Some intense core abdominal Pilates exercises have potential to cause or increase pelvic floor dysfunction. Unfortunately at times women commence Pilates exercises to strengthen their core muscles only 
to find that they develop or worsen pre-existing pelvic floor problems as a result. Women returning to general exercise programs after gynaecological surgery should be particularly aware of the potential for intense core PIlates exercises to cause pelvic floor strain.
Not all Pilates exercises are unsafe for the pelvic floor and many can be performed with confidence despite pre-existing pelvic floor problems. This expert article is intended to inform women about appropriate Pilates exercises not to alarm.
Read on now to learn:
- Who is at risk with some Pilates exercises
- How intense core exercises can cause pelvic floor problems
- Pilates exercises to avoid with pelvic floor dysfunction
- How to modify Pilates floor exercises
Who is at risk with some Pilates exercises?
Some women are more at risk than others with some intense core Pilates exercises including women:
- With pelvic prolapse and after prolapse surgery
- After a hysterectomy
- After bladder surgery
- With increased pelvic floor muscle tension or pelvic floor muscle spasm
- During and after menopause
- During and after pregnancy.
How can intense core Pilates exercises cause pelvic floor dysfunction?
There are two waysthat intense core Pilates exercises can contribute to pelvic floor problems:
A. Pelvic floor overload caused by strong contractions of the abdominal muscles (particularly the upper abdominal muscles which can generate a large amount of downward pressure onto the pelvic floor). If the pelvic floor is not able to withstand the associated downward pressure, then it can be forced downwards. When this type of exercise is repeated over time the pelvic floor can become stretched, strained and pelvic floor problems can become worse.
B. Increased pelvic floor muscle tension or overactive pelvic floor muscles resulting from intensely activating the core muscles including the pelvic floor muscles without learning to relax these muscles. In this way intense Pilates core exercises, particularly those that involve sustained core and pelvic floor contractions have the potential to cause overactive pelvic floor muscles that are unable to relax.
Pilates floor exercises with potential for pelvic floor dysfunction:
Please note: this following description refers to these exercises being performed without modification.
1. The Hundred
The Hundred exercise (pictured right) is a core strength and stability exercise involving both legs being raised and held in ‘tabletop’ position or the hips and knees raised simultaneously above the body at right angles. The intensity of this exercise is increased by raising the head and shoulders of the ground while maintaining tabletop position (including ‘Oblique Lifts’) and by extending one or both legs straight at 45 degrees from the ground (known respectively as the Single or Double Leg Stretch). This exercise and its variations have potential to contribute to pelvic floor overload and increased pelvic floor muscle tension.
2. Scissors
Scissors is also a core stability and core strength exercise. From tabletop position the legs are lowered to the floor alternately without changing the angle of the knee. The Scissors also has potential to contribute to pelvic floor overload and overactive pelvic floor muscles.
3. Dead Bugs
Dead bugs are another core stability and core strength using tabletop position. Dead bugs involve lying in tabletop position this time with the arms raised to the ceiling at right angles to the body. From this position the arms are raised above the head to the ground and one leg straightens while the other is held aloft. Dead Bugs activate those muscles having potential for pelvic floor overload and may also promote overactive pelvic floor muscles with insufficient muscle relaxation.
4. Chest Lift Holding (Sit-Up)
Maintained chest lift (pictured left) is a sit-up exercise that involves the head and shoulders being held lifted off the ground and maintained for a series of breaths. This exercise has the potential to force the pelvic floor down and overload it especially when repeated over time.
5. Roll Ups /Rolling Back
This exercise is designed to enhance spinal mobility. Roll ups involve rolling the body back into lying from a seated position on the ground. The legs are extended in front of the body. The body is then raised back up into sitting from the lying down position. The action of rolling down and returning to upright can both increase pelvic floor pressure and pelvic floor tension. Rolling Back involves similar abdominal muscles to the Roll Up but is performed with the knees bent Rolling back involves the strong upper core abdominal muscles contracting strongly when reclining and rolling back and also when returning upright. Both exercises have potential to contribute to overload the pelvic floor and/or inappropriately increase pelvic floor muscle tension. muscle activity.
