The Trainer’s Guide to Pelvic Floor Dysfunction

There are health and fitness professionals that train the pelvic floor muscles with the same enthusiasm that a bro does biceps. Unless you’re in the niche of women’s health, this level of zeal about the levator ani and coccygeus is overkill. Although, the pelvic floor still deserves some attention if your role is to guide people towards better health and fitness.  

That’s because a good training plan is about more than a beach body. It should also include accessory work to fight off injury and illness, and training the pelvic floor can dramatically improve wellness and livelihood over a lifetime. Furthermore, pelvic floor issues can affect a person’s ability and desire to work out, which is pertinent to personalizing and guiding workout programs.

Despite its importance, the pelvic floor gets little attention in general exercise science curriculums. Hopefully, this article will get the ball rolling and provide the fundamental knowledge that every trainer or strength coach needs on the topic.

What is the Pelvic Floor?

Notice the bowl shape of the pelvis and the hollow cavity that it forms. Lower in the pelvis, in a space called the lesser pelvis, are things like the colon, rectum, bladder, and sex organs. Then, the greater pelvis sits directly above, surrounded by the ilium walls, which houses the intestines.  

It’s a useful structure for both supporting and protecting the internal organs, but it needs some help to keep everything from falling out the bottom. That’s where the pelvic floor comes into play.

The pelvic floor has three layers of muscles running from the pubic bone and back towards the tailbone. It creates a hammock that closes off the bottom of the pelvic bowl to keep the internal organs supported. They also control the openings to let stuff go out, commonly referred to as number 1 and number 2, and play an important role when things go in (ahem…sex.)

Like other muscles, these muscles can be too tight or too loose, which can cause problems that we’ll cover next.

Pelvic Floor Dysfunction

Women are the usual suspect when it comes to problems with the pelvic floor. 1 in 4 women will report major pelvic floor issues (ref), and about 20% of women require surgery to correct problems with their pelvic floor by the age of 80 (ref).  

It’s partly due to variations in the female anatomy. The design to carry a child and different plumbing of the lower urinary tract predispose women of all ages to pelvic floor problems (ref). But, by far, the greatest challenge is the normal restructuring that occurs with pregnancy and childbirth. 

A rapid increase in body mass, the added size and weight of the fetus, stretched abdominal muscles, increased laxity, and greater lordosis, pelvic tilt, and hip-width, along with the trauma of giving birth, all place tremendous stress on the pelvic floor and is the starting point of these issues for many women.

Pain and Pressure

Pelvic floor insufficiency can lead to pain and symptoms within the pelvis, most notably a form of hernia called pelvic organ prolapse. With this condition, the pelvic muscles cannot support the uterus, bladder, or rectum, which puts pressure on the vagina. It’s reported to affect 50% of women over 50 to some degree (ref).  

Symptoms include:

• Feelings of heaviness or pressure (for mild cases, it may only occur after a long time of standing or after heavy physical exercise.)
• Incontinence, frequent urination, or constipation.
• A pulling or stretching feeling in the groin or pain in the lower back.
• Discomfort or numbness during sex.

This is a medical issue that you, as a trainer, shouldn’t feel burdened to fix unless you specialize in this realm. But, being aware is important if you work with females, and it is within your scope to equip women to help prevent these issues.

Peeing with Sports and Fitness

Another common pelvic issue is incontinence. Which is usually controlling urination, but it may affect the ability to hold back poop as well. For someone dealing with this, it can be an embarrassing struggle that has an impact on happiness and quality of life (ref).

The matter of stress incontinence is common among females with an increase in abdominal pressure, like a sneeze, but also happens during heavy exertion. Among female athletes, 42% of runners, 55% of ball sports athletes, and 26.1% of CrossFit athletes report leakage during participation (ref, ref).  

Obviously, this is a problem for women who want to avoid an awkward situation, but bigger than that, it’s on the long list of contributing factors to our global health crisis. This may sound like hyperbole, but in a study of American women, almost 30% stated that stress incontinence is a barrier to exercise and their workout intensity (ref).

Exercise professionals should be aware of these psychological and physical constraints and taught to handle them effectively and appropriately as part of a workout plan.

Men’s Health & Core Strength

Men too, need a strong and functioning pelvic floor. They can have bathroom problems just like the ladies, but other symptoms of concern include, pain in the testicles, erectile dysfunction, and premature ejaculation (ref). Again, not anything a person wants to talk about during their workout session, but things they do want to avoid.

It’s also important to understand that the pelvic floor muscles are part of the sacred “core.” With the transverse abdominis in the front, the obliques on the side, the diaphragm on top, and then the pelvic floor supporting the bottom. These all work together to help create stability and for intraabdominal pressure for lifting.

Along with the core, the pelvic floor muscles also help to control and stabilize the pelvis and lower torso. For that reason, pelvic floor dysfunction can get involved with the pathology of pain in the low back, SI joint, and hip (ref). 

