Why this quest 3
So much pain?… And a little about pelvic floor dysfunction in general 5
The physical 6
The emotional 7
Laying the foundation 9
The words we use 9
The Breath 12
The seven vital guiding principles 13
Teaching Yoga 16
Simple postures to start from 17
Alignment and Asana 18
The pelvic-feet connection 19
The pelvic-rib connection 20
The pelvic -jaw connection 22
Pranayama, Bandha and Vayus 23
How it is no longer about the pelvic floor 24
There are three main reasons why I find Vijnana Yoga a particularly strong tool in supporting the healing of various pelvic floor dysfunctions. The first is the emphasis on feeling from the inside. When we speak about the pelvic floor muscles, most people have no mental grasp on what that really is. I will be asked for example if the pelvic floor is the uterus, the sacral area or the genitals. But even if we were to look at the very complex structure of the pelvic floor in an anatomy book or simply google it and get – “the muscular base of the abdomen, attached to the pelvis”… it would still leave most people shrugging their shoulders. Because how does this all feel? Those that I meet who do have an idea of how the pelvic floor might feel are mostly people who either are aware of their own weakness hence don’t actually feel much at all, or on the other hand those who suffer for example irritation or chronic pain and therefore in a way feel the pelvic floor too much. Which brings me to the second reason – connectedness. The emphasis in Vijnana Yoga on a constant seeking of a sense of interconnectivity, allows people who need to awaken the hidden pelvic floor or contrary “smooth out” the intensity of the local sensation, to individually search for a balanced practice and energetic flow. The third reason is that whatever we may be practicing – pranayama, asana or a small repetitive movement, we are always guided by the seven vital principles. If practiced correctly and in balance with each other these principles along with the unique language of Vijnana Yoga offer students an empowering and compassionate way of seeing themselves especially since the source of suffering is concealed hence feels always somewhat secretive.
Although this essay is being written in the context of a teacher training with Orit Sen-Gupta, I am hoping to broaden that context and see this paper as an opportunity to share with other yoga teachers my experiences. I am interested in offering some key principles on how to relate to this sensitive but also “trendy” topic as I feel that there are a lot of misconceptions around it. Though I have been teaching yoga since 2003 and intrigued by the topic for over a decade, it is only in the last six years that I have really shifted my inner gaze to be more proactive about finding balance in my body and not expect healing to happen on its own. For the last four years I have been offering weekly Yoga for Pelvic Health group classes for women, worked individually with both men and women and offered workshops in the USA, Israel and Denmark. And though I keep learning and changing and shifting my ways and angles, I believe the core of my work is now steady and can be of benefit for others.
In this paper I will share a little about my own journey and how I came to focus on the topic. I also realized as I sat down to write, that I cannot separate the stories of my students from my journey as a teacher, as they continuously stirred me to try and better understand their experiences and shaped and fine tuned my teaching and skills. It is therefore that some of these stories and voices are embedded in this paper. In addition to constantly checking in and asking for feedback, I also periodically give out questionnaires that help me focus on the needs and wants of my pelvic health students and for the purpose of writing this paper I interviewed and recorded six conversations with students who volunteered to interview. To honor their privacy I changed their names.
Why this quest
I remember taking a weekly Ashtanga yoga class in Jerusalem in my early twenties where the teacher explained that one should hold mula bandha for the entire class – meaning – squeezing ones pelvic floor for the duration of an hour and a half minus savasana. I remember feeling deeply uncomfortable with this idea, on both a physical level (a gripping sensation in the chest and throat) and on the mental level as well as it felt like a forceful action, detached from others. I then felt both guilty for not being “a good enough” student who’s able to execute the teachers instructions, and embarrassed for being so weak at the core. In retrospect, I am grateful that I listened to my body and ignored this repeated instruction as I now know that an action such as this may easily cause hypertension which could have easily for example stood in my way of having two wonderful natural births later in life.
