Do you have bowel, bladder and/or sexual problems? Here, I discuss pelvic floor exercises, which may help alleviate all these symptoms.

Pelvic floor exercises are one of the treatments recommended for all patients with bladder problems.¹ However, when I ask patients if their continence advisors have formally instructed them on how to do these exercises, most say they were given an instruction sheet, referred to the pelvic floor exercise NHS site or other online resources. What is clear is that few people have been adhering to the pelvic floor exercise regimen; I estimate this to be less than 20% or even 10% of patients. 

• Who should do pelvic floor exercises? 
• Do you know how to do them and at what intensity? 
• Have you adhered to doing them? 

Pelvic floor structure and function

The pelvic floor consists of muscles and other tissues at the bottom of the pelvis. The muscles attach to the pelvic bones and sacrum. The pelvic floor supports the lower abdominal organs and is essential for maintaining bowel, bladder and sexual function. The pelvic floor muscles have a constant tone at rest, i.e. they are tonically contracted. Voluntary and involuntary contraction and relaxation of the pelvic floor allow for normal bowel, bladder and sexual function; for example, reflex muscle contraction in response to sudden increases in intra-abdominal pressure, such as coughing or sneezing, maintains continence. Pelvic floor dysfunction causes symptoms such as urinary incontinence, voiding difficulty, pelvic organ prolapse, anal incontinence, evacuation difficulty, sexual dysfunction and pain. 

Pelvic floor muscle training

Like all muscle training programmes, pelvic floor muscle training (PFMT) is designed to improve pelvic floor muscle strength, endurance, power, relaxation or a combination of these. PFMT is typically unsupervised and self-administered. On the NHS, PFMT can be supervised by an HCP, typically a physiotherapist or a continence nurse. The National Institute for Health and Care Excellence (NICE), recommends PFMT to manage symptoms of pelvic floor dysfunction in women. NICE also recommends encouraging all women aged 12 and over to perform preventive exercises. This makes sense; the pelvic floor is just another muscle, and strengthening it should help prevent pelvic floor dysfunction in the future. Therefore, I have added PFMT to my list of exercises for my MS prehabilitation programme. 

PFMT is indicated mainly for urinary incontinence, pelvic organ prolapse and faecal incontinence. These are all problems associated with MS; in many cases MS either causes or contributes to these symptoms. 

PFMT for women

A self-administered programme should include basic voluntary contractions, which aim to improve pelvic floor muscle reaction to activities such as coughing, sneezing, exercise, and lifting, as well as sustained voluntary contractions that enhance endurance.

• Sit comfortably with your knees slightly apart and contract the pelvic floor by lifting and tightening the muscles around the anus and vagina—as if to prevent the passage of gas and stop your urine flow.
• Once you can achieve PFMT seated, you can perform the exercises in a standing position and during activity.
• If you experience stress urinary incontinence (e.g. when sneezing), you can contract the pelvic floor in preparation for a leakage-provoking event; this is called the “knack”.
• A basic voluntary contraction involves a hold of 1 ̶ 2 seconds, with the same rest time; a sustained voluntary contraction should last for 6 ̶ 10 seconds, with the same rest time. Once you establish a baseline sustained contraction, gradually increase the length of the contraction (to a maximum of 10 seconds). 

Approximately one-quarter of women cannot perform a pelvic floor contraction on their first attempt with just verbal instruction. Digital assessment of the pelvic floor – using biofeedback devices, electrical stimulation, or vaginal cones – is therefore useful to help them know when they are contracting effectively. If your progress is minimal, please ask your MS team for a referral to a suitable HCP for clinical assessment and a personalised, supervised PFMT programme.

Other resources providing useful instructions are available, e.g. a patient education leaflet from the International Urogynecological Association and smartphone applications such as the Squeezy NHS pelvic floor app. 

PFMT for men

Pelvic floor dysfunction can also occur in men, and PFMT is a recommended first-line conservative treatment. The following is an extract from the Pelvic Obstetric & Gynaecology Physiotherapy ‘Pelvic floor muscle exercises and advice for men’. 

Sit comfortably with your thighs, buttocks and tummy relaxed. Squeeze and lift the muscles from the front by either imagining you are trying to stop yourself from passing urine or trying to shorten or draw your penis up and inwards. Now try lifting the muscles from the back as if stopping the escape of wind. When you feel you have the hang of it, try lifting the front and back together. Don’t worry if you find it too difficult; after some practice, you will find the easiest and most comfortable method. This is a pelvic floor muscle contraction. To check that your pelvic floor muscles are working correctly: 

• Place your fingers on your perineum. You should feel the perineum lift upwards as you contract your muscles.
• Stand in front of a mirror; when you do a pelvic floor muscle contraction, you should see the base of your penis draw inwards and your testicles/ scrotum lift. 

Try not to hold your breath while you contract your pelvic floor. You are more likely to breathe easily if you lift your pelvic floor on your out-breath. Do not actively clench your buttocks, but don’t be concerned if you simultaneously feel a tightening in your buttocks and/or lower abdomen. This is normal. If you cannot feel a definite tightening in the pelvic floor muscles, you should seek professional advice.

Reference

1. Kajbafvala M et al. Pelvic floor muscle training in multiple sclerosis patients with lower urinary tract dysfunction: A systematic review and meta-analysis. Mult Scler Relat Disord 2022;59:103559.