Training the Pelvic Floor

Despite the strengthening effect of regular exercise, the pelvic floor muscles in active women don’t appear to be any stronger than those in inactive women (ref). This is shown in several studies, the most interesting being an unpublished trial comparing elite powerlifters with the general population. It showed no significant difference in pelvic floor strength, except for a single lifter who regularly trained her pelvic floor to help increase abdominal pressure to improve performance. Her pelvic floor strength tested 60% greater than the average of other lifters (ref).

This shows that general lifting doesn’t effectively train the pelvic floor and that specific pelvic floor work is necessary, especially for an active woman, who’s more susceptible to stress incontinence.

Although, before covering exercise strategies, there’s an essential understanding of this type of training. If approached inappropriately, rather than being helpful, you could just come off as weird and creepy.

Know your crowd before deciding to be the pelvic floor guru—most definitely if you’re a male trainer.

Approaching this without any rapport with a client, or singling out women in a group, can be extremely uncomfortable and will only be a bad experience. Also, despite pelvic floor dysfunction among women of all ages, if you coach youth athletes, this is better left to parents and health care professionals.

With that disclaimer, a generalized and low key approach for the right crowd can be impactful. Regular exposure to pelvic floor training can have a cumulative effect. It also provides strategies for people to implement on their own and serve as a reminder of the importance of preventative work for this obscure part of the body.

The Right and Wrong Way to Train The Pelvic Floor

To effectively exercise for the pelvic floor, imagine you are a brand new skier. Never stepped foot on a mountain, and just got all your equipment with no idea how to use it. An experienced ski teacher would never strap on your skis and push you down the hill while yelling instructions. 

You wouldn’t be able to process that information in the midst of trying not to die.

Instead, a good teacher first removes the hard stuff. You learn how to use the equipment then slowly introduce the fundamentals. You then practice on the bunny hill until you’re comfortable. Then you actually go up the lift and tie all the pieces together to ski.

You should think about working on the pelvic floor in this way.  

Rather than jumping into the advanced level exercises, training the pelvic floor should start slowly. Just like the novice skier, learn how to do things effectively until the movements become automatic, and then progress to the higher-level stuff.

Yet, the other end of the spectrum is a problem as well.  

Some spend tons of time working on low-level isometric contractions and rarely turn that into functional movements. Health care professionals who are not specialists in this area are notorious for this approach. They provide Kegels, clamshells, and dead bugs, but then leave you on the bunny slope.

Neither of these strategies is great. 

Remember, the pelvic floor is just a set of muscles.  Albeit a unique set of muscles that are hard to “connect” with, but they’re muscles nonetheless. They can be trained just like any other muscle, and with practice and repetition, their function can improve.

Pelvic Floor Progression

During a training session, contracting the pelvic floor should be a subconscious process. Focusing on this amid a workout will only limit exercise intensity and performance. Nor should a session of pelvic floor training be the cornerstone of your exercise prescription or training plan. 

A better strategy is to implement simple core “Activation” drills as part of a dynamic warm-up. Similar to how Crossover Symmetry is programmed for the shoulders, or the hip and core muscles.

A brief, but specific focus, establishes the cues and muscle activation to carry on in the background of an exercise. And again, like Crossover Symmetry, when repeated regularly, it has a cumulative effect.

Here are examples of exercises to include as part of a warm-up. This progression should start with this first movement.  Then after about 20 sessions, start integrating the techniques into the more advanced drills down the list.  

1. Hold a kegel contraction while laying only your back. The best cue I found for this came from a TED Talk on the pelvic floor. She said…

“I want you to imagine you’re walking into really cold water. As the icy cold water gets higher up your thighs, I want you to try to lift your most sensitive bits”.

Also, here is an excellent demonstration of coaching the Kegel exercise.  It’s unawkward and integrates nicely into the conversation of core bracing.

Start with a 10 Second hold for 10 Reps.

2. Clamshells and Dead Bugs with Kegel

3. Squat while doing a Kegel

4. Walk then running while doing a Kegel

5. Work on dynamic singles (box jump or squat clean)

6. Practice short sequences of dynamic movements (short sets of box jumps or jump roping)

It will also fit perfectly into training with the Hip & Core System.  Learn about the other muscles we target with the Glute & Core Guide.

Does Everyone Need Kegels?

The tricky thing is that not everyone needs the same exercises.  

There are some situations where the pelvic floor can be too tight. In these cases, deep squats and diaphragmatic breathing are indicated over a bunch of Kegels, which could actually make things worse.  

Some pelvic health specialists say pelvic floor exercises should not be done without the guidance of an evaluation. I believe this is overly cautious and more likely to create greater problems around fear of contracting the pelvic floor.

Just be aware of this cautionary tale. Give the training 2-weeks and if it makes things worse (e.g., pain increases, pressure increases, spasticity, and urinary frequency increase,) it would be best to see a specialist.

See…It’s not so awkward

Hopefully, you’re now armed to help more people with this common and uncomfortable issue.  At the very least, you should appreciate that not everyone wants to do certain exercises.  Even if you may think it’s the greatest movement, they may have reasons to think that it’s not.  Just be cool with that and look for alternatives.