I remember even as a child leaking urine if I laughed too hard. Then, when I had my first baby and even more so when I had my second, the leaking would happen with jumping, running, sneezing and coughing too. Stress incontinence (lack of control when abdominal pressure is suddenly increased) is considered in the USA at least, very “normal” and the aisles in the pharmacy selling pads, special panties for women and diapers for adults, keep growing and growing… The professional and medical advice I received caused me extreme frustration. Midwives in California advised me to do up to 250 kegels a day (“do it when you chop your salad”, “in every stop light when you are driving”) and a urologist in Florida advised a surgery inserting a mesh sling under the bladder (a surgery known for its low rate of success and often damaging, pain inducing effect, yet commonly recommended). Some people around me disregarded my concerns because I seemed strong and stable in my yoga practice and one yoga teacher even told me that my flexibility is probably the source of my weakness. I finally understood that looking outside myself for one complete solution would be a waste of time, and even more so, could be harmful. Changing my approach I began to look outward in a different way. I looked now not for solutions but for inspirations. My research included learning more anatomy, reading books, co teaching a yoga and Feldenkrais workshop on the topic with a Craig Stubbs, who I learned so much from, speaking extensively with a specialized physical therapist, and drawing upon my years of professional dance background and pilates training. Now however, all this information was processed through my ‘yoga eye’. Previously the gap between how I related to my body in yoga and how I viewed, understood and felt my pelvic floor, was tremendous. A blind spot. The journey for me was that of closing that gap.
Pretty early it was clear to me that I would find a way to offer others the support I lacked, especially since continuously learning how many people around me feel at lost and unsatisfied with the answers they receive, as I did. Or worse perhaps, they do not seek any answers but just accept their disorder as if there is nothing to do about it. The willingness to talk about the topic openly, yielded fascinating conversations, mountains of emotions, many many questions and lots of contradictory material. Overtime I found in my body a new awareness and began to articulate it with the conclusion that there is no bypassing explaining in more depth the pelvic floor work not as an isolated practice, but in the context of our whole body, our emotional world, the way we relate, the way we move – in our yoga practice and then, everywhere else as well.
So much pain?… And a little about pelvic floor dysfunction in general
In seeking professional support for this very specific class, I reached out to Lisa Whiting, a local physical therapist specializing in pelvic health (in fact, the only one at the time) in Tallahassee, the capital of Florida and where I live. At the time I still felt quite insecure about how much I knew and didn’t know about the topic. After all, I was just a yoga teacher… What surprised me the most about our initial conversation was her enthusiasm about being able to refer who she called her ‘pain patients’ to a yoga class that would be suitable. Until then when I thought about pelvic floor related problems I thought mainly in terms of weakness. This assumption, that many suffer weakness and that ‘weak muscles need to be strengthened’ is too simplistic and is probably one of the main reasons that telling women to do kegels, very often doesn’t actually help. Indeed, many people lack tone in the pelvic floor and would benefit from strengthening those muscles once they achieved a mental access to them, what I was unaware of was how many people, and especially women, suffer from overly tight pelvic floor muscles, constant discomfort and chronic pelvic pain. At least 5 percent of women suffer chronic pelvic pain according to pelvic floor specialist Amy Stein (1) , while according to other medical sources 1 the rates of chronic pelvic pain for women of childbearing age range from 14% to 32% worldwide. (2)
Thanks to the strong relationship Lisa and I developed and the fact that she herself takes yoga with me and understands the way I teach, she continuously refers patients to my pelvic health classes. While physical therapy includes internal work that is based on the constant feedback of the provider, the experience in a yoga class is very different. While being guided by the teacher, the student is doing the ‘internal work’ on themselves and learn to identify their tendencies on their own. I find that while people with mild disorders yoga can be sufficient in their process of healing, for persons with severe dysfunction physical therapy and yoga can complement each other in a balanced and beautiful way. In the conservative environment in which I live (I would say most of the United States), it is safe to assume that most people who have reached the point in which they seek the help of a PT for pelvic problems, their level of distress regarding their health is pretty high. At least half of my students are coping with severe pelvic dysfunction accompanied by discomfort and pain, some recovering from related surgeries. A very young student helped me understand this new world to which I stepped in when she explained – “My vegina hurts ALL THE TIME”. I met women who are married for decades but fear intimacy as intercourse is torture for them. Women who have had numerous procedures and surgeries while being misdiagnosed, people being dismissed with disregard, and so forth. There are many excellent books written on the topic by leading experts so this is not an attempt to replace reading them were the interest to arise (3). But in order to give a better idea of the range of pelvic floor dysfunction and what people might be dealing with I will give a brief overview of some of the more common conditions and disorders.
