I AM playing a video game on my phone, making a bird climb and dive to avoid hazards and collect points. It is pretty simple and unremarkable except for one thing: I am using my vagina as a game controller.
The device I am using, which looks like a sex toy and wirelessly talks to my phone via Bluetooth, is designed to encourage users to exercise something that is usually ignored: the pelvic floor. Hidden away at the base of our abdomen, this hammock of muscles, nerves and tissues supports internal organs including the bladder and bowel. It is a critical part of our anatomy, yet most people only start paying attention to it when it becomes too weak 鈥� and they experience incontinence 鈥� or too tight. Such problems are often thought of as a 鈥渇emale thing鈥�, but everyone has a pelvic floor, with weakness also linked to erectile dysfunction.
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Recently, there has been a renaissance in our understanding of what the pelvic floor is made of and how it can go wrong. Exercise programmes promise healing, and an ever-increasing array of digital devices, like the one connected to my phone, advertise strength training for these elusive muscles.
But many people aren鈥檛 getting their diagnoses or treatments right. The best known way to improve control of the pelvic floor muscles is squeezing exercises known as Kegels, but these aren鈥檛 suitable for everyone and won鈥檛 fix everything. Some people who would benefit from Kegels are activating the wrong muscles or not working the right ones hard enough. It鈥檚 time to get to know your pelvic floor better.
The pelvic floor is made up of layers of muscle fibres, which together are roughly the size and shape of two cupped hands, surrounding the urethral openings. This bowl-like structure, which is typically about 10 centimetres wide and 1 centimetre thick, must be strong enough to support the organs above but flexible enough to allow sexual function and the opening of the bowel and urethra, plus childbirth.
The strength and thickness of the muscles of the pelvic floor vary from person to person, and over time, they are affected by repeated stress and strain from activities such as jumping or trauma due to childbirth. This means they can weaken, over-stretch or tear. 鈥淭he damage is cumulative,鈥� says John DeLancey, a pioneer of pelvic floor research at the University of Michigan in Ann Arbor. All this can contribute to incontinence or, in severe cases, organ prolapse where the rectum, uterus or bladder start to fall out of the body.
Almost a quarter of women are affected by pelvic floor dysfunction, rising to nearly half of women over the age of 80, according to . About 1 in 10 women in the US will have surgery for these issues, says DeLancey.
These problems disproportionally affect those who have given birth, who might urinate a little when they laugh or cough 鈥� a condition called stress urinary incontinence (SUI). But younger people can have issues too. A for example, found that all of the participants aged between 16 and 22 experienced urinary leakage due to copious jumping.
Male sportspeople can have similar issues. A found that 15 per cent of the male participants experienced SUI during their training, especially running and lifting weights. But more generally, problems are most commonly experienced after surgery for prostate cancer, which will .
The muscles in this area were well documented by 19th-century anatomists, but since then things have got more muddled, with a variety of names given to the same structures, especially for the web of connective tissues surrounding the muscle. This 鈥渇ascia鈥� remains mysterious, says 茅lanie Morin at the University of Sherbrooke, Canada, who last year co-authored a . The fascia is riddled with nerves and probably plays an important, misunderstood role in pain, she says.
鈥淎lmost a quarter of women are affected by pelvic floor dysfunction鈥�
DeLancey became fascinated with the structure of the pelvic floor and how it worked in his early years as a doctor. His investigations threw up some surprises. Back in the 1990s, he says, everyone thought that an unsupportive hammock of muscles was the primary cause of urinary incontinence. His studies using ultrasound and MRI scans showed instead that it often has more to do with the ring-like muscle that tightens around the urethra.
In the past, if someone鈥檚 pelvic floor failed, physicians simply shrugged about the details, says DeLancey. Imagine if engineers had the same lack of knowledge about the structural failure of a building or bridge, he says. 鈥淯ntil recently, people just said: 鈥楾he bridge failed.鈥� Now we can identify which part failed.鈥� His work also showed that childbirth can tear a specific muscle in the pelvic floor region, leaving it dangling from the usual point of attachment.