6. Plank
The Plank Pilates exercise (pictured right) is designed as a core and upper limb strength and stability exercise. Plank is performed prone and body weight taken through the forearms or hands and the balls of the feet as the body is raised and held off the ground for a series of breaths. The Plank involves intense sustained contraction of the core muscles.
7. Push Up
Push Up is primarily a strength exercise for the core and a strength/stability exercise for the upper limbs. The Push Up involves the body in prone and weight bearing through the hands and the balls of the feet. From this position the body is lowered to and raised from the floor. This exercise involves intense repeated upper abdominal core muscle activation.
Are Pilates exercises inappropriate for all women?
No. Your ability to perform pelvic floor safe Pilates exercises is determined by how well your pelvic floor functions. If your pelvic floor is in good condition and you are not at increased risk of pelvic floor problems owing to your life stage or life events, then you may be someone who can perform these exercises unmodified. Unfortunately some women commence core exercise programs such as Pilates with a normally functioning pelvic floor only to find that they develop pelvic floor problems such as incontinence, prolapse or pelvic pain and increased pelvic floor muscle tension result.
How to modify Pilates floor exercises
Most of the exercises listed above aside from the Chest Lift and Rolling exercisescan be modified to reduce the pressure on the pelvic floor. Similarly women can learn to relax their pelvic floor and core abdominal muscles having once contracted them. These modifications will be discussed in an upcoming Pilates and pelvic floor safe exercises article.
Lisa Westlake physiotherapist and international fitness presenter has produced an innovative Fitball and Pilates DVD ideal for home exercise programs.
We welcome all comments from our readers below
About the author: Michelle Kenway is an Australian Pelvic Floor Physiotherapist, women’s exercise instructor and author of Inside Out – The essential women’s guide to pelvic support.
Please read our disclaimer regarding this information
This information is provided for general information only and should in no way be considered as a substitute for medical advice and information about your particular condition.
While every effort has been made to ensure that the information is accurate, the author accepts no responsibility and cannot guarantee the consequences if individuals choose to rely upon these contents as their sole source of information about a condition and its rehabilitation. Pelvic exercises accept no liability to any person for the information or advice provided, or for loss or damages incurred as a result of reliance upon the material contained herein.
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Hello. I’m so glad I found your site before beginning an exercise program. Thank you for providing free information & videos. Many of us can’t afford to buy the information we need so your help is appreciated immensely. I just recently learned about Callanetics exercises and wondered if there are any concerns for pelvic floor injury with any of the Callanetics exercises?
Re Callanetics and Pelvic Floor Safe Exercises
Hi Joanne
Thanks for this great question. From what I can see online, Callanetics is low impact which is great. I can see that there are a range of exercises in the Callanetics program that look quite suited to pelvic floor safe exercise. I have contacted Callanetics.com for some more information regarding their exercise program. I have not been able to view their abdominal exercises yet so I am unable to comment on these. I can see some really nice exercises in their online snippets. Are you watching a specific exercise DVD? Do you have any specific exercises that you wish to ask about in relation to Callanetics? I can answer this question when I have seen more details of the exercise program but let me know about specific exercises. Are there a lot of wide leg/forward bends standing exercises? Look forward to hearing from you further on this exercise program Michelle
Michelle, thank you for the quick response. I have the Beginning Callanetics DVD but haven’t done it yet so don’t have any specific questions. A clip can be seen here http://www.youtube.com/watch?v=fydaIpqPzZo
I was planning to start tomorrow so I’ll watch the whole DVD & be back with questions then!
Hi Joanne
I am glad you sent this link. See the exercises that comence at 8 seconds with the head lifting off the ground? This exercise involves the strong upper abdominal muscles which when activated increase pressure on the pelvic floor. Exercises that recruit these strong upper abdominal muscles lifting head and shoulders off the ground are not pelvic floor friendly if the pelvic floor is at risk, especially in women who have had previous vaginal deliveries. However this is not to say that this is not an appropriate exercise program. Like many exercise programs many exercises can be modified to be pelvic floor safe, a single leg raise without lifting the head and shoulders but rather with a gentle lower abdominal core contraction would have much less pressure on the pelvic floor. Send through your questions on this, it is an interesting exercise program. Cheers Micelle
I have often done the pilates abdominal strengthening exercises, situps, crunches and other similar exercises because I was told they would strengthen my back as I have some lower back problems – can you suggest how can I still strengthen my back muscles while avoiding those exercises that can negatively impact my prolapse? The two seem to be at odds with each other. Thanks so much!!