Amy Stein in her book Heal Pelvic Pain divides pelvic floor disorders into two main categories: musculoskeletal aches and pains and bladder, bowel and sexual dysfunctions. She explains clearly how one category of irritation or pain can easily impact the other category and cause a vicious chain of disorders, infections, inflammation, nerve irritation, etc. “musculoskeletal disorders range from bones being out of alignment to muscles feeling knotted, tight, tired, or weak to nerve irritation. The pain can be local or it can radiate to other parts of the body”(4). Stein reveals the complexity of the topic and how often both the origins and their impact are elusive. Some of these conditions include: Tailbone pain, Endometriosis (for women) – a pelvic inflammatory disease which can affect the reproductive system, Dyspareunia (for women) – painful intercourse, Vulvodynia (for women) – chronic pain around the opening of the vulva that can be accompanied by burning sensation and irritation, and Vaginismus (for women) – severe pain and spasms as a result of any touch. Bladder disorders include interstitial cystitis both common in women and men. This irritation in the lining of the bladder can cause frequency, pain and urgency and may affect the back, the sex organs and the abdomen. Bowel disorders include diarrhea, constipation, urgency, inflammation of the bowel and rectum, and fecal incontinence. Another not uncommon condition is organ prolapse that happens when the pelvic floor musculature and connective tissue is strained and weakened which causes the fall of the inner organs toward or through the openings. Both men and women may suffer from a rectal prolapse and women may have bladder and uterus prolapse as well. When it comes to urinary stress incontinence Stein points out that as many as 38% of women engaging in athletic activities experience the involuntary loss of urine. Urge incontinence results similarly but is the sudden strong urge to empty the bladder. In the last category Stein refers to sexual dysfunctions such as lack of libido, inability to achieve orgasm and in men erectile dysfunction (5).
Tell a person who has overly tight pelvic floor muscles that other people have their inner organs collapsing through the lower openings and see the horror on their face if they have never heard about prolapse before. Tell a person with prolapse or urge incontinence that other women cannot use a tampon or wear jeans because of the level of pain they experience, and see the relief on their face that this isn’t what they are dealing with, as well. When we talk in more detail about the pelvic floor, emotions are provoked, and when we start to find movement in that area there is very often a clear response. This can happen in a very positive way and it is evident that once persons are able to experience more awareness in the pelvic floor, their whole level of vitality shifts. Andrea (in her early 30s) describes feeling lax after her second birth, she had some urine leakage and had no sensation during intercourse. Overcompensating in her backside she had no tone in the front of the pelvic floor and had to overcome bladder prolapse. She tells me in our interview that after just a couple months of taking my pelvic health class her symptoms are gone. Andrea says “when I leave yoga I feel blood flow, sensation, I feel strong”. In intercourse she regained her sense of control. But I am most touched when she exclaims – “I’m alive!”. When students regain sensation and find a flow of energy and connectedness to the base of the pelvis, they report a sense of aliveness everywhere and I can see the joy on their faces.
Though pleasure, relief and joy can be associated with this area, many other emotional aspects may be tied to that area in our body as well. With the physical untying of knots in the body, so do emotional ties begin to unravel. Sometimes, overwhelmingly so. Karol (mid 30s) tells me that four weeks after having her baby she started feeling heaviness and dragging and like she was sitting on a rubber ball, uncomfortable all the time. When she discovered she had prolapse the doctor reassured her that this was a normal postpartum condition, that she would be fine and that she should just continue to do her kegels (6). But she didn’t feel fine. Karol’s eyes well up with tears when she describes the feeling of her body being broken and how it had let her down. When she felt and saw the bulging of her inner organs through the vaginal opening, she felt angry at her body and desperate. She tells me she was depressed and anxious, and found herself crying all the time.
Clara (in her 50s) tells me “This is a part of my body that has been ignored for so many years and all that sadness…” Clara has had an abortion many years ago in a culture that condemns women for abortions and has lived with a strong feeling of shame and sadness. She says that with yoga “I started to feel new life coming in back to this area. Yoga somehow opens up some memories and pleasant places from the past and the focus on the pelvis is freeing something that for so many years has been locked”. For men it is no less “shameful” when erection is challenging or when they suffer incontinence and leakage. A couple of my male students talk about the pelvic floor problems that arrive along with the recovery from prostate cancer. While people would have no problem mentioning to their yoga teacher for example that they have a twisted ankle or injured shoulder, it is rare to hear complains about chronic constipation or pelvic pain. There is so much embarrassment and shame associated with pelvic floor dysfunction and sadly very often doctors, nurses and other professionals cause some of these emotional scars as well. I have heard endless stories from complete dismissiveness towards patients’ complaints to outright shaming, ridiculing or disregard in the labour room and so forth. Another emotion that comes up frequently and is worth mentioning here is fear. Fear of lack of control, exposure, of being ridiculed, of too much to be released.
