Focused Pelvic Floor Muscle Training

There is consistent evidence that pelvic floor muscle training can prevent and improve the symptoms associated with Pelvic Floor Dysfunction, offering a 50-80% success rate   (Dumoulin et al., 2018, Wiegersma et al., 2018, Heymen et al., 2001) as well as producing physiological changes, such lifting the pelvic floor, reducing the levator hiatus area, and inducing pelvic floor muscle hypertrophy (NICE_Guideline, 2021, Hoff Brækken et al., 2010, Díaz-Álvarez et al., 2022). Despite this established success rate, 44-70% of female athletes may not be recruiting their pelvic floor muscles correctly when attempting to train them (Ornö and Dietz, 2007, Dietze-Hermosa et al., 2020). As such, supervised pelvic floor muscle training is the first line management for athletes with symptoms of Pelvic Floor Dysfunction (Dumoulin et al., 2018, NICE_Guideline, 2021). 

Strength and conditioning principles which apply to muscle strengthening in other regions of the body apply to the pelvic floor too. This means considering the principle of individualisation, specificity, overload and progression (Kasper, 2019, Garber et al., 2011). A common mistake with pelvic floor muscle training is that women, or those guiding them, assume they only need to do gentle, recurring activation of the muscles. In order to meet the principles of muscle strengthening, the pelvic floor muscles must be trained to induce overload and fatigue.

How do you guide or advise athletes to engage in pelvic floor muscle training?

All athletes should ideally engage in pelvic floor muscle training within their programming. If not engaging already, athletes presenting with symptoms should commence training as first line approach to management. Helping athletes understand what their pelvic floor muscles are can be difficult as it is a blind area that we do not see or observe someone else training. Using ready made resources can be useful such as the examples below:

Download World Rugby Women’s Health Resources - Pelvic Health

Coaching Tips:

• Cues that may offer useful prompts to help athletes understand pelvic floor muscle training include, but are not limited to:
  • “Imagine you are stopping wind or gas escaping”
  • “Imagine you are trying to stop the flow of urine mid-flow”.

Be aware and guide athletes to ensure that they are not compensating by recruiting the surrounding lumbopelvic muscles. If engaging the pelvic floor muscles effectively, no one will see the athlete moving (as no-one can see the pelvic floor muscle region), but the athlete should feel the muscles at the back passage, perineum, around the urethra lift and tighten. If they cannot feel the muscles tighten, they feel like the muscles do not relax again, or if there is pain elicited when trying to do pelvic floor muscle exercises, referral to a pelvic health physiotherapist is recommended.

In some presentations, the pelvic floor muscles are not weak, but rather tight and non-relaxing (Donnelly and Moore, 2023). Therefore, accessing the appropriate education and management for individual athletes is essential.

If pelvic floor muscle training is appropriate, training should be made up of rapid maximum voluntary contractions and slower endurance holds (Donnelly and Moore, 2023).