Re Back pain, core abdominal sit-up exercises and pelvic prolapse exercises
Hi Krystyna
Thanks for your comments. Unfortunately sit-ups and crunches won’t help with back pain. In fact they can often make low back pain worse depending on the problem, both through the sit-up action of repetitively bending forward and the over strengthening of the global abdominal muscles ( outer abdominal trunk moving muscles) as opposed to the local abdominal muscles (the inner trunk and spine core stabilisers). Furthermore sit-ups can overload the pelvic floor muscles (part of the core muscle make up) and place pressure on a prolapse.
There is considerable confusion regarding the issue of low back pain and appropriate core strengthening and I am glad you have raised this issue.
Regarding safe core exercises for the spine…the focus should be initially on the deep innermost core/trunk stabilising muscles. This involves a variety of methods from appropriate Pilates exercises with gentle deep abdominal muscle core control exercises (without both legs raised in the air!), appropriate fitball seated exercises including using weights while seated, you will see many of these types of exercises on our online hysterectomy recovery exercise videos such as this one http://www.pelvicexercises.com.au/safe-core-exercises/ for floor based exercises. Abdominal exercises for your spine are essentially about gaining control of the innermost local trunk muscles first. You don’t need to “feel the burn” for them to be effective for spinal control.
I hope this gives you some ideas on appropriate exercises for your low back pain and your pelvic floor.
Cheers Michelle
Thank you so much – that makes sense, I shall research how to strengthen those inner most core muscles more and watch your video etc – having been a dancer (modern dance) in my younger years I do have an innate understanding of the distinction you are making, just need to develop a good exercise regimen that is suitable. But your comments have been a good “aha” for me – so thanks for being there and willing to share your expertise and knowledge, I truly appreciate it.
Great to hear Krystyna, I am so glad you understand this, hope it helps with your long term health and spinal management, Michelle
Hi, thanks for sharing this
Info. Michelle how about yoga? Can that develop or worsen PFD?
Thanks!
Re Yoga Exercises and pelvic floor dysfunction
Hi Roweda
Yes some Yoga exercises can also increase pressure on the pelvic floor. Yoga exercises with potential to increase pelvic floor pressure include intense core exercises such as Plank holds and sustained positions such as deep wide squat holds amongst others. I do not in any way wish to detract from the fact that Yoga is a great form of exercise with a multitude of potential benefits for physical and emotional well being. Just like many forms of organised exercise it’s a matter of modifying or simply avoiding those exercises that may compromise the pelvic floor. Hope this helps Cheers Michelle
Thanks heaps Michelle!
Thank you for clarifying the problems related to Pilates and prolapse. I underwent surgery recently for a prolapse and hysterectomy Prior to this a physio experienced in women’s issues advised against Pilates. However not one of the physiotherapists where I did Pilates knew why! I will certainly continue my exercises further before returning to these classes. Thank you for preventing me from perhaps making problems return.
My pleasure Pauline, so glad to help clear this up a little for you
Best wishes
Michelle
Hi thankyou for your email. I had posterior prolapse surgery a year ago & this week am having:
1)sacropcolpopexy
2) rectopexy
3)AP Repair
I am really worried about returining to a gym. In the past I did aerobics, jogging & weights & circuit training. My first prolapse problem occured when I started weight training & I never lifted very eavy weights. What about exercise with the ball. Could I sit on the ball & do arm weight . I won’t ever jog againor do high impact aerobics. What about the , stepmaster elliptical machine, sideways & elliptical machine forward & back Cycling & spinning?
