Pelvic Floor Exercises for Older Adults

Who may benefit

• Women and men with stress incontinence: leaks with coughing, sneezing, laughing, lifting or standing up.
• People with urgency or an overactive bladder: exercises help to suppress urgency; see bladder training and timed toileting.
• Women with mild pelvic organ prolapse or after childbirth.
• Men after prostate surgery, or with dribbling after passing urine.
• People with mild bowel leakage or leaking gas; see bowel incontinence and constipation in later life.
• People wanting to prevent problems.

Exercises are less suitable, or need adaptation, for people who cannot follow instructions, such as many with advanced dementia, or who have very weak or nerve-damaged muscles, or an overactive pelvic floor that is too tight. In those cases, other approaches, such as prompted toileting, are used; see incontinence and dementia: routines and reassurance. Overflow incontinence, from a bladder that does not empty, needs medical assessment, not exercises alone; see incontinence in older adults: causes and types.

Step 1: find the muscles

It can be surprisingly hard to find the right muscles, since they are internal. Try one of these, in private, sitting or lying with knees bent and apart, and relaxing the thighs, buttocks and belly:

• Imagine stopping wind. Squeeze the muscles around the back passage as if trying to hold in gas. You should feel a lifting and tightening inside.
• Imagine stopping the flow of urine midstream. Feel the muscle tighten at the front.
• For women: imagine lifting a tampon or a marble upwards inside the vagina. A clean finger gently placed inside the vagina can feel a gentle squeeze and lift. A physiotherapist can confirm.
• For men: imagine pulling the penis inward and upward, or lifting the testicles slightly, while holding back gas. Standing in front of a mirror, you may see the base of the penis lift and the testicles rise slightly.

Important: you can use the "stopping urine" trick to identify the muscles, but do not practise your exercises regularly while urinating, since this can interfere with normal emptying and may increase the risk of infection. Do the exercises at other times.

Check that you are not using the wrong muscles: the belly, the buttocks and the thighs should stay relaxed. Place a hand on the abdomen: it should not bulge or push out. Do not hold your breath. If you are unsure, see a physiotherapist.

Step 2: the exercises

### Slow, strong holds (endurance)

1. Sit, lie or stand comfortably. 2. Breathe normally. 3. Squeeze and lift the pelvic floor muscles gently, like holding in wind and urine, and hold. 4. Hold for as long as you can, up to about 10 seconds, while continuing to breathe. If you can only manage two or three seconds at first, that is fine. 5. Relax completely for a count of about 4 to 10 seconds. The rest is as important as the squeeze. 6. Repeat 8 to 10 times.

### Quick squeezes (strength and speed)

1. Squeeze and lift quickly, and release immediately, like a flick. 2. Do 5 to 10 quick squeezes, with a pause.

### How often

• Do the slow holds and quick squeezes three times a day, every day. Build gradually.
• Give it time: it may take three months or more to see a big improvement; many people notice some change within a few weeks. Guidance such as the NICE guideline for women with urinary incontinence recommends supervised pelvic floor muscle training for at least three months.
• Keep going afterwards, perhaps once a day, because muscles weaken again if exercises stop.

### Build into daily life: "the knack"

Squeeze and lift the pelvic floor just before and during actions that cause leaks, such as coughing, sneezing, laughing, lifting, standing up from a chair or bending. Practise until it becomes automatic. This can reduce leaks by a large amount in many people.

### Link to routine

Link the exercises to everyday events so they are not forgotten: after each toilet visit, while brushing teeth, waiting at traffic lights, during television advertisements, while sitting at meals or when lying in bed. Use a reminder on a phone or a chart on the wall. An exercise diary helps.

Progression

• Increase the hold time gradually towards 10 seconds, and the number of repeats towards 10.
• Practise in different positions: lying, sitting, standing and walking, as strength improves.
• Add functional movements, such as squeezing when climbing steps or standing from a chair.
• Combine with general exercise: walking, gentle strengthening and balance work; see chair exercises for seniors and walking programme for older adults.

