 th floor to the basement but unfortunately the pain persists.

The approach to this condition is always multidimensional with the involvement of the GP, gynaecologist and physiotherapist and often with the anaesthetist. Long term presence will often need the help of a psychologist. Care of the skin, desensitisation, pelvic floor relaxation, postural and general musculoskeletal education as well as practical advice all form part of the physiotherapy approach.

Pudendal neuralgia

Disorders that involve compression or restriction in mobility of the pudendal nerve along its pathway are called pudendal neuralgia. Where the nerve is truly entrapped it may be diagnosed as an entrapment, however this is quite rare. Sometimes the pudendal nerve is involved in chronic pelvic pain conditions and sometimes it is diagnosed as such but is not the main cause of the pain. The cause is often unknown.

Endometriosis

The diagnosis of Endometriosis is usually after confirmation by laparoscopy. Before this diagnosis is ever made the pelvic floor muscles may already have settled in to a pattern of dysfunction. The behaviour of the muscles may be as described as above under the section of Hypertonic Pelvic Floor. Often bowel symptoms are present too and because the bowel descends on the left side restrictions on this side are more common. This is treated similarly to other pelvic floor dysfunctions as above.

Menopause

One of the distressing symptoms of menopause is the genito-urinary symptoms of menopause (GSM). Bladder urgency, bladder frequency, itch and pain with sexual activity are all a feature. Using local vaginal oestrogen is vital to address these symptoms. However pelvic floor physiotherapy in parallel can help bladder and bowel dysfunctions and any associated sexual pains.

Pain after surgery

Rarely, a person can develop pain after a surgical procedure. Sometimes the musculoskeletal system is involved. The diagnosis of a pain condition is often a process of elimination and one of the systems that needs to be eliminated is the musculoskeletal system.

This means that there may be tension with muscle or other soft tissue (fascial) restrictions in the area of the pain. These are treated by addressing postural, pelvic and spinal movement dysfunctions as well as using manual therapy to the areas of restriction and progressing to rehabilitation. Ultimately, the goal is to restore normal movement and function to all muscle groups and the nervous system in general.

Other pain conditions are:

• Urethral pain syndrome
• Constipation and rectal pain
• Anismus - pain with defecation

They all have the same treatment approach

There is more information available on these conditions on the following websites:

• Vulval Pain Society - www.vulvalpainsociety.org
• National Vulvodynia Association - www.nva.org
• International Society for the Study of Vulvar Disease - www.issvd.org
• Pudendal Hope - www.pudendalhope.info
• Vulvovaginal Disorders - www.vulvodynia.com

For more help with any of these conditions contact the Irish Society of Chartered Physiotherapists at ISCP.ie or phone 01 4022148 and they will provide you with a list of Chartered Physiotherapists working either in the HSE or in Private Practice.

Pelvic Organ Prolapse

Pelvic organ prolapse is usually (but not always) a consequence of childbirth. It may happen as a result of chronic straining as well. It occurs at a rate of approximately 30% in the general female population.

How Does it Manifest?

Prolapse through the vagina can be of any of the following:

• Urethrocele - prolapse of the urethra through the vagina
• Cystocele - prolapse of the bladder through the vagina
• Uterine Prolapse - rolapse of the uterus through the vagina
• Rectocele - prolapse of the rectum through the vagina

The rectum can also prolapse through the back passage (rectal prolapse).

Types of Prolapse

Prolapses are staged according to how far they come down. Stage II (two) is the most common and this is where the part comes down as far as or even to 1 cm just outside the entrance to the vagina. This measurement is on straining (Valsalva manoeuvre). Typically prolapses behave differently depending on the time of day and on what is in the bladder and in the bowel.

The pelvic floor muscles may be weak as a result of damage to part of the pelvic floor. The remaining muscles then become overloaded as a result of the damage to the neighbouring muscle. This is in part because of how hard the muscles have to work in compensation and in part because of how the woman holds herself in response to the feeling of something coming down.

Rehabilitation involves postural alignment, addressing diet, releasing any negative pelvic floor muscle tension and intensive strength training.

Please see pelvic floor exercises on the Bladder Control tab above.

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Pelvic Organ Prolapse

Physiotherapy for Male Bladder Control

Where are the Pelvic Floor Muscles?

The pelvic floor is a sheet of muscle and connective tissue (fascia) stretched across the floor of the pelvis. On the outside this is known as the perineum which is the area between the base of the penis and the back passage (anus). The pelvic floor muscles stretch from the pubic bone at the front to the coccyx behind, and out to the bones that you sit on. There is an extra ring of muscle around the back passage (anal sphincter), which is important for bowel control. Men also have two other sphincters that help to prevent urine leakage. One is at the base of the bladder and the other just underneath the prostate gland.

Why do the exercises?

After surgery, whether prostatectomy or TURP (transurethral resection of prostate) the pelvic floor musculature and nerve supply can be affected. Men may suffer from stress incontinence i.e. leaking urine on coughing, lifting, rising from a chair etc. Other symptoms after surgery may include urge incontinence, an urgent need to pass urine, with leaking on the way to the toilet and/or erectile dysfunction (difficulty achieving and maintaining an erection).