Thank you would love to know your views
Re Exercise after Prolapse Repair
Hi Pam
Thank you for your questions regarding prolapse repair. Just briefly for the understanding of other women reading this comment I will provide a couple of definitions here:
1. Sacrocolpopexy – surgery to suspend the vagina in some cases of vaginal vault prolapse (to part of the vagina)
2. Rectopexy – surgery to reposition the rectum in some cases of prolapse of the rectum
3. AP repair – surgical repair of the front and back walls of the vagina in some cases of anterior or bladder prolapse (cystocoele) and posterior vaginal wall prolapse (rectocoele).
Pam you can see that the surgery is a number of surgical procedures and this surgery involves lifting your pelvic organs back into position in your pelvis. In terms of exercise after this type of surgery this means that long-term it is advisable to avoid exercises that place downward pressure on the pelvic floor in addition to ensuring that the pelvic floor muscle support is as good as it can be.
Strength training needs to be supported and appropriate without a doubt to ensure minimal pressure is placed on the pelvic floor. This is indeed quite possible however you need to become educated about what is safe and what to avoid. You will see many free articles and videos on pelvic exercises designed for this purpose at Exercise after Prolapse Repair . Inside Out is entirely dedicated to teaching women such as yourself and I suggest that you would benefit greatly from reading this information, especially since this is your second prolapse operation and this seems to be far more extensive than the first.
In terms of specific exercises and how much pressure they place upon the pelvic floor: cycling and spinning whilst using low gears and sitting in the saddle is appropriate for women to minimise pelvic floor pressure, the elliptical machine is similar in that it is low impact, but it is important to use little force through the upper body. Stairmaster may have the potential to increase pressure on the pelvic floor compared with the previous two forms of exercise.
I hope this helps you with your long-term recovery and return to fitness following your prolapse repair Carol.
Best wishes
Michele
4 weeks ago, I had a repair of my Stage III cystocele (prolapse of bladder). The surgery I was fortunate to have by a uro-gyn surgeon: sacrocolpopexy. I am extremely pleased with the results, especially when walking and no longer feeling that heavy bulging with each step.
I downloaded your exercise book, and have been using it during my rehab. Your careful explanations and your video clips give me the confidence to exercise! Thank you for your expertise and evidence-based recommendations!
Is the yoga ‘downward dog’ position ok to perform after I’m 3 months post-op (i.e. surgeon says to be careful until then).
Re Downward Dog Yoga Exercise and Prolapse repair
Hi Lela
Thank you for your comments.
There is little research available to my knowledge on this type of yoga exercise and the pelvic floor, epecially after prolapse repair. We do know that bending forwards increases pressure within the abdomen but if your think about the position of your pelvis in downward dog (i.e. pelvic floor elevated) one would think that it should not place major pressure on the pelvic floor. I always ask women to try to recall those exercises that they noticed placed pressure on their pelvic floor and prolapse prior to surgery. This can often give many clues to what to avoid post op too. Downward dog can always be modified too by leaning onto a bench or a stabilised fitball against a wall. This would be a good way of easing into this exercise post op when you have approval to recommence yoga exercises.
Best wishes for a good recovery Lela
Michelle
Thanks, I’ll try those tips! Your information and website are helpful! Lela
Hi Michelle,
Thank you very much for your help!
You mentioned some time ago about a dvd with yoga exercises that are pelvic floor friendly.
Did you change your mind or still working on it?
I wish I had found this before I started at the gym 6 years ago! They gave me exercises to strengthen my pelvic floor. They are the very ones which you have pointed out as being the wrong ones. I now have a slight bladder prolapse which I didn’t have before! I am 64, had four vaginal birthings, one instrument assisted in which I felt pulling of the tendons supported the bladder. You have a brilliant website here and I am emailing the link to my daughters. Thanks heaps.
Pilates and bladder prolapse
Hi Sue
Yes this is such a shame to hear. Pilates is such a great from of exercise for most women. It is so frustrating to hear about well intentioned women such as yourself encountering this issue with exercise prescription. I will say that knowledge in this area is only recently becoming more available with studies from about 2005 revealing some of the risks associated with core abdominal exercises.
Sue you have had multiple births, instrumental delivery and pelvic floor injury during childbirth and this says in flashing lights that your pelvic floor is and probably has been vulnerable to injury for quite some time. Added to this your post menopausal status and the risk of pelvic floor injury with inappropriate exercises increases. Wouldn’t it be great if women were screened before starting their exercise program as to their risks for pelvic floor dysfunction. Then their exercise program could be tailored more specifically to them and avoiding intense inappropriate core exercises such as those in this article where appropriate.
