While wisdom is a welcome cornerstone of aging, some of the physical changes are not. Stiffer joints, weaker bones and wrinkles are all common complaints associated with growing older. But other challenges — like pelvic floor problems — are just as prevalent even if they're not as widely discussed.
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Like any other muscle in the body, your pelvic floor (the bowl of skeletal muscles that sit at the bottom of the pelvis) tends to lose strength as you age. And having a weak pelvic floor can drive a damaging domino effect of other issues, including urinary incontinence.
Though aging is inevitable, pelvic floor dysfunction doesn't have to be. Here, we spoke to pelvic floor physical therapists to understand why your pelvic floor function may decline over time and what to do to prevent it.
"Skeletal muscle atrophy and associated weakness are inevitable as we age, and the pelvic floor muscles are no exception," says Ruth Maher, PT, PhD, DPT.
Once you hit 30, you 'll lose as much as 5 percent of your muscle per decade, according to Harvard Health Publishing. By the age of 70, muscle mass and strength may decline by 10 to 15 percent per decade (and accelerate by as much as 40 percent per decade thereafter), Maher says.
"Many of these changes occur microscopically in the muscle fibers and the nervous system in addition to metabolic changes, which affect protein synthesis and body composition," Maher explains.
This decreased strength and muscle mass is related to myriad pelvic floor dysfunctions, including stress UI, pelvic organ prolapse, fecal incontinence and sexual dysfunction, she says.
For this reason, people assigned female at birth (AFAB) who never experience pregnancy or childbirth (more on that below) are still at risk for declines in pelvic floor function, says physical therapist Jessica McKinney, PT, DScPT, vice president of medical affairs and clinical advocacy at Renovia.
Pregnancy can weaken the pelvic floor muscles in a few substantial ways.
"First, the increased size and weight of the uterus alone places new strain on the pelvic floor," McKinney says. "During pregnancy, the pelvic floor and pelvic organs descend lower than their usual pre-pregnancy position, creating an increased burden for these muscles."
Secondly, constipation — which is common during pregnancy — can pose problems for the pelvic floor muscles. "If a pregnant person is regularly straining to have bowel movements, this can negatively affect the pelvic floor," McKinney says.
Plus, as pregnancy progresses, the body produces a hormone called relaxin, which reduces stiffness in the muscles and joints in preparation for birth, Maher says. The hormone allows your pelvic muscles to stretch — up to three times their normal length — during a vaginal delivery, she says.
The issue is, the pelvic floor muscles often become overstretched and weakened, with 70 percent of pregnant people experiencing stress urinary incontinence (UI), or urinary leakage during exertional stress such as coughing, laughing, sneezing or exercise, Maher says.
In some people, vaginal birth can result in damage to the pelvic floor, Maher adds. Factors like multiple pregnancies and a higher BMI can increase a person's risk of developing pelvic floor disorders, she says.
Maternal age is another factor. As you age, your pelvic floor muscles have a decreased ability to stretch during delivery, which makes them more susceptible to pelvic floor dysfunction (and a higher rate of C-section), Maher says.
"Consequently, it is essential for women to engage in pelvic floor training [more on this later] during pregnancy and after birth to facilitate a return to normal function," she says.
Insomnia, decreased libido and hot flashes are all hallmarks of menopause, and now you can add a weaker pelvic floor to the list.
In menopause, hormonal shifts are the culprit of pelvic floor problems. "The drop in estrogen level that occurs with menopause can cause pelvic tissues to become thinner, dryer and less resilient, making the pelvic muscles more prone to becoming weak," McKinney explains.
As a result, pelvic floor muscles may not be able to provide their supportive function, which can result in prolapse, or the descent of the pelvic organs through the vagina, Maher says. The first signs of prolapse include a feeling of fullness in the pelvis or vagina often accompanied by difficulty emptying the bladder and bowel.
What's more, decreasing hormone levels can also affect the integrity of the urinary sphincter's closing mechanism, which can increase a person's risk of developing UI during menopause, Maher says.
Menopause is also a time when general physical activity declines, and the subsequent loss of strength and muscle can, as we know, contribute to weakness throughout the entire body, including the pelvic floor, McKinney says.
Because of less-than-ideal dietary habits and decreased muscular activity in the intestinal tract, constipation (and its cousin, bloating) becomes more common as we age, especially in people older than 65, according to University of Michigan Health. And being backed up in the bathroom may be promoting problems in your pelvic floor.
"Chronic constipation and associated straining can take a toll on the pelvic floor, resulting in urinary symptoms and pelvic organ prolapse," Maher says.
In severe cases, some people even struggle with a defecation disorder caused by an issue with the mechanics of emptying the bowel, Maher says. "They cannot coordinate the abdominal, recto-anal and pelvic floor muscles to evacuate their bowels," she explains. Essentially, the pelvic floor muscles won't relax and release, so the stool cannot be excreted.
Pelvic floor-strengthening exercises are not appropriate for people with defecation disorders, Maher says. “Instead, these individuals may be taught by a physical therapist to relax or down-regulate the pelvic floor muscles using biofeedback,” she explains.
Consequences of a Weak Pelvic Floor
"Not surprisingly, muscles that aren't working well may not be able to do their job well," McKinney says. Weak or tight pelvic floor muscles can lead to a host of issues with a person's urinary and reproductive systems as well as sexual function.
Urinary incontinence (UI), or the involuntary loss of urine, is by far the most common consequence of pelvic floor issues as you get older. Indeed, the number of people who report incontinence drastically increases with age — from 37 percent of people AFAB in their 30s to 64 percent in their 80s, McKinney says.