Common mistakes

• Tightening the wrong muscles: the buttocks, thighs or belly.
• Holding the breath, or pushing down instead of lifting up (bearing down can worsen leaks and prolapse).
• Squeezing too hard or for too long, causing tiredness, or doing too many repeats in one go.
• Not relaxing between squeezes.
• Doing them while urinating as a routine.
• Using vaginal cones, weights or electrical stimulation devices without advice, since some are unsuitable or unsafe; ask a physiotherapist or doctor.
• Expecting immediate results, and giving up too soon.
• Stopping after improvement.
• Ignoring the cause, such as constipation, chronic cough, obesity or smoking, which put pressure on the pelvic floor.

Other measures that help

• Treat constipation and avoid straining; see constipation in older adults.
• Treat chronic cough and stop smoking.
• Keep a healthy weight.
• Lift safely, squeezing the pelvic floor and bending the knees.
• Reduce bladder irritants: caffeine, fizzy drinks and alcohol.
• Keep drinking normal amounts of fluid; see hydration for older adults.
• Sit properly on the toilet and do not strain or push hard.
• After menopause, discuss local oestrogen for dry, thin tissues with the doctor, which may help some women alongside exercises.
• Use pads as a safety net while exercises take effect; see pull-ups or briefs: choosing the right product.

Special situations

Men after prostate surgery. Exercises are widely advised before and after surgery, to speed return of urinary control. A physiotherapist can teach the technique, including the knack and exercises to prevent dribbling. Leakage often improves over months. See prostate problems and urinary symptoms in older men.

Women with prolapse. Exercises may help with mild prolapse and symptoms. Report a bulge, heaviness, dragging sensation, difficulty emptying the bladder or bowel, or discomfort; the doctor may advise a ring pessary, surgery or other treatment. Avoid heavy lifting and straining.

People with arthritis or limited mobility. Exercises can be done lying or sitting. Adapt positions.

People who are frail. Gentle, short sessions work. Combine with chair exercises, and avoid fatigue.

People with Parkinson's disease or after stroke. Exercises may help, but muscle coordination can be impaired; a physiotherapist should guide. See Parkinson's disease at home: a practical guide and stroke recovery at home guide.

People with an overactive or too-tight pelvic floor. Pain, difficulty starting urine or stool, pain with intercourse or constant tension suggest muscles that are too tight; strengthening exercises can worsen this. See a pelvic health physiotherapist.

People with dementia. Exercises are hard to teach; prefer prompted toileting.

Getting professional help

Pelvic health physiotherapists are trained to assess the muscles with an internal or external examination (with consent), teach the correct technique, use biofeedback (devices that show muscle activity on a screen) and set up a programme. Ask the doctor for a referral, or search for physiotherapists specialising in women's or men's health or continence. Availability in India varies; major hospitals and some private clinics offer it, and teleconsultation may be available; see using home readings in a teleconsultation. Be sure to explain to the clinician your comfort needs and preferences for a same-gender therapist; see dignity in intimate care: words, privacy and consent.

Keeping track

Keep a simple record of exercise sessions, leaks per week and pad use. Compare after four, eight and twelve weeks. Share it with the doctor. If there is no improvement after three months of correct practice, ask about other treatments such as medicines, devices, bladder training or surgery.

Warning signs: see a doctor

• Blood in urine, or pain on passing urine.
• Inability to pass urine or an incomplete emptying, weak stream or dribbling.
• A bulge in the vagina or at the anus.
• New back pain with leg weakness or numbness, or loss of bladder and bowel control with numbness around the groin or buttocks: an emergency; call 112.
• Sudden onset of incontinence, especially after a fall, stroke or surgery.
• Persistent pelvic pain.
• Recurrent urinary infections; see urinary tract infections in older adults: atypical signs.
• Fever or confusion with urinary symptoms.

See when to see a doctor about bladder or bowel changes.

When to ask a professional

Ask the doctor to check why leaks are happening and whether exercises are appropriate. Ask a pelvic health physiotherapist or continence nurse to teach and review your technique. Ask the pharmacist about medicines that affect the bladder. Seek urgent help for inability to pass urine, severe pain, fever with confusion or loss of bladder and bowel control with numbness or leg weakness.