When it comes to your gym routine, early morning jog or weekly netball game, protecting your pelvic floor muscles probably isn't the first thing to spring to mind. After all, isn't simply moving your body what health professionals have been harping on about for years?
Well, it turns out that many women who suffer from or are at risk of developing pelvic floor problems such as incontinence – which affects an estimated five million Australians – can make matters worse with some types of exercise.
Here's what you need to know about being pelvic floor safe.
The pelvic floor muscles look a bit like a round mini-trampoline. They support the pelvic organs – the bladder, bowel and uterus – and give us control over the bladder and bowel. Busting for the loo but need to hang on because the line for the public bathroom is super long? Those are your pelvic floor muscles working.
When you exercise, the internal pressure in the abdomen changes as you move. Strong, healthy pelvic floor muscles respond to the change in pressure and continue to protect the pelvic organs, whereas weakened pelvic floor muscles may become overloaded and unable to cope with the extra strain.
READ MORE: Are you suffering from pelvic pain?
"If there's any downward pressure, like if you jump up and down or lift something, the pelvic floor muscles will stop you leaking," says Jill Wood, a pelvic health physiotherapist at Pelvic Floor Physio. "The pelvic floor lifts the pelvic organs up inside the pelvis and resists the force of intra-abdominal pressure and impact exercises.
However, if the force on the pelvic floor is too great, it may result in some problems, such as urinary leakage [incontinence] and even prolapse."
WATCH: How to do your pelvic floor exercises.
Common symptoms of a weak pelvic floor include leaking when you sneeze or laugh, failing to reach the toilet in time and tampons that dislodge or fall out.
You're at higher risk of a weak pelvic floor if you're pregnant or have ever had a baby (an estimated one in three mums are affected by incontinence), you're going through or have been through menopause or you've had gynaecological surgery like a hysterectomy. Other risk factors include a history of back pain, a chronic cough, being overweight and regular heavy lifting at work or the gym.
READ MORE: The best and worst exercises for pregnancy.
Some women have a naturally weak pelvic floor. "I see young women who haven't had children and aren't menopausal but they have weak pelvic floor muscles," says Wood. One study published in the Annals of Internal Medicine found 13 per cent of young women who hadn't had children were affected by incontinence.
Plus, Melissa Davidson, a pelvic floor physiotherapist at Remarkable Physios and spokesperson for Physiotherapy New Zealand, says a weak pelvic floor is more common among bendy folks.
"We know that if you are super flexible – about 10 per cent of the population – your collagen or muscle fibres are looser than everybody else's, which means you're at higher risk for damage to ligaments and muscle."
If you have or are at risk of having a weak pelvic floor – which, let's face it, is a significant proportion of the sisterhood – high-impact aerobic and resistance exercises are best avoided or modified, as they're more likely to place a strong downward strain on the pelvic floor.
Basically, that's anything that includes a lot of running, jumping and rapid changes of direction such as netball, trampolining or lots of running.
Research into the effects of resistance exercises is still in its infancy, but it's believed that exercises such as sit-ups and crunches, medicine ball rotations, deep lunges, jump squats, lifting heavy weights and full push-ups are risky.
"In particular, anything where you're twisting your trunk can be a problem because when you compress the abdominals, if there's weakness with structure and support of the pelvic floor, you're going to get a downward pressure which could aggravate prolapse symptoms, cause prolapse or aggravate bladder and bowel problems," says Wood.
Davidson cautions that much of the current advice on resistance exercises is based on clinical observation rather than scientific study, but says it's best to steer clear of extreme forms of training.
"If you're five foot nothing, weighing 40kg and you're trying to heave a tyre, for example, I personally wouldn't be happy with that," she explains. "We might not know yet but we'll probably find out that that's not very good for your pelvic floor."
So which exercises are safe? Walking, swimming, seated cycling, "jogging" on a cross-trainer and low-intensity exercise classes are great choices to get your heart rate up without putting your pelvic floor at risk. In the gym, seated exercises, dumbbell exercises on an exercise ball, shallow squats and wall push-ups will protect the pelvic floor.
Technique is extra important when it comes to resistance training.
"If the exercise is done perfectly with good attention to posture and technique, there's not as much risk," says Wood. "You must also be able to breathe through the exercise, because if you close the throat, it increases downward pressure – so don't hold your breath. And when you're lifting weights, lift and contract your pelvic floor so it stays up for the duration to resist that downward pressure."
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She says it's best to release after each set of eight to 10 repetitions to allow the pelvic floor to rest. With standing or squatting exercises, keep your legs no further than shoulder width apart.
Unsurprisingly, there is one exercise that the experts say all women should perform every day. You guessed it: pelvic floor exercises.
Davidson says daily squeezing helps keep the pelvic floor strong, and can cure incontinence in 80 per cent of cases.
"Women who haven't done pelvic floor exercises before, and have some kind of leaking, will likely find that if they do pelvic floor exercises a few times a day, in about two weeks they'll notice some difference," says Zumbraegel. "It's like any muscle: if you don't use it, you'll lose it."