A Body’s Dome: The Pelvic Floor

By Katharina Claeys for Yoga Medicine.

The Interconnection of the Body’s Domes article by Katharina Claeys for Yoga Medicine provides background on the anatomy and the functions of the different domes of the body and the interconnections between them.

This following article focuses on this connection and on the pelvic floor dome, for which specific therapeutic yoga practices are proposed to support and regain pelvic floor health, aiming to alleviate people’s ailments such as discomfort, leakage, hypertonic and hypotonic pelvic floor.

When the Pelvic Floor Does Not Do Its Job Anymore

Products such as anti-leakage panties and pads are helpful means to make it through day to day life. They are helpful products that at best should only be temporary (not simply accepted as something to be used forever), until the pelvic floor is healthy again.

There are various causes of pelvic floor ailments, such as traumatic (psychological or physical), birthing injuries, surgery, and protracted postural & life-habits.

Pelvic floor ailments and age are not directly correlated. If such ailments do come more frequently in older age, it is rather linked to poor life habits (e.g. posture, exercise, diet).

The female body is made for birthing – the body is resilient. The living standards, birthing conditions and daily habits may well have changed over the past century, impacting the pelvic floor recovery after childbirth.

Yoga, exercise or workout are key to maintaining physical and mental health, although poor alignment and overworked muscles can lead to an imbalance.

The Pelvic Floor Dome

As per the previous article, the pelvic floor diaphragm is a dome shape, not a basin as it was believed up until the late 90s.

It comprises of three layers and is a group of muscles stretching from the pubic bone (front) to the tailbone (coccyx; back). They extend outward on both sitting bones (ischial tuberosity) on the right and left sides of the pelvis. The pelvic floor muscles have two main functions: They provide support or accessibility as a floor for the viscera of the abdomen, including the rectum. Furthermore, they provide a constrictor or continence mechanism for the urethral, anal, and vaginal openings (in females).

Ideally, the pelvic floor has a dome shape in a resting position. The pelvic floor stretches on the inhalation and contracts on the exhalation. This is where we see a direct correlation between pelvic floor and respiration.

If ailments arise, it is important to differentiate between hypertonicity (tight) and hypotonicity (weak) of the pelvic floor muscles. Both are not ideal and will be explained based on the example of accidental urine loss.

Hypertonicity is when the muscles are excessively tight or contracted. Imagine a fist being the pelvic floor and a person coughs. With such a tight muscle, urine cannot be held.

Hypotonicity is a condition characterized by the presence of a lesser degree of tone or tension, i.e. weakness in the muscles. Imagine a flat hand, or even a bit of a convex curve while opening the hand, where the water would simple flow off. People experiencing a hypotonic pelvic floor commonly have weak gluteus muscles. Therefore, strengthening and stabilizing exercises for this area of the body is an essential part of recovery.

Some people may have both: one weak side and/or one tight side. If a combination of both is experienced, then the tight muscles need to be addressed first by learning to let go or release again, before adding in strength practices. Chronical muscle tightness can be improved in a short period of time although in some cases, it can take up to a year or more and may therefore require consistency and lots of patience to see results.

Why Yoga?

Yoga is not a 1:1 replacement for scientific, medical approaches. However, it can benefit the healing process in many ways, and should always be considered as a first course of action before undertaking any sort of ‘aggressive’ medical procedures.

Pelvic floor ailments are very different to a broken (arm) bone for instance. The root cause of pelvic floor ailments are not as obvious and easily diagnosed by a medical doctor as that of a broken bone and may require more in-depth analysis. In turn, a broken bone can be diagnosed with a simple x-ray.

Through understanding the anatomy and muscles, gaining body awareness and various insights of the functions of the own body, one can more easily describe how the body feels, gain more awareness and play an active role in the diagnostics and recovery process.

There is still much to come regarding research and medical studies about how yoga can help alleviate pelvic floor ailments and health, but it is gaining more attention and traction in the medical and physiotherapeutic field, as shown through several recent studies.

Where to Go from Here?