This is an injury that doesn鈥檛 heal with exercise, time or even surgery, says DeLancey, although other muscles can often step in to compensate. That has been a double-edged discovery 鈥� while it is good to better understand the trauma, it has left many women feeling like they are broken and can鈥檛 be fixed, he says.
鈥淧elvic floor weakness has been linked to erectile dysfunction鈥�
The good news is that physiotherapy can help many other issues, from weak muscles to over-tense ones. But it can be hard for people to know what to do with their pelvic floor. Kegel squeezes 鈥� named after the US gynaecologist Arnold Kegel who promoted them in the 1940s 鈥� can be frustratingly difficult, like trying to isolate the right muscles to wiggle one eyebrow.
The usual advice is to imagine trying to stop the flow of urine or the passing of gas, without tightening your buttocks, legs or tummy. 鈥淪ome people clench their fists or teeth, hold their breath, or make a face. This does not help,鈥� on its website. Those struggling with Kegels can either insert a finger into their vagina to see if they can feel a tightening or lifting, or stand in front of a mirror and try to move their penis up and down without moving any other part of their body. For those who have the benefit of medical supervision, an ultrasound or physical exam can reveal if the right muscles are activating.
Biofeedback can also be helpful. Typically, internal pressure sensors are used to measure the location and strength of contractions. According to physical therapist Kari B酶 at the Norwegian School of Sport Sciences in Oslo, co-author of , the problem is that many of these devices can鈥檛 tell if the right muscles are being activated; contracting buttock muscles might produce the same outcome on the screen. The device I am using has two different sensors and tutorials to help prevent this, but it is still possible to cheat by clenching something other than the pelvic floor. When done right, though, such tools can help measure the strength of contractions and evaluate if they are increasing over time.
There is strong evidence that, performed correctly, these exercises can help. 鈥淲e now have so many randomised controlled trials, and systematic reviews. They all conclude that pelvic floor muscle training is effective,鈥� says B酶, and should always be the first line of action before surgery is considered.
Studies show that doing three sets of between eight and 12 contractions, three times a week, is a reasonable target for an exercise programme, says B酶. Do that for six months, she says, and this should tighten and lift the muscles, along with about a 15 per cent thickening of the pelvic floor. A .
Study results are more mixed for men. 鈥淭here are about 20 good trials, but the results differ more than they do in women,鈥� says B酶. 鈥淪ome studies find no effect; some find excellent effect.鈥� The difference, she suspects, may be due to the fact that most men with pelvic floor muscle issues experience these problems as a result of prostate cancer surgery, which causes a different sort of damage. One , however, found that a three-month programme of dozens of daily contractions helped to restore erectile function in a group of men. Only 25 per cent of the participants didn鈥檛 improve.
Regular training
Although most studies are carried out on people experiencing issues with their pelvic floor, there is some evidence that doing exercises before problems arise can have a preventative effect: , for example, tend to have better control over urine flow afterwards, at least in the short term. Similarly, who underwent gender-affirming vaginoplasty surgery to create a vagina if they attended physical therapy training beforehand.
For these preventative reasons, the authors of the study of Spanish athletes recommended that pelvic floor exercises should be part of athletic training programmes. Pelvic floor health is also part of the national healthcare plans in certain counties. In France, for example, postnatal 鈥�, and are much touted in the media with headlines such as 鈥淲hy French women don鈥檛 pee their pants when they laugh鈥�. Surprisingly, though, there is little if any evidence that this has a significant effect on levels of pelvic floor dysfunction or surgeries for French women, says B酶.
Like with any muscle-building activity, you have to work hard to get results. 鈥淚t is a problem that many women aren鈥檛 contracting strongly enough. It鈥檚 like doing this,鈥� says B酶, flapping her arms, 鈥渁nd expecting to build up your biceps.鈥� When I ask B酶 why my own Kegel attempts feel so frustratingly inconsequential, without the typical muscular burn I experience from other exercises, she implies that I am simply not doing it right. 鈥淚 have had women who say they can feel it the day after,鈥� she assures me.