While UI is common — affecting approximately 250 million people AFAB worldwide — it is not normal, McKinney says. And it can have a significantly negative effect on a person's quality of life, including their mental health, relationships and intimacy.
For instance, people often limit their social engagements to avoid the unpredictability of UI, and consequently, experience feelings of isolation, McKinney says.
Many also reduce physical activity and stop exercising (which can trigger urine leakage) to manage UI symptoms, but this just exacerbates the problem, as it can cause functional decline and even worsen UI over time, McKinney says.
Avoiding exercise due to UI, along with the resulting loss of muscle mass and strength, can also have a snowball effect, putting older people at a greater risk for falls, hospitalization, nursing home admission and dependence on a caregiver, McKinney says.
In addition to UI, pelvic floor problems can also cause fecal incontinence (the involuntary loss of stool) and prolapse (when the pelvic organs drop low enough to bulge into the vagina), McKinney says.
How to Prevent (and Manage) Pelvic Floor Problems as You Age
What can you to do to protect your pelvic floor over time? "That's the good news: a lot," McKinney says. "And you can begin at any age. Even if your pelvic floor is already weakened, and you know it isn't working as well as you would like, it's not too late to start and be successful."
The following interventions will help treat a weak pelvic floor and promote healthy pelvic floor muscle function.
1. Talk to Your Doctor
"The most important thing a person can do to protect their pelvic floor health is to have an open, honest dialogue with a health care provider," McKinney says. Not enough people are talking about bladder leakage, which suggests pelvic floor weakness, she adds.
Maher agrees: "Sadly, pelvic floor trauma is frequently underdiagnosed, with many unaware of its long-term effects."
That's why it's essential to speak to a doctor or physical therapist with expertise in pelvic floor health if you're having symptoms such as UI.
Avoid certain foods like caffeine, alcohol and carbonated drinks, which may irritate the bladder and worsen symptoms of UI, McKinney says.
2. Maintain a Healthy Weight
"Having overweight is a risk factor for many pelvic floor dysfunctions, including urinary incontinence," Maher says. Excess weight can put stress on the pelvic floor and cause problems.
3. Exercise Regularly
"A sedentary lifestyle further compounds the effects of aging, so we must engage in regular exercise, especially resistance training, to stimulate muscle and bones and help maximize mobility and overall function," Maher says.
Strength training is especially essential to help protect against age-related bone conditions like osteoporosis.
4. Combat Constipation
5. Do Pelvic Floor-Strengthening Exercises
"Like any other muscle group, your pelvic floor can be strengthened," McKinney says. Pelvic floor muscle training (PFMT) involves a program of exercises that helps build strength in the pelvic floor muscles and maximizes their function.
The major challenge of PFMT is ensuring that you recruit and contract the correct muscles. "We cannot see the [pelvic floor] muscles — they do not move a joint — so, consequently, many people perform these exercises incorrectly," Maher says. For example, some will engage the gluteal or inner thigh muscles, or perform a bearing down maneuver (like when you have a bowel movement).
"To perform pelvic floor exercises appropriately, people need to identify the contraction they would use to stop the flow of urine or prevent wind from escaping from their back passage," Maher explains.
How to Do Pelvic Floor Exercises (Kegels)
Once you’ve located the correct muscles, follow these steps, which are only meant as a general guide for those with a weak pelvic floor, per Maher:
- Make sure your bladder is empty before you begin. But never perform PFMT on the toilet while urinating, as this can cause problems with voiding the bladder.
- Start by lying flat (or with your knees bent) on the floor or a bed.
- Relax, then gently contract the pelvic floor muscles and hold for eight to 10 seconds (if you can’t contract your muscles for this long, start with four to five seconds).
- Release the contraction, relaxing the muscles entirely for the same amount of time. The relaxing phase is just as important as the contraction phase.
- Repeat this contract-release pattern for 10 repetitions.
- Follow this with 10 brisk short contractions. These quicker contractions help improve your muscles’ coordination.
"Your muscles may tire quickly at first, so stop and try again later in the day," Maher says. Once you've built some strength in this lying position, try your pelvic floor exercises while sitting and standing. "It is essential to load the muscles in various positions, especially for individuals with stress urinary incontinence, as most leaks occur while standing," she says.
You can also practice the short, brisk contractions during activities that cause leaks (like coughing, sneezing and laughing). This helps train the pelvic floor muscles to resist increases in abdominal pressure, Maher explains.
Because locating and recruiting these muscles can be difficult, people who work with pelvic floor experts are usually more successful when doing PFMT, McKinney says. In fact, data shows that only 25 percent of people can do pelvic floor exercises effectively on their own, she adds.
Need help finding a pelvic rehabilitation practitioner? Resources like PelvicRehab.com and the Academy of Pelvic Health Physical Therapy are great places to locate a qualified pelvic floor physical therapist.
If you consistently do pelvic floor exercises, you can build strength and coordination over a few months. “Don’t stop when you start to see an improvement,” Maher says. “You need to make pelvic floor exercises part of your self-care routine — do them in bed, in the shower, driving or standing in line.”
6. Try a Pelvic Floor Trainer Device
"The expansion of digital health technologies has ushered in smartphone applications and devices that are available to help women with daily PFMT practice," McKinney says.
But keep in mind: Not all devices are created equal. "Aim for an FDA-cleared device supported by published data and clinical studies that allows a health care provider to participate in a person's training," McKinney says.