The following suggestions are rather general and not tailored to any particular individual as would be the case in a one-on-one therapeutic session:

Recommended practices for tight pelvic floor muscles (hypertonic):

1. Daily whole body breathing.
2. Mindful posture (avoid the common ‘Hanging’ in one hip while standing or sitting in a hunchback).
3. Poses to relax and stretch the pelvic floor muscles (e.g. relaxation pose with weights to start, happy baby or half happy baby, figure four, supported bridge, DFD, wide legged forward fold, child’s pose and savasana).

The tight muscles need to be addressed first by learning to let go or release again, before adding in strength practices.

Recommended practices for weak pelvic floor muscles (hypothonic):

1. Daily whole body breathing.
2. Mindful posture (avoid the common ‘Hanging’ in one hip while standing or sitting in a hunchback).
3. Pelvic floor contractions (both quick and longer holds in several different positions: lying prone or supine, sitting, all fours, puppy pose).
4. Poses to stabilize and strengthen (e.g. tadasana, warrior pose, triangle pose, cat and cow, plank, supported bridge, legs up the wall).

The following practices are aimed at supporting and regaining pelvic floor health and are just as useful for healthy individuals, as they are also aimed at teaching body awareness. The ‘useful for’ below will help navigate for people experiencing pelvic floor ailments.

Note: Check the previous article for recommended props and alignment for asana practices such as tadasana, DFD and child’s pose.

1. Whole Body Breathing

Useful for: General wellbeing and any health condition.

A whole body breathing practice focusing on the domes of the body and expansion of the respiratory diaphragm and pelvic floor diaphragm. Lie in these two positions shown on the pictures above and change according to the following instructions.

For full guidance, listen to the Whole Body Breathing Audio Practice by Katharina Claeys.

Props: Blanket or rolled up towel for neck support, bolster or cushion under the knees.

How to practice:

1. Place the hands on the upper chest between the collarbones and the breast tissue. Direct the attention to the movement of the breath. Focus on the inner-side ribs while widening the breath. Observe the chest as the lungs fill, front, side and back.
2. After a few minutes, slide the hands onto the belly beside the navel. Shift the focus to start breathing deeply into the belly and pelvis.
3. The movement of the breath will become less pronounced in the chest as the focus shifts to the sensations in the belly, pelvis and lower back.
4. Linger here as long as desired.
5. Finally, expand the breath awareness to include the limbs, paying attention to the tips of the fingers and toes.

Duration: 5-15 minutes, or as long as desired

Modification: If lying down is not accessible, sit in a comfortable upright position (e.g. on a chair).

2. Child’s Pose – Balasana

Useful for: More for hypertonic pelvic floor, since it is also a stretching pose. However, it is also suited for hypotonic pelvic floor, due to its benefits for breath awareness and relaxation of the other domes.

This pose is a forward fold and resting pose, also recommended in the article The Interconnection of the Body’s Domes. Generally it can be done without any props. To gain the full benefits for hypertonic pelvic floor muscles it is recommended to use props and focus on the described alignment.

The stretch of the pelvic floor muscles can be better supported by practicing this pose with the sides of the torso resting on a bolster and the big toes slightly apart. The sitting bones should point away from the crown of the head (not down toward the floor). Test the amount of support on the top of the heels that your body needs to achieve this.<

Props: Bolster, two blocks and one or two blankets (for e.g. knee cushioning and one-two between buttocks and heels).

How to practice:

1. Place the big toes 2 inches away from each other and bring the knees slightly wider than hip distance apart. Place the folded blanket on the heels. The bolster supports the ribcage but does not restrict the movement of the breath in the abdomen.
2. Walk the hands forward (with or without the blocks) and rest the forehead on the bolster (folded towel for the forehead to keep the head straight (e.g. neck pain) or to a preferred side).
3. Rest here for 1 minute.
4. Now gently press the hands into the blocks and focus the attention on the breath.
5. With each inhalation, let the breath come to the sacrum and the back of the pelvic floor. With each exhalation, visualize unwanted tension leaving the body.
6. Then shift the focus of the breath to the lower back and breathe here until walking up to the mid back.
7. Stay as long as you like.
8. To get out of this pose, walk the hands in, until they are in front of the knees and push into the hands and arms to come up.

Duration: 1-5 minutes

3. Cat & Cow – Marjaryasana & Bitilasana

Useful for: It is highly recommended for hypertonicity and prolapsed uterus, bladder or rectum.

