What Causes Pelvic Floor Issues?

When we talk about pelvic floor issues, looking for causes can lead to frustration and confusion. 

This is because the complete picture of what exactly causes pelvic floor issues is just not clear.

Pelvic floor issues are complex and influenced by a number of different factors. Sometimes you might develop a pelvic floor issue because of one specific thing (like an injury) but that doesn’t mean other risk factors aren’t having an impact too. 

The pelvic floor is a complex set of 14 muscles that are connected to so many fundamental aspects of our physical and mental selves that whether it is working properly or not is a function of a combination of different things. 

Everyone is different. Everybody is unique. 

Having said that, there are a number of things that are being studied as risk factors for pelvic floor issues.

The risk factors affecting your pelvic floor and how it responds are unique to you. 

Just because you have one or more of the risk factors does not mean that you will definitely have a specific pelvic floor issue. 

Understanding what pelvic floor risk factors are can help us prevent pelvic floor issues in the first place.

In this week’s blog, we’re going to walk you through some of the most common risk factors for pelvic floor issues and point you in the direction of some strategies for each one. 

Risk Factors for Pelvic Floor Issues:

1. Pregnancy

During pregnancy your pelvic floor muscles have to work harder to support the weight of the growing baby, extra fluid and placenta. They also become softer and more stretchy due to the pregnancy hormone relaxin which affects all the muscles and tissues in your body.

When you are pregnant, you might develop symptoms like leaking wee or poo or feel a heaviness in your vagina which could be an indicator of pelvic floor issues.

Healthy pelvic floor muscle tone helps maintain bladder and bowel control throughout pregnancy. It also helps reduce the risk of developing a prolapse during or after pregnancy and helps with recovery after birth. This is why it is recommended that pregnant women do Kegel exercises (pelvic floor squeezes) and continue them after the birth.

2. Childbirth

During childbirth, there are many things that can happen which might increase your risk of pelvic floor issues.

If you have a C-section (caesarian), you’re still at risk of pelvic floor muscle weakness due to the increased weight you’re carrying and the changes brought about by pregnancy hormones.

In a vaginal birth, as the baby moves down the birth canal, the nerves and muscles of the pelvic floor stretch to allow the baby to come out. The muscles sometimes become overstretched and weak and can’t keep urine, wind or poo inside the body as effectively. 

This is more likely to happen if:

Your baby is more than 4kg

You have a long second stage of labour 

Your baby is delivered with the help of forceps or vacuum

You suffer a 3rd or 4th degree tear 

You have an episiotomy. An episiotomy is an incision made by your midwife or obstetrician to help get the baby out. Episiotomies have been linked to an increased risk of pelvic floor weakness as well as pelvic pain and painful sex.

There are a number of things you can do to reduce the risks during childbirth including adopting more active positions during labour, using gravity to help you push the baby out, your midwife can actively support your pelvic floor while you are delivering your baby, pelvic floor exercises (relaxing and contracting) during pregnancy and perineal massage prior to birth. 

If you have any concerns about your pelvic floor being at risk during childbirth, talk to the medical professionals who are attending you and they will support you. 

3. Factors that put pressure on the pelvic floor

Stress incontinence is very common and is caused by a combination of increased abdominal pressure (pressure in your tummy) and a weakness of the pelvic floor muscles which means your pelvic floor muscles can’t respond to the pressure strongly or quickly enough to keep leaks from happening. 

When we cough, sneeze or laugh, there is a fast and high impact load of intra abdominal pressure which squeezes our bladder and our pelvic floor muscles need to contract quickly and strongly to prevent leaks. If we have a chronic cough, this can tire the pelvic floor muscles and put them under strain increasing the risk of prolapse over time.

One way to help your pelvic floor muscles support your organs and manage the incontinence symptoms is to practise ‘the knack’. This is a squeeze of the pelvic floor muscles which will prevent further damage as you cough, sneeze or laugh. 

Obesity adds to your risk for pelvic floor issues because the pelvic floor muscles are held in an elongated or stretched position. This makes it harder for them to contract strongly when you need them too. There is also a heavier load for the muscles to lift and support.

A healthy diet and regular exercise can help you lose weight and reduce the pressure on your pelvic floor.

Chronic constipation and straining when pooing can also damage the pelvic floor (see pooing and the pelvic floor). Minimise constipation by eating enough fibre and using a step when you poo.

Heaving lifting can damage the fascia in the pelvis which can restrict movement in your pelvic floor muscles. This is particularly true if we hold our breath so doing a pelvic floor contraction, a transverse abdominal contraction, and exhaling as you lift can help protect the pelvic floor muscles. In other words, squeeze your pelvic floor, pull your belly button in towards your spine and breathe out as you lift (bend your knees to protect your back too).

Impact exercises like running and jumping can also cause leaks. This is because the landing increases the downward pressure on the pelvic floor so the muscles have to work harder to stop leaks. Modify your exercise routine to reduce the heavy landings and get some specialist support from a women’s health physiotherapist for personal advice about running. 

4. Getting older/menopause

During the perimenopause there are significant hormonal changes in a woman's body, including a decrease in the hormone oestrogen. oestrogen plays a critical role in maintaining the health and function of the pelvic floor muscles.

When oestrogen levels decrease, the pelvic floor muscles can become thinner and weaker, losing their elasticity and ability to contract and relax. This can lead to pelvic floor issues, including urinary incontinence, faecal incontinence, pelvic organ prolapse and painful sex.

We are particularly at risk if we already have a weakness from a birth injury or another risk factor. 

Hormone replacement therapy and/or local oestrogen creams can help maintain muscle strength and regular pelvic floor exercises can also help improve muscle tone. 

5. Having weaker tissues

Some people are genetically predisposed to having weaker muscle tone which can lead to pelvic floor issues.

6. Trauma/Surgery

Some traumas, like a car crash, can impact pelvic floor function as can some surgeries. Bizarrely, one of the surgeries that increases your risk of pelvic floor issues is previous pelvic floor surgery. This is because failure rates for prolapse surgeries can be as high as 60%. Despite this ‘high’ failure rate, many women still report increased quality of life and improvement of symptoms. 

7. Race

Some studies suggest that more white and latino people suffer pelvic floor issues than other races. 

8. Chronic Stress 

The muscles of the pelvic floor contract in direct response to physical and mental stress. This is known as the pelvic stress reflex response. When we are chronically stressed, this can lead to hypotonic pelvic floor where the pelvic floor muscles are hard to relax which can cause urinary incontinence symptoms. 

Learning how to manage stress using simple techniques like belly breathing and meditation can improve pelvic floor issues caused by overly tense muscles. If you’d like to know more about how stress is affecting your pelvic floor you’ll find more information here.

Whatever your unique circumstances, it’s likely that you will encounter some of these risk factors at some point in your life. 

The important thing to remember is no matter your age or your circumstances there are many interventions to help you prevent, manage and treat pelvic floor issues. 

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Lastly, if there is a woman out there you think might need to hear any of this, please share. Talking about these issues is essential if we're going to help women move past them.