“Under Pressure” - Breathing and the Pelvic Floor, Part 1
To make a long story short (& oversimplified), your pelvic floor relaxes as you inhale and it contracts as you exhale.
But let’s make a long story long and talk about what really happens…
To understand how your pelvic floor and beathing are related, we must first understand the anatomy. In the image below, you can see that what we traditionally think of as our “core,” is not just the abdominal muscles. It also includes the respiratory diaphragm (aka. diaphragm) and the pelvic diaphragm (aka. pelvic floor).
“Quiet breathing” is the type of breathing you don’t think about, unconscious breathing, and the type of breathing that happens while you are sleeping. When you are quiet breathing, as you inhale, the diaphragm contracts and pulls downwards. As you exhale, the diaphragm relaxes and goes back to its resting position. The diaphragm and the pelvic floor generally move in the same direction, at the same time. As you inhale the pelvic floor muscles lengthen (not necessarily “relax”), and as you exhale the pelvic floor muscles shorten (not necessarily “contract”). When you inhale as the diaphragm and the pelvic floor both move down, and vice versa an exhale.
However, during times of high pressure in your abdominal cavity (intra-abdominal pressure, aka. IAP), such as with exercise, coughing, sneezing, or straining (Valsalva), your pelvic floor muscles *should* contract to support the pelvic organs and prevent the sphincter muscles from opening. If the muscles are not able to close the sphincter muscles it could result in accidental urinary or fecal leakage. When you inhale and hold your breath (i.e. during weight lifting) or forcefully expel the air (i.e. during a hard cough), your abdominal pressure significantly increases. If this happens and you your pelvic floor and abdominal muscles are not prepared for the increase in IAP, it may cause injury to the muscles and even lead to pelvic organ prolapse or incontinence. If you already have these issues, your pelvic floor muscles may not be supportive enough due to weakness, incoordination, or incorrect bracing technique during high instances of IAP.
If that wasn’t already confusing, now I’ll throw you for a loop. This doesn’t mean that everyone should practice as many Kegels as possible or constantly keep their pelvic floor active. The opposite can also be true. If you are someone with overactive and stiff pelvic floor and abdominal muscles, it can impair the ability to use your diaphragm to breathe. This can be because your abdominal and pelvic floor muscles can’t relax to allow for a diaphragmatic breath. But remember, if you’re not properly using your diaphragm then your pelvic floor and abdominal muscles may continue to tighten. It can be a vicious cycle. This can also cause issues such as incontinence because the pelvic floor muscles are simply too stiff and stuck to effectively contract during high instances of IAP.
What does this mean for you? Well, in order to find out why you are having incontinence, pelvic organ prolapse, difficulty evacuating your bladder or bowels, or pelvic floor muscle tension issues, you must also think about how you are breathing and managing high IAP.
Try this: laying down on your back, try to relax your abdomen and pelvic floor muscles as you take a deep breath in through your nose. Which part of your body do you feel moving, your chest & shoulders or your stomach? It should be your stomach. Your belly should inflate and get bigger as you inhale and deflate and get smaller as you exhale. If you have trouble with this then you may have pelvic floor muscle tension/stiffness or incoordination.
Now try holding your breath while bearing down or straining, what happens to your stomach, do your stomach muscles bulge out or do they contract inwards and tense up? It should be that they contract inwards and tense up. Now try bearing down, WHILE you exhale through your nose. Can you bear down, exhale, and contract your abdominal muscles inwards all at the same time? Ideally you should be able to do that. If you can’t you may have trouble effectively managing IAP. Did you have any leakage when this happened? If so, you may have weak or uncoordinated pelvic floor muscles as well.
If you want to get better at coordinating your pelvic floor and diaphragm, I encourage you to try two breathing exercises at home. First, focusing on the inhale, take 10 deep breaths in through your nose while trying to lengthen your pelvic floor, then as you exhale just relax. Second, focusing on the exhale, complete another 10 breaths, as you exhale try to make sure your pelvic floor and abdomen are gently tensing up and contracting inwards towards your spine.
You may have noticed that this post is “part 1.” As you have probably learned, there is a lot more to breathing and the pelvic floor than you may have originally thought. This is a good starting point and can help you understand and lead discussions with your pelvic rehabilitation provider. I will be writing more about breathing and the pelvic floor in the future, so stay tuned.
As always, please email me at restorepelvicrehab.net if you have any questions.
x, Dr. Bethany
Citations:
Talasz H, Kremser C, Talasz HJ, Kofler M, Rudisch A. Breathing, (S)Training and the Pelvic Floor-A Basic Concept. Healthcare (Basel). 2022 Jun 2;10(6):1035. doi: 10.3390/healthcare10061035. PMID: 35742086; PMCID: PMC9222935.