This pose is very practical to feel the different layers of the pelvic floor muscles, in particular layers one and three. By practicing this pose one can feel the tucking (posterior tilt) and untucking of the pelvis (anterior tilt). This shortens and lengthens the pelvic floor muscles from pubic bone to tailbone and from sitting bone to sitting bone.

When practicing the cat and cow pose, breath and movement will be combined. It is an exaggeration of what happens during normal breathing in relation to movement of the pelvis. Take a few moments to coordinate the movement with the breath (Inhale cow, exhale cat).

Props: Optional; perhaps a blanket for cushioning for the knees.

How to practice:

1. Come into the hands and knees and start in table top position. The pelvic floor should be in a neutral position.
2. Make sure the hands are directly under the shoulder joints and the knees directly below the hip joints.
3. The top of the feet flat on the floor. If this is uncomfortable for the knees, tuck the toes under, but make sure the pelvis stays neutral.
4. Start with cow pose: On inhalation lift the head and the tailbone toward the ceiling – the spine will automatically arch. Lengthen the front abdominal muscles. By bringing head and tailbone up, the pelvic floor lengthens.
5. Transition through neutral (table top) into cat pose: On the exhalation, round the spine up toward the ceiling, arching now in a dome shape. Draw the sides of the navel toward the spine and move the head and tailbone toward each other, same as they would like to see and greet each other. By tucking the head and tailbone, the pelvic floor shortens.
6. Continue in your own rhythm by following the breath for 3-6 rounds and alternating between cat and cow.
7. Stop in table top, come to a comfortable seat and shake the wrists out.

Duration: 3-5 minutes

Modification: If experiencing discomfort with the wrists at a 90 degree angle, use blocks to rest the forearms. A folded blanket or mat can elevate the heels of the hands higher than the fingers and reduce the angle of wrist flexion. Alternatively, make gentle fists and lean on the knuckles.

Note: People experiencing severe pelvic pain should not curl the tail too intensively in cat pose. Follow and listen to the guidance of your unique body.

4. Locust Pose – Salabhasana

Useful for: Hypotonicity of the pelvic floor.

As described above, people with hypotonic pelvic floors commonly have weak gluteus muscles. This can be the case across the entire buttocks or on one side more than the other (imbalance). The locust pose helps to balance the gluteus and pelvic floor muscles.

This variation of the pose focuses on using the gluteus maximus muscle to lift the leg. This helps to evaluate the tone of the gluteus maximus and determines the extent of a left-right imbalance. The postural mechanics are similar to that of proper walking.

By practicing this pose, ensure the pelvic floor and the abdominal muscles engage simultaneously and the pelvic floor is lifting (not pushing down). This process requires particular patience.

4.1.Half Locust – Ardha Salabhasana

Props: Blanket to support the forehead and elongate the cervical spine (neutral position). Option to use a blanket to pad the frontal hip bones (ilium).

How to practice:

1. Prepare the blankets on the mat, one providing padding for the hip bones and the other for the forehead.
2. Lie down in a prone position with the arms by the side. Place the forehead on the blanket.
3. Press the fingertips into the mid buttocks. Turn the thighbones slightly inward to create space around the tailbone.
4. On exhalation (not inhalation!), lift the perineum whilst gently drawing the abdomen away from the floor. Focus on the right side and the fingertips. Raise the right leg up.
5. Keep the leg raised for 30-60 seconds, breathe and maintain the lift in the perineum and abdomen. Check the buttocks’ firmness with the fingertips. Pause and stop earlier if the alignment of the pose cannot be maintained.
6. Lower the right leg on exhalation.
7. Rest for a few breaths and repeat the same on the left side.
8. Notice if one side does engage differently than the other or is less firm.
9. Lift the legs together and compare both sides. Hold again for 30-60 seconds and slowly lower the legs and relax the whole body with the help of deep breaths.

Duration: 3-5 minutes with restful moments

Modification: Make sure the abdominal muscles are engaged if the lower back compresses. Double- check the height of the lifted leg – it does not have to be raised too much.

If there is an imbalance of the gluteus and pelvic floor muscles, start on the weaker side and practice this side a few extra times.

4.2 Full Locust Pose – Salabhasana

The full locust pose focuses on lifting both legs at the same time. If the body showed a left-right disparity, consciously engage the weaker buttock before lifting the legs.