This is one area where biofeedback might help, because having the exercises be part of playing a game makes it easier for some people to get motivated and work hard. However, many studies indicate that women don鈥檛 need such devices to benefit from Kegels. And the advertising for some of these devices might give women the incorrect impression that Kegels will fix absolutely everything 鈥渄own there鈥�, says DeLancey. 鈥淭here鈥檚 a lot of voodoo in this area,鈥� he says. 鈥淲e shouldn鈥檛 be asking millions of women to do something that isn鈥檛 necessarily going to work for them.鈥� Some women have muscles that are so weak they simply won鈥檛 be able to do Kegels even if they try their hardest, says Morin. She suggests that electrostimulation of the muscles might help them to build these up to a level where Kegels are a possibility 鈥� yet another reason why it is so important to get advice from a pelvic floor specialist before starting an exercise regime.
DeLancey also often directs people to myconfidentbladder.org, which provides exercises and simple coping tricks for dealing with a weak pelvic floor, such as waiting to have that third cup of coffee until after your commute, or setting an alarm to empty the bladder at 4am. Another common trick, often called 鈥渢he knack鈥�, is to muscles just when you feel a cough or other problematic moment coming on, which can dramatically reduce urine leakage.
Recommendations are different for those who instead experience a painful, over-tight pelvic floor (sometimes diagnosed as vulvodynia). This may be due to physical pain from another cause, such as endometriosis, which puts the whole area on 鈥渉igh alert鈥�, and can lead to . It may also be influenced by psychology, says Morin 鈥� if someone is afraid of sex or unable to relax with their partner, for example, this can make the pelvic floor tighten in the same way as people who sometimes suffer from tight muscles in the shoulders or jaw. This area has been radically understudied, says Morin. Internal massage and physiotherapy can help, she says. While the goal of strengthening muscles by tightening pelvic floor muscles may not be relevant, the idea of gaining enough control over them to consciously relax (the other half of a Kegel) is helpful, she says.
That kind of control is what my app is now training me to gain, as I learn to tighten and relax a part of my body that I never thought about before giving birth. For me, Kegels have become yet one more exercise to add to my weekly regimen of cardio and weights, in hopes of staving off all kinds of physical issues as I age. I take a deep breath, and get the bird to move around the screen 鈥� aiming for a new high score.
Childbirth conundrum
It has long been a puzzle why the birth canal of modern humans is so narrow for pushing out our big-headed babies, with a relatively high risk of them getting stuck. Other species, including other apes, don鈥檛 have this problem. This 鈥�. of the pelvic floor muscles might also play a role.
According to the pelvic floor hypothesis, the size of this structure is the result of a trade-off between the muscle stiffness needed to support the inner organs and foetus versus the flexibility needed to push a baby out. To test this, Ekaterina Stansfield at the University of Vienna in Austria and her colleagues developed a 3D model of the pelvic floor and how it changes as the birth canal widens or narrows. They found that a large opening gives the pelvic floor muscles more room to stretch, just as a larger trampoline will have a deeper bounce.
The effect was dramatic: an increase from an 11-centimetre-wide pelvic floor to a 13-centimetre-wide one, for example, resulted in a 50 per cent greater bend in response to pressure. 鈥淪ize matters,鈥� says Stansfield. The bigger the stretch, the greater the risk of dysfunction like incontinence or organ prolapse.
Evolution could theoretically compensate for this extra stretchiness by developing thicker muscles. But Stansfield鈥檚 team found that the pelvic floor would need to be at least twice as thick to support a 13-centimetre opening versus an 11-centimetre one鈥� and that comes with negative effects on childbirth. Previous work has shown that athletes with thicker pelvic floor muscles need to push 45 per cent harder to get a baby out. At some point, says Stansfield, you hit the limits of what a woman can do.
