This article was written by Dr. Sarah Duvall of Core Exercise Solutions. Sarah is a Doctor of Physical Therapy who specializes in women's health and pelvic floor function.
Pelvic Floor Physical Therapy
The current treatment strategy for the pelvic floor looks at managing pressure, pelvic floor coordination, and the entire kinetic chain. Surprise! It’s no longer just kegels. (That was 1990!)
What research is showing us now is that pelvic floor issues are caused primarily by inappropriate pressure or poor muscle coordination, resulting in the pelvic floor overworking to stabilize the pelvis and manage this pressure.
In other words, many athletes have issues with pelvic floor tightness and need to be doing fewer kegels, not more.
Pelvic Floor and Heavy Lifting
So what happens when you want to lift heavy and, dare I say, use a valsalva, but you leak during exercise? On the one hand, women are being told that leaking is normal. Just because something is common doesn’t make it normal or something that you have to live with.
On the other hand, conservative pelvic floor treatment seeks to decrease all pressure in the core and never have a woman hold her breath during exercise. If you’re suffering from prolapse, you may have been told that you should never lift anything heavy again.
These are not good solutions for a woman who wants to lift heavy, not worry about leaks, and keep her spine safe all at the same time.
Women can have it all. So let’s take a closer look at how to make that happen.
Step 1: Coordinate the Pelvic Floor With the Diaphragm
As you inhale (breathe in), your diaphragm expands down and your pelvic floor relaxes down, which is eccentric loading of the pelvic floor and abdominals when done under load.
As you exhale (breathe out), your diaphragm goes up and your pelvic floor lifts. This is a natural feedback loop within the body that creates a strong, dynamic pelvic complex. Ready to see if you are breathing correctly?
Strong abdominal and pelvic floor muscles can handle this eccentric load of breathing while holding a brace to stabilize the spine and pelvis and support pelvic organs. This helps to balance out pressure so it’s going to all the right places.
Leaking While Lifting: 3 Compensation Patterns
1. Do they overbrace their abs and pelvic floor and go into a shallow breathing pattern when lifting?
When you slip into a shallow breathing pattern, that sets you up for reverse breathing. If the inhale goes up, then the pressure from the exhale will go down.
Now, usually you can rein in this pressure with strong pelvic floor muscles, but when you overload with heavy weights or inadequate postpartum recovery, that strategy can catch up with you.
The downward pressure can overwhelm the pelvic floor and leaking or prolapse can occur. This will often happen along with some pelvic floor tightness because the pelvic floor has been working overtime to try and manage this pressure.
2. Do they breath hold and direct the pressure down when lifting?
This is similar to the pattern above but can be even more forceful. You can breath hold safely. You just have to be aware of where the pressure is going.
If it’s all being directed down to the pelvic floor because your upper abs are a lot stronger than lower abdominals, then you won’t be able to help your pelvic floor contain the pressure. The most helpful fix here is to learn how to not brace down and to balance out abdominal strength.
Try this lower ab challenge to see if you can isolate your lower abdominals:
Check your crunches here to see if your lower abs are strong enough to help you contain the pressure:
3. Are they contracting more of the back of the pelvic floor than the front, creating a tight / weak scenario with the pelvic floor that makes it more prone to leaks?
Learning how to initiate the pelvic floor contraction from the front instead of the back can be very helpful for stopping leaks!
Learn how to contract the front here:
All of these steps involve “connecting” with your pelvic floor. Can you feel your pelvic floor when you take a deep breath? Most people are able to mentally feel what their pelvic muscles are doing when they take a really deep breath, but it often takes a little focus and time practicing first.
Work on being able to feel your pelvic floor respond to your diaphragm as you take a deep breath. Just remember: relax on the inhale.
The pelvic floor contracts and relaxes all day long as the diaphragm works. If you are only able to utilize your diaphragm when you are thinking about it, that’s not good. That will often cause the pelvic floor to hold itself too tight (high muscle activation) or too loose (low muscle activation).
It may also cause your sympathetic nervous system to be high! Be mindful as you go through your daily life. Are you utilizing a deep breathing pattern, or are your neck and shoulders rising with each breath?
Step 1: Get the Diaphragm Working
Step 1 is to get your diaphragm working 24-7 for awesome deep breathing that turns on the pelvic floor.
This will be automatic, so when you cough or sneeze (forced exhale), your pelvic floor will naturally go up. No leaks!! (We probably just helped or fixed your pelvic floor issue significantly.)
Step 2: Incorporate Deep Breathing with Movement.
Now that you are deep breathing, let’s test your system with something simple, like a squat and a side plank. The squat tests movement and a side plank generates intra-abdominal pressure.
Recap: You are now deep breathing with pelvic floor coordination, and you can maintain this system under the stress of exercise. Awesome! Now, let’s take it to the next level.
What About Holding Your Breath?
A 2012 study showed that holding a Valsalva maneuver did NOT harm the pelvic floor, but a bearing down or straining maneuver did.
What does this tell us? Women who leak when they utilize a Valsalva during heavy lifting might not be performing a Valsalva correctly. They may be bearing down instead.
If you have a pelvic muscle dysfunction, it’s important to be able to feel and understand the difference between a proper Valsalva and bearing down when you hold your breath.
The safest way for women who leak to hold their breath during lifting for spinal support is to hold it at the end or middle of your exhale, because you get that natural recoil up of your pelvic floor.
So, start your exhale getting that nice pelvic floor and core response managing the pressure well, and then hold your breath with that intention to maximize pressure.
After you’ve mastered that or if it isn’t working, you can then try to hold your breath on the inhale, but starting with an exhale is often a bit easier.
Sometimes if our exhale pressure management muscles are weak then holding on the inhale might feel easier, but the bottom line is that you’re aware of where that pressure is going and how you’re managing it!
If you still find yourself leaking even after you know your diaphragm is coordinating with your pelvic floor and you are not bearing down, here are a few things to take a closer look at:
Better Form: Little technique issues can have a drastic effect on your pelvic muscles. Take a moment to analyze your form and look at what’s happening in your pelvis.
Hip Strength: You need a dynamic system from both the top and bottom of the pelvic floor. The pelvic complex needs the support from the diaphragm and abdominals, but it also needs the deep hip rotators, adductors and glutes as well. If you are having hip pain during squats, check out this article.
Ability to Load Eccentrically. Do not underestimate the power of being able to lengthen and open your glutes, adductors and pelvic floor to create a strong contraction and proper leak-free muscle firing! Deep squatting is awesome.
Perfect Your Diaphragm: Utilize a 360 breath and not just a belly breath to really get your diaphragm to turn on your pelvic floor.
- Park H, Han D. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. J Phys Ther Sci. 2015 Jul;27(7)
- Talasz H. et al. Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor. Eur J Obstet Gynecol Reprod Biol. 2012 Oct;164(2):227-33.