Symptoms may include:

• Urinary leakage during activities such as coughing, laughing, sneezing or during sporting activity.
• Urinary leakage from sitting to standing.
• A sudden feeling that you need to rush to the toilet, or leaking on the way to the toilet.
• Anal incontinence which is leakage of stool (faeces) or difficulty in controlling wind.
• Post-micturition dribble (leakage of a few drops of urine after you have finished passing urine).
• Erectile dysfunction.
• Premature ejaculation.

How to do the exercises?

Pelvic floor exercises may help these symptoms after interventions for prostate cancer but ideally the exercises should be started before you have surgery and resumed after your operation, once the urinary catheter has been removed. You should not attempt to perform the exercises while your catheter is still in place.

Pelvic floor muscle exercises can be done lying on your back with your knees bent and apart and your feet flat on the ground. They can also be done while you are sitting or standing.

To perform pelvic floor muscle exercises:

• Relax your abdominals. Gently lift up on the inside, drawing your testicles up towards your bladder or your navel. You should see a slight lift of your testicles and the penis pulls back and inwards. Then let go. Completely.
• Place one of your fingers directly behind the scrotum and in front of the anus and feel that the area is soft. Keep some pressure on. Lift up as described above and you should feel it becoming firmer if the muscle is contracting. Now relax it completely and feel the difference again.
• Squeeze as if to stop the flow of urine mid-stream.
• It may be beneficial, if you are unsure, for your physiotherapist to test the muscles internally.
• Belly Flop: Do not let the abdominals contract / brace / flatten when you are lifting the pelvic floor. Practice flopping out your tummy. Gently breathe into your tummy it make it relax.
• Breathing: Never chest lift or draw breath in when you are squeezing. Never puff out when you are letting go. The pelvic floor muscle squeeze should be in isolation and the release should be in isolation. When you are good enough to hold for 10 seconds you can keep breathing gently while you hold.

All of the above areas should be contracting at the same time, and there should be no movement or tilt of your pelvis when you are performing the exercises. Do not brace or harden your abdominal (tummy) muscles. Pelvic floor muscle exercises should not include active contraction of your buttock muscles or the muscles of your inner thighs. You can assess whether you are doing the exercises correctly by looking at the movement of the pelvic floor muscles. This is best done with a hand mirror while reclining on the bed.

How much and how many?

• Sigh out gently. Slowly engage the pelvic floor muscles to 50%. Without changing your breathing hold this for 5 seconds. Let go completely. Do 10 reps.
• Sigh out gently. Slowly engage the pelvic floor muscles to 50% and hold it there with gentle breathing for up to 10 seconds. Let go completely. Do 10 reps.
• Sigh out gently. Relax the abdominals. Rapid onset squeeze to 100% and rapid release all the way down. Release completely. Do 10-15 reps.
• Sight out gently. Relax the abdominals. Squeeze up to 100% effort. Let it drop down to 30-50%. Keep it there for 5-10 seconds. Keep breathing gently. You may need to fire again as it slips down under 30%. Do 10 - 15 reps.

Target a total of 60 - 90 GOOD reps per day over three sessions. Mix it up any way you like. Bad reps don't count!

• Practice in lying / side lying / sitting / standing.
• Tighten your pelvic floor muscles before and during any activity that makes you leak e.g. coughing, sneezing, lifting, rising from sitting, so that with practice this will become an automatic reaction.
• After urinating, tighten your pelvic floor muscles strongly to empty the last drops out. This may help to stop "after dribble."
• If you are sexually active, tighten your pelvic floor muscles during intercourse to maintain the quality of your erection.
• Urge control techniques - you learn to suppress the urge to urinate by doing the pelvic floor muscle contractions as well as using a number of distraction techniques.
• Postural awareness and control - pelvic muscles work more effectively when you are sitting upright as opposed to slumping or slouching.

If you practise your pelvic floor muscle exercises as above, you should notice an improvement in 3 months. It is important that you continue with your exercises even if they do not seem to be helping. Further advice is available from a chartered physiotherapist.

Urologic Chronic Pelvic Pain in Men

Chronic pelvic pain in men can be a painful debilitating condition. There are many cases where it is related to posture and hypertonic or overactive pelvic floor muscles.

It presents in young and middle aged men at a prevalence rate of approximately 6%. It can either be associated with an initial episode of prostatitis or mistaken for and treated as chronic prostatitis where there is no response to antibiotics and other Urology tests are negative. Quality of life is almost always affected.

Symptoms May Be:

• Rectal pain
• Perineal pain to behind the pubic bone
• Pain to the tip of the penis
• Lower abdominal pain
• Pain increased with either bladder emptying or bowel movements
• Bladder frequency and / or urgency
• Incomplete bowel evacuation
• Decreased sexual desire / arousal
• Pain worse with or after erection or ejaculation
• Associated lumbar spine, hip an inner thigh pain
• Pain often worse with sitting but not always

How Do We Help?

We assess the following addressing the cause and making changes to behaviour, lifestyle and patterns of movement. Uring manual therapy and devising comprehensive exercise programs forms a key part of this treatment.

• Spinal posture and alignment
• Spinal and pelvic and lower limb positions and range of movement
• Seating
• Abdominal holding patterns
• Breathing patterns
• Pelvic floor muscle tension, the ability to contract and ability to release

Much of the focus is on down training the pelvic floor rather than strengthening, which can often make the problems worse.

For more help with any of these conditions contact the Irish Society of Chartered Physiotherapists at ISCP.ie or phone 01 4022148 and they will provide you with a list of Chartered Physiotherapists working either in the HSE or in Private Practice.