Another issue that cannot be ignored is the topic of sexual trauma. It is my experience that many more people than I would have liked to think, hold some form of sexual trauma; at times in the extreme form of rape or continuous child abuse and at other times, the sense of being objectified repetitively. It would be unwise to ignore the sensitive nature of this work, if only to avoid any “surprises” if a student experiences a vigorous reaction to the more subtle practice. It is essential to be able to hold space for things to come up. The naturally compassionate, but not weak, voice of Vijnana Yoga teachers (at least the few I have been lucky to study with), is remarkably important here in my view.
Laying the foundation
The words we use
Healthy pelvic floor muscles are required to support our inner organs by being strong and contractile, as well as being able to fully open, release and relax. To be able to function optimally the pelvic floor, like all other muscles really, requires elasticity. In a way perhaps the words we use need to be elastic too.
Because of the nature of the area we are working on, hidden under our clothes and between our legs, I believe the words we use as yoga teachers are particularly of importance. Though a very skilled eye can see indeed a lot by looking at the alignment of the student, their breath, their general energy flow, facial expression etc. it is still virtually impossible to know exactly what they are doing internally. Also, because of this particularly subtle work, students are not able to imitate what the teacher is doing and need to be able to find the awareness for themselves. In order to guide people on their individual search for awareness and balance, the words we use need to be precise and it is important to try different words with different people 9 as one might click for them in a way other words do not. We are looking for the words that will allow the transference of texture.
Isuf – In Hebrew we have a perfect word to describe the action we are looking for in place of saying contraction. Using plain translation Isuf will mean collecting. This word however on its own implies that one is collecting one by one that that is scattered or widespread. The word Isuf however can be used in different ways. While it can also be used for ‘one at a time picking up and collecting papers from the floor’, it can also be used for ‘embracing your little child in your arms’. You would bend down and gather, hug, embrace, and lift the child, and all of that could be felt from the use of the word Isuf. In addition something in this Hebrew word implies from out – to in, a meaning that is missing from the plain translation of collecting. I find myself teaching the concept of Isuf as I find it to have a richness no one word in English contains.
Kegels – In the book The Bathroom Key, Kathryn Kassai And Kim Perelli give an excellent overview of Dr. Kegel’s work and his in-depth research on how to help women prevent urinary incontinence. Born in 1894 he operated in the USA in the first half of the 20th century focusing on nonsurgical, noninvasive approaches to gynecological problems. When Dr. Kegel realized that more than 30% of women he saw were unable to contract their pelvic floor muscles following a verbal instruction, he invented a pressure sensor that he inserted vaginaly that allowed both the doctor and the patient to See in a graph what they were doing. Biofeedback is still widely used today and the contribution of Dr. Kegel who’s name is synonym to pelvic floor exercises is undeniably tremendous (7). The problem arrives after decades of using the word Kegels without real understanding of its meaning, without biofeedback and without making sure that the person knows at all what they are supposed to do. This is an important point for me to emphasize as people often ask me – “so to do a kegel”? And I most of the times opt to requesting of the student to forget what they know about kegels and just drop that word all together. Again, not out of lack of respect to the practice of kegels but because this word today translates to most people as- ‘just squeeze everything down there as hard as you can and as many times as you can’. Which we are not interested in. Because it’s not holistic, because it can be counter effective to many and because it does not allow a real connection to be made with those parts of the body.
Contractions – Similarly to kegels there is no problem with the word contraction itself. In fact we are actually looking for the muscles to both be able to contract and release, one needs the other. The problem however is with the way the word is so often understood and interpreted in the body. The instruction to contract often yields a balled in fist like quality. Something hard. We are looking in yoga for breath and movement and the sense of flowing energy, and even when we do look for contractions there is a dynamic to it that is easy for students to miss. Once the person develops skill and has a deep understanding of how they use their body, using words like kegels or contractions are no longer an issue.
Squeezing – This word as well yields a sort of tension we try to avoid. The muscular/mental/emotional quality we are looking for is not one of gripping or locking. Rather than using the word squeeze which often yields a forceful draw of the vaginal walls for women and a gripping of the anal sphincter for both sexes, better to use the words – narrow and lift. Once again I will emphasize that every person is different. If there is a student that has very limited body awareness or strong cultural or personal inhibitions, it may be wise to start with the thought of holding in or squeezing as if trying to prevent the flow of urine. Once a person feels more movement in the area, a shift in the words would be wise.