I think it is great that you are making your daughters aware of this issue. The more women that exercise safely according to the status of their pelvic floor, the better.
Thank you for taking the time to comment Sue
Best wishes
Michelle
Hi Michelle,
Thanks so much for your informative information.
Although I had never heard of these potential risks to pelvic floor I have always suspected that some exercises I have been doing for years were having a negative effect in certain areas.
What a wonderful thing your knowledge is their to be shared for us women just at the click of a mouse .
I am very grateful to have learned such helpful information from spot on articles you have supplied
Thankyou
suzie.
I am so glad I found you! I am floundering when it comes to what exercises are ok. What about brisk walking? I am desparate to find the right things to do. I have not had to exercise for weight control, but now that I’m 56 yrs young, I am losing my strength and flexibility. Help!
Re Strength exercises post menopause
Hi GentleWind
Brisk walking is an ideal exercise for weight control and pelvic floor protection but it won’t address your overall strength. Women really need to perform strength training exercises to maintain lean muscle and strength post menopause. Just make sure you select the correct strength exercises and techniques too. Remember that with menopause a woman loses lean muscle mass. This causes loss in strength, more difficulty with weight management, along with other physical issues. The American College of Sports Medicine recommend that healthy active adults aged 18-65 years perform at least 5 days of aerobic fitness activities per week, and resistance training exercises on at least 2 alternate days per week, exercising the major muscle groups. Sounds a lot doesn’t it? I think it can be readily achieved with a good walking program or varied with cycling, and a basic strength training program such as the one outlined in inside Out. I really believe strength training for women is vital for strength, tone, bone density not to mention mood and personally I find weight management too.
Hope this snippet of information helps you. You are indeed not alone Gentle Wind!
Kindest regards
Michelle
I have had an hysterectomy , bowel and bladder prolaspe repair.Should l avoid doing double table top in my pilates class and stick to single leg.Or is it ok to build up to double table top as long as my head is flat. Cheers
Pilates after hysterectomy and prolapse surgery
Hi Christine
Thank you for your question, it is a good one. I am unable to answer you specifically with respect to your condition. What I can say is that table top with both legs will increase pressure on your pelvic floor and this will be reduced with a single leg tabletop exercise. Keeping your head flat will also reduce downwards pressure you are absolutely correct. What I cannot answer is whether or not your pelvic floor and your prolapse repair is strong enough to withstand the associated pressure of full tabletop progression. The only way to answer this would be with a thorough physio assessment perhaps using ultrasound on your abdomen to view your pelvic floor and test what happens to your pelvic floor with one and then repeated table top exercises. This would tell you whether your pelvic floor is being pushed down with your tabletop exercises or whether it is able to withstand the associated pressure. Some Australian physiotherapists are using real time ultrasound are able to assess movement of the pelvic floor during regular exercises.
I also suggest strongly that if you remain in doubt, then leave it out, especially with the increased risk of repeat prolapse following your prolapse surgery already.
Cheers Christine
Michelle
Hi Michelle thank you for your quick reply. I love your website and have showed it to my pilates teacher. I have your book and hope that one day you make a dvd on all your safe exercises to do after and before prolapse surgery. Take care kind regards Christine.
Hi Michelle, You mention a screening survey for women to measure risks before beginning exercises. What is the screen’s name? That’s a great idea to screen women before they begin an exercise program. Thanks, Lela
Hi Lela
Sorry I can’t give you a name for name for the survey, I just think there should be a universal screening tool/questionaire that can be used prior to any form of exercise participation with discreet questions that help to determine a woman’s susceptibility to pelvic floor problems before she commences her exercise program. In this way women who are at risk such as post menopausal, previous traumatic deliveries, forceps, previous gynaecological surgery etc could be picked up and their exercise program tailored accordingly. I know that Pelvic Floor First, an intitative of the Continence Foundation of Australia has commenced working with fitness professionals to teach them to screen and then prescribe exercises accordingly. I will let you know if they have devised a screning tool.
