Physiotherapy for Pelvic Health After Cancer

Pelvic health is a fundamental aspect of overall health and well-being. Similar to all other muscles in the body, the pelvic floor can become weak and deconditioned, which may benefit from rehabilitation. Due to the specific symptoms pelvic floor weakness may cause, the topic is often considered taboo and opportunities to support pelvic health and rehabilitation may be overlooked. This blog post aims to provide some insights and guidance, drawing from the experience and expertise as a physiotherapist specialising in cancer (@strongerthanphysio).

What is the pelvic floor?

The pelvic floor, also known as the pelvic diaphragm, is a group of muscles and ligaments that extend from the coccyx to the pubic bone.  It plays a vital role in supporting the bladder, uterus, and bowels, as well as in continence, sexual health, and preventing prolapse [1].   

The pelvic floor is composed of several muscles, including the levator ani (which itself consists of three smaller muscles) and the coccygeus muscle. Several factors can impair pelvic floor muscle function, including cancer treatment, pregnancy and childbirth, persistent heavy lifting, excessive straining (like coughing or toileting), and aging. 

It is helpful to remember that the pelvic floor is an integral part of our ‘core’, which consists of our pelvic floor, our deep abdominal muscles (transverse abdominis), deep spinal stabilisers (multifidus) and our diaphragm. Therefore, in order to achieve good pelvic health, we should consider more than just the pelvic floor muscles. Optimising core stability, specifically back and abdominal strengthening and addressing breathing dysfunction, is crucial. Other dysfunction in other muscle groups, such as tightness or overactivity in the glutes, hip flexors and hamstrings can also impact our biomechanics and pelvic floor health.

Image used by permission of Pelvic Guru, LLC

How will a physiotherapist assess my pelvic health?

When completing a physiotherapy assessment for pelvic health, a fundamental starting point is completing a thorough subjective assessment to discuss your symptoms. This will take into account your cancer diagnosis, other health conditions and important life events, such as childbirth or surgery and will also consider lifestyle factors like diet and exercise.

A physical or objective assessment should incorporate breathing and core stability assessment to gain a wider view of pelvic health. Questionnaires, such as the Australian Pelvic Floor outcome measure are a helpful tool to evaluate bladder, bowel, and sexual function, as well as organ prolapse in the general population, including those who have undergone gynae and colorectal surgery for cancer treatment [2]

If you are being seen by a physiotherapist with specialist training in pelvic health, they may also perform a physical examination, if you are comfortable with this, to gain further understanding of your pelvic health and further guide your rehabilitation plan.

What exercises can help with pelvic floor health?

Kegal Exercises

The most common pelvic floor exercises are known as Kegal exercises; these simple exercises involve contracting and relaxing the pelvic floor. They are targeted and specific exercises that do not involve contraction in any of the surrounding muscle groups, such as glutes and hamstrings.

Kegal exercises should include practising both slow and fast contractions, to mimic and prepare for the use of the pelvic floor muscles in daily life. Over time, the aim is to practice 10 repetitions of each, 3-5 times daily. Digital apps such as Squeezy or Emy can help to prompt you regularly.

For some people, it can be hard to identify whether the pelvic floor muscles are contracting and whether the exercises are effective. It is important to start small and build up slowly, as your confidence grows. It can be easiest to start in a lying position and progress from there.

Once confident with your Kegal exercises, you may wish to practice them in various positions, such as half lying, sitting, standing and during dynamic movement, such as squats and bridges.

Pelvic Floor Stretches

Tightness in the pelvis, hips and lower back may impair pelvic floor function and therefore regular stretching can carry many benefits. Introducing 2-3 weekly stretching sessions would be an ideal goal, with exercises such as happy baby, child’s pose, figure-of-4

Core Stability Exercises

It has been shown that incorporating core stability exercises into your physical activity and rehabilitation routine, can help to improve the pelvic floor contraction strength [3].

Breathing Exercises

Breathing exercises can help to relax the trunk and reduce tension in the pelvic floor. While in practice it is recommended that breathing exercises can support pelvic health, a recent systematic review found that conclusive evidence for this remains limited [4]. Generally, breathing exercises can have many benefits: by improving respiratory function, improving efficient gas exchange, preventing chest infection, managing stress and anxiety, supporting blood and lymphatic circulation and many other benefits.

As a physiotherapist, I recommend regular breathing exercises to a majority of my cancer rehabilitation patients: to optimise physical and mental health, encourage efficient lung function, and prevent breathing pattern disorder. Exercises may include belly breathing, box breathing with hold, rectangle breathing, nose breathing, and pursed lip breathing.

Staying physically active with pelvic floor issues

The good news is that exercise is safe and important when managing pelvic floor health. It is important to consider the factors that may impact your physical activity and choose a form of exercise that is most suitable for you. For example, if you are concerned about urinary leaking, you may choose to wear a pad while exercising or opting for home exercise rather than attending a gym to ensure prompt toilet access.

Generally speaking, opting for lower impact activities like walking, swimming, yoga, and pilates will be the most comfortable choice. Higher impact activities such as running and fast-paced circuits (e.g., burpees, sit-ups) can put excessive strain on pelvic floor and abdomen and may potentially aggravate symptoms.   

In summary…

Pelvic floor dysfunction is common, particularly in women. It is also more prevalent for those who may have undergone gynaecological surgery as part of their cancer treatment. Always consult with your medical team, who will be able to assess and make a referral to your local women's or pelvic health physiotherapist for ongoing support.   

Getting into the habit of practicing daily Kegal exercises is likely beneficial for most women, to regain or maintain optimal pelvic floor function. You can find trusted resources at POGP (Pelvic Obstetric and Gynae Physiotherapy)

While pelvic health may feel taboo and difficult to talk about, there is much that can be done to support pelvic floor dysfunction and many specialised professionals who can help. I highly encourage anyone who is experiencing symptoms to speak to a health professional and request a referral to a specialist pelvic floor/women’s health physiotherapist.

For more information and support about physiotherapy for pelvic health after cancer, you can visit www.strongerthan.co.uk or contact Hannah Furness at hannah@strongerthan.co.uk. 

References

[1] Curillo-Aguirre CA, Gea-Izquierdo E. Effectiveness of Pelvic Floor Muscle Training on Quality of Life in Women with Urinary Incontinence: A Systematic Review and Meta-Analysis. Medicina (Kaunas). 2023 May 23;59(6):1004.

[2] Lin KY, Frawley HC, Granger CL, Denehy L. The Australian Pelvic Floor Questionnaire is a valid measure of pelvic floor symptoms in patients following surgery for colorectal cancer. Neurourol Urodyn. 2017 Jun;36(5):1395-1402.

[3] Embaby HM, Ahmed MM, Mohamed GI, Koura MH, Salem HH, Elbanna M, Aboeleneen A, El-Sayed AF, Elnahas EM. Impact of core stability exercises vs. interferential therapy on pelvic floor muscle strength in women with pelvic organ prolapse. Eur Rev Med Pharmacol Sci. 2023 Feb;27(4):1255-1261.

[4] Bø K, Driusso P, Jorge CH. Can you breathe yourself to a better pelvic floor? A systematic review. Neurourol Urodyn. 2023 Aug;42(6):1261-1279.