Sunday, July 14, 2013

Bored with Kegels? Well, I've got a workout for you!

Does this sound like you?

"Yes, I tried kegels after I had a baby... they didn't seem to help much. I still do them at stoplights occasionally."

We can do better than this, ladies! And this blog is about why we need to.

The wonderful pelvic floor.

This set of muscles, collectively referred to as the levator ani, can do some amazing things. (For an anatomical reference that will blow your mind, check out Pelvic Guru's Ultimate Pelvic Anatomy Resource.) They sometimes get pigeonholed as the "muscles that stop the flow of urine". What a shame! Check out this list of what these muscles can actually do.
  • Avoid leaking with coughing, sneezing, jumping, and lifting.
  • Hold back gas when you're in an elevator.
  • Suppress your urge so you don't have to do the "pee-pee dance" on the way to the bathroom.
  • Stop the flow of urine when needed.
  • Support the bladder, uterus, and colon so that they don't fall down into the vaginal area and possibly even cause the wall of the vagina to protrude from the vaginal opening.
  • Ease your ability to have a bowel movement. 
  • Improve your posture and trunk strength.
Now that list should make you want to start that kegel program again, right??

But wait!

When working on your pelvic strength, it's really important to remember that we're not only trying to get these muscles to be strong, but we want them to function efficiently, quickly, with endurance, with coordination, and with the ability to completely relax. And yes, that can take a little more effort than 5 quick flicks at a stop light... especially if you're already having issues with any of this stuff already.

Here are some of the finer points of what we need to ask of our pelvic floor:

We need quick, efficient squeezing with quick, thorough relaxing. Why? Because sneezes happen in a hurry. We need these muscles to be able to jump in and work in a pinch! Sometimes we tend to think of the things that happen inside the pelvis as magical and mystical and have a "I think I'm doing it??" attitude as we inch our pelvic floor up to a contraction that we hope is correct. Imagine if your biceps worked like that! Imagine having to concentrate and focus attention in order to get a not-so-confident, SLOW contraction. It would take forever to get enough food to your mouth to eat a meal! Well, guess what - our pelvic floor is the same type of muscle as our biceps and we should be able to control it just as well and with the same level of confidence. If we can do that, then we can run a load of laundry up the stairs and sneeze... or jump rope... or jump on a trampoline with your kids... without any problems.

We need these exercises to work for longer than just a little flicker. Some activities take a little longer than that. To use your pelvic floor for extra support while you're picking up something heavy would certainly require more than just a quick contraction. Being able to pull that support up and in and then maintain it while you do the strenuous task can certainly be a good skill to have!

The pelvic floor kind of has psychology of its own. You know how the muscles in your neck and shoulders get tight when you're stressed or anxious? Well, the pelvic floor does the same thing... and studies have shown that the pelvic floor actually responds faster than the upper trapezius (shoulders/neck area) to perceived threats! These muscles can hold tension and make things not work as well as they're supposed to. Part of this group, a muscle called the puborectalis, is actually a muscle that acts as hook, to keep the rectum closed by pulling it forward. That muscle is actually one that has to RELAX in order to allow your bowels to empty properly. So, if your pelvic floor is staying tense and guarded, constipation might be an issue you experience that can be treated by learning how to relax your pelvic floor! It's the same thing with having difficulty starting a stream of urine... the pelvic floor has to be able to turn off so that things can flow through it. When doing your pelvic floor exercises, make sure you pay just as much attention to the relaxation of the muscles as you do the squeezing.

This is possibly the most awesome of all the pelvic floor functions. Your bladder (the muscle surrounding your bladder, actually) and the pelvic floor muscles have a great way of communicating. Whenever your bladder muscle squeezes, it creates the sensation of an urge and the way that your pelvic floor responds to it by relaxing. Why? So that urine can pass through. Makes sense, right? You have an urge and your pelvic floor says "Go ahead! Empty! I won't stand in your way!". The problem, of course, is when this happens at an inopportune time. So here's the really cool feature we have built in. If you do your pelvic floor squeeze as soon as you feel the urge, it can communicate back to your bladder "back off! not yet!". Seriously, how cool is that? Not only does our pelvic floor provide support, sphincteric (tube squeezing) control, and sexual pleasure, but it's also like a walkie talkie to our overzealous bladder.

One of the things we need from our pelvic floor is good resting tone. This basically means that we need to have good bulk of our pelvic floor even when it's relaxed. Think of working out for muscle definition in your legs. You don't only want that muscle bulk or definition while you're lifting weights. You also want it while you're just walking around. The same is true for the pelvic floor. We need it to be a really strong hammock to support the uterus, the bladder, and the rectum ALL THE TIME. We certainly don't want to try to walk around with our pelvic floor constantly contracted in order to provide support because that can cause another set of problems (pain, constipation, difficulty starting a flow of urine, and sexual dysfunction).