Cheers
Michelle
Hi Michelle, I must say I’m disappointed to learn that pilates is not recommended for post menopausal women. I am 62 and have just started pilates classes which I love. I would not want these exercises to effect my pelvic floor as I do have a problem if I cough or sneeze and was hoping that pilates woulp strenghten these muscles. Glad I saw your article, thanks for the info. Regards Carol
Pilates and pelvic floor dysfunction
Hi Carol
Please do not think that because you are post menopausal that Pilates is not suitable for you. You are correct in that Pilates won’t cure your stress incontinence, to address this appropriately through exercise rehabilitation requires dedicated pelvic floor exercises. However if you do have some incontinence symptoms it may be an indication that you have some pelvic floor muscle weakness. This along with being post menopausal could potentially increase your risk of worsening pelvic floor problems with the wrong king of intense core Pilates exercises. It would be wise to speak with your instructor about modifying the intense core abdominal component of your exercise program to avoid or modify the exercises such as those in this article. Your instructor may have some alternative exercises for you to help you improve your core control and at the same time protect your pelvic floor. Pilates can have wonderful benefits for a post menopausal woman’s body – the exercises just need to be appropriate to your level of pelvic floor function and avoid overloading if your pelvic floor is vulnerable.
Hope this helps Carol and enjoy your Pilates
Michelle
need help. Have begun Pilates doing at least 4 of the 7 that hurt the pelvic floor. I have a bulge of my bladder protruding and it is irritated also. Will this improve if I stop the exercises? I am 64 and had a hysterectomy 20 years ago.
Pilates and bladder prolapse
Hi Lynda
Thank you for your question regarding Pilates and bladder prolapse. With this kind of a concern I would advise that you seek the assessment of your medical practitioner to ensure that you do indeed have a bladder prolapse and the severity.
Pilates does have many excellent core exercises. Unfortunately for some women when they are given intense core abdominal exercises such as those in some Pilates sessions, then their pelvic floor dysfunction including prolapse can be worsened. This is because the pressure on the pelvic floor created from these exercises may be greater than the ability of the pelvic floor to withstand the pressure. This forces the pelvic floor downwards and can have the effect of worsening a bladder prolapse. In mature women, the pelvic floor can lack the strength to withstand the pressure of intense Pilates core exercises.
Some women find that when they cease the aggravating abdominal exercises, their pelvic floor condition improves. This will often depend upon the size of the prolapse. If the bladder prolapse is large then ceasing intense core abdominal Pilates exercises is definitely an important part of overall management however alone this may not necessarily resolve the prolapse symptoms. In the case of mild bladder prolapse it may be that ceasing intense abdominal exercises combined with pelvic floor muscle rehabilitation may help to reduce and even eliminate prolapse symptoms. Every woman is different so it is difficult to generalise.
Hope this provides the information your require Lynda
Michelle
Hi Michelle,
Four years ago I had a complete vaginal hysterectomy. Six months later my bladder and rectum began to prolapse. I was so distraught to find out that I had suffered a pelvic prolapse (I am currently 54 years old). I would like to start some type of yoga and was wondering if there is any dvd that you can recommend that is addressed for women with prolapse issues. Also, which exercise is safer to do, stationary cycling or eliptical training? Thank you in advance for your response. I am so glad to have found this site!
Hope
Yoga and prolapse
Hi Hope
To my knowledge there is no specifically designed pelvic floor safe yoga DVD at this stage, I may stand corrected on this. You are wise to be cautious with some yoga exercises and prolapse. My feeling is that many yoga exercises are pelvic floor safe and that in many cases the ones that aren’t can be modified or substituted with others. It is a matter of understanding safe core exercises and positions for exercise.
Regarding elliptical versus stationary cycling they are both low impact cardiovascular fitness exercises and therefore both suited to pelvic floor safe exercise programmes. To be reduce impact on the pelvic floor avoid intense work of the arms on the elliptical. Also, keep gears low and avoid standing in the saddle when cycling. If you think about positioning and support, perhaps cycling would place the least pressure on the pelvic floor however I am not aware of studies comparing the two.
Hoping this information assists you
Michelle