Props: Blanket to support the forehead and elongate the cervical spine (neutral position). Option to use a blanket to pad the frontal hip bones (ilium).

How to practice:

1. Prepare the blankets on the mat, one providing padding for the hip bones and the other for the forehead.
2. Lie down in a prone position with the arms by the side. Place the forehead on the blanket.
3. Bring the hand to the buttocks and press the fingertips in the middle of each buttock.
4. Engage the abdominals up from the floor and contract the gluteus and hamstring muscles simultaneously.
5. Lift both legs from the floor on an exhalation. Hold for 10-30 seconds and keep breathing.
6. Lower down again on exhalation.

Modifications: If the lower back still feels compressed, place a folded blanket under the abdomen between the navel and pubic bone. A commonly-known fun variation to complement chest opening is to clasp the hands behind the back while lifting the legs.

Further Resources with Yoga Medicine

1. Whole Body Breathing Audio Practice – Katharina Claeys
2. Yoga Medicine Podcast Episode 25: Pelvic Health with Melissa Oleson
3. The Interconnection of the Body’s Domes – Katharina Claeys for Yoga Medicine
4. An Intro to Fertility Yoga – Kendra Tolbert for Yoga Medicine

References

1. Digitale, Erin (2024): Low-Impact Yoga and Exercise found to help older women manage urinary incontinence. Article for Stanford Medicine. News Center. 03.09.2024. https://med.stanford.edu/news/all-news/2024/09/yoga-exercise-incontinence.html, last accessed 12.11.2024
2. Blagg, M.; Bolgla, L. (2023): The Relative Activation of Pelvic Floor Muscles during selected Yoga Poses. Elsevier Ldt. (Publisher). Complementary Therapies in Clinical Practice. Vol. 52. Aug. 2023.
3. Hjartardottir, S; Nilsson, J.; Petersen, C., Lingman, G. (1997): The female pelvic floor: a dome –not a basin. Acta Obstetricia et Gynecologica Scandinavica. Vol. 76. Issue 6. Jun. 1997. Pages 495-611. https://obgyn.onlinelibrary.wiley.com/doi/epdf/10.3109/00016349709024586, last accessed 11.11.2024
4. Howard, Leslie (2017): Pelvic Liberation: Using Yoga, Self-Inquiry, and Breath Awareness for Pelvic Health. Leslie Howard Yoga (Publisher).
5. Huang, Alison J.; Chesney, M.; Schembri, M.; et al. (2024): Efficacy of a Therapeutic Pelvic Yoga Program versus a Physical Conditioning Program on Urinary Incontinence in Women: A Randomized Trial. Annals of Internal Medicine. Issue 177. Aug. 2024. Pages 1339-1349. https://www.acpjournals.org/doi/10.7326/M23-3051, last accessed 12.11.2024
6. Myers, Thomas W. (2020): Anatomy Trains: Myofascial Meridians for Manual Therapists and Movement Professionals. Elsevier (Publisher).
7. Park, H.; Han, D. (2015): The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. Journal of Physical Therapy Science Jul; 27(7). Pages 2113-2115.
8. Raizada, V.; Mittal, R. K. (2008): Pelvic Floor Anatomy and Applied Physiology. Gastroenterology Clinics of North America. Vol. 37. Issue 3. Sept. 2008. Pages 493-509. https://www.sciencedirect.com/science/article/abs/pii/S0889855308000423?via%3Dihub, last accessed 11.11.2024

About the Author

Katharina Claeys is an experienced and registered RYT 500, RPYT, RCYT, baby yoga teacher and Yoga Medicine® Therapeutic Specialist specializing in women’s and children’s health and corporate yoga.

By giving every student the space, respect and attention they deserve, she is committed to the growth of her clients and teaches with the hope that each student will find the spark they need to stay mindful, curious and inspired during their time on and off the mat. Breathing exercises (pranayama), myofascial release techniques (MFR) mindful practices and meditations are a key aspect of her classes. In her 1:1 sessions, Katharina creates individualized therapeutic yoga practices whatever health concern or age. She emphasizes on optimizing physical and physiological function by combining anatomy, physiology, mental health, in relation to modern science and research.

Links

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