Before we get to the fun part, first I want to say that if sexual pain is something you deal with, the relaxation part of the pelvic floor function might be what you need. Not only can a tight/short pelvic floor cause pain on it's own but that pain can be made worse when you are trying to have sex. Bummer. Also, the thing with "the pelvic floor has a psychology of it's own"... well, anticipating pain with sex from a previous experience where sex was painful can cause the pelvic floor to guard and try to protect itself, which, as you might have figured out, can also cause more pain with sex. So, relaxing the pelvic floor can fix these issues as well. Granted, if you have a short, tight pelvic floor, "just relaxing" is harder that it sounds. You might need some help from a pelvic PT (see below for how to find one).

Now for the more fun stuff. The pelvic floor muscles are the ones that pulls of the walls of your vagina in closer during penetration. The excellent part of this is that it brings the front part of your vagina (the g-spot, or the back part of the clitoris... however you want to assign it) into a spot where it gets better stimulation. Woo hoo!! Regardless of if you have vaginal orgasms or not, this can be a lovely addition for sexual pleasure.

For a functional exercise program that is decidedly more fun than sitting at a stoplight doing a few quick flick squeezes, do these during sex! If you have a male partner, his "pressure gauge" can usually detect the changes in your ability to squeeze over time and you can feel like you're making progress based on his feedback. If you don't have a partner, or your partner is a woman, you can still get a good idea of what your muscles can do either by her feedback, what you can feel on your own, or on how tightly you can grip a dildo (especially one that has a slightly larger head).

For overachievers, here's a fun game to further challenge your coordination and your ability to control your lift and your drop:
  • When you're having sex, slow things down.
  • Whenever you are being thrusted into, relax completely.
  • When the pulling out occurs, pull up and in as tightly as you can.
  • Repeat.
This creates a milking type phenomenon that can be a lot of fun to practice. It gives a lovely on and off compression stimulation for you while being pretty cool for the one doing the thrusting. Plus, you can really challenge your control and coordination by trying to keep up at faster speeds! Oh, the fun we can have when we're creative with our workouts!

While we're on the sex topic, let me address "vaginal rejuvenation" for a moment. There are some surgical procedures that women elect to have done to change the shape or size of their labia. There is also a procedure that involves removing part of the back wall of the vagina and then stitching it back up so that the opening is "tighter". The "tightness" we're after in sex does not come from having our soft tissue shortened... it's the muscular gripping that we can get with the pelvic floor muscles that's the good stuff. The opening needs to stay relaxed and able to allow entry (which can become problematic after some of these surgeries) and then our internal muscle tone is what's going to do the trick! And the best part, is that when you have control over how tight your vagina can be, it can be blissful for both you and your partner. Surgical intervention can create scar tissue and nerve damage that can make sex less pleasurable for women. Ugh!

I've heard many different ways of teaching this contraction. The key for any of the methods is understanding that you actually want a LIFT not really a SQUEEZE. Here's the way I like the best.

Imagine you have a marble at the opening of your vagina (or anus). Without moving your pelvis, back, or tummy, vacuum that marble up into your vagina (or anus). Hold it as long as you can (up to about 10 sec) and then relax. If when you relaxed, you noticed that nothing happened, then you probably let your contraction fade without realizing it. Try a shorter period of time and try to re-engage (think "lift, lift, lift" instead of "hold, hold, hold").  Figure out how long you can hold a true lift while getting a full relaxation at the end and let that be your starting point and build up to 10 sec. Remember to lift straight up, hold at the top and then drop it back down quickly (or aim for that ability if it's difficult at first).

It is also great to practice quick flicks, but the key to those is not just to squeeze fast and furious at the top of your range, but to lift as strong as you can and then drop (relax) thoroughly as quickly as you can. The quick flicks only count if you go through the entire range of what your muscle can do.

Your goal is to be so stealthy that you can can carry on a conversation without anyone knowing you're doing a contraction. Be a pelvic floor ninja! Don't let any tummy squeeze, leg shake, butt squeeze, breath holding, toe curling or eyebrow raising show what you're actually doing inside your pelvis.

Go Pelvic Ninjas!!
If you try to do these squeezes and you find you are unable or are really unsure if you're doing the right thing, or you're having some of the dysfunctions mentioned in this blog, I'd highly recommend going to see a pelvic physical therapist. They can help you with all of the above. If you need to know where to find one in the USA, try checking out the American Physical Therapy Association's Section on Women's Health. At the left side of the page, there's a "FIND A WOMEN'S HEALTH PT" button. I would like to point out that pelvic PT's see men for incontinence, pain, and weakness issues as well (hopefully one day they'll actually stop just calling it "women's health"). 

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