Engaging / Awakening – Both these words can be used excellently but are hard to explain to a beginner. I find that these words are best used in relation to the rest of the body. For example when we sit if we root the tops of the feet down, we might notice a natural engaging or awakening in the base of the pelvis. If one doesn’t (because they have not yet found that connection and it may feel blurry still), then these words can actually help to find that gentle tone.
Tightening – I am particularly careful to use this word. The reason is that the word tight is so often used as a “positive” thing. In the fitness/gym era we live in, people around me strive continuously to look thin and tight. This concept derives from what I concieve as our cultures false and non-energy-including western aesthetic point of view (how for example we look in photos has become so important in a world consumed by social media). Tight has no range, no breath, no flow and in fact when too tight – deep weakness occurs. Nonetheless, if we think of our deepest layer of the abdominals, the transversus abdominus, it can be very helpful at times to think of that muscle as a band wrapped around our body attached from the spine and forward to the sternum and pubic bone. And when we exhale we can think of gently tightening that band (translated to Hebrew as Hiduk not Kivuts).
Mula bandha – To quote from Dancing The Body Of Light; “The word bandha in Sanskrit means ‘to bind’… However just ‘binding’ the energy to a particular spot in the body would not make much sense. As in the cyclone, when the energy is compressed towards the center, the center is consequently pushed upwards”. We are therefore not looking to simply trap energy… “The art of distributing the energy throughout the body is to send it from bandha to bandha, thus connecting all the parts of the body.” (8) Often I hear the term mula bandha used as a synonym to kegels, both used in a superficial way. But other versions come up as well. Very recently I learned that one of the more respected yoga teachers in my town closes her yoga classes with mula bandha, instructing the students to lift their hands in prayer position and then squeeze their buttocs three times. Though I understand that it may be challenging and complex to teach the bandhas, I think that if one decides to teach them, there is no avoiding delving at least a little into their complexity. In any case it is particularly of importance with students who suffer pelvic floor disorders that they avoid locking and understand that we seek movement and transference of energy, even within the context of the bandhas.
In yoga, when we come to meet our breath intimately, we mostly don’t think about our respiratory muscles, the atmospheric pressures that allow breathing etc. We do however use some very important points of reference; hands on the belly, on the ribs, on our back. Watch the expansion on the in breath and the softening and narrowing on the out breath, and so forth. The same approach applies exactly as we come to meet what is called our pelvic floor – intimately and up close from the inside and out, from front to back, up and down and side to side. Our points of reference are first the four corners of the pelvic floor – the pubic bones on the front, the tailbone on the back and the two sitz bones on both sides. Once we begin to grasp the space between these four points can we begin to move in more directions and connect to the deeper layers of the pelvic floor and its many connections to everything else in the body. All this cannot happen without first understanding the breathing – The breath is everything. It is what makes this yoga and what brings a profound shift into a practice sometimes very simple and even familiar.
As we inhale and the respiratory diaphragm moves down so are we looking for the pelvic diaphragm to move slightly down. As we exhale and the respiratory diaphragm moves up so are we looking for the pelvic diaphragm to gently move up. When we inhale we can allow the floor of the pelvis to relax, to release to open up while gently moving downwards, as we exhale we can allow a subtle toning, a gentle lifting to occur. It goes without saying that as yoga practitioners when we start moving into deeper asana and practice variations of pranayama and bandhas, this pattern may change. Having said that, it is vital that at first – we insist on this pattern as it is only through this very conscious understanding of the reflection of the breathing in what the pelvic floor is doing, can healing begin. It is the breath that carries the awareness, here as always.
The seven vital guiding principles
In order to transfer with more accuracy the process that I feel is conducive to this work, I have slightly rearranged the order in which the seven vital principles are generally presented.
Relaxing the body – It is not enough to say “relax the body”, most people don’t know how to. Sinking, feeling the weight of the body, allowing the body to be even heavier, allowing the head to be heavy, the face to soften, the jaw to soften, all these together and more can begin to yield a sense of relaxation and letting go of tensions. Our goal in developing awareness to the pelvic floor muscles is to equally be able to direct and feel – Isuf and release. For those who’s pelvic floor muscles are hypertonic, relaxing that area requires high levels of concentration. For those who have lack of tone, it is often that other areas are contracted, as a form of compensation. Therefore, it is crucial to start with the relaxation of the body in order to recognize where tensions are held. Otherwise it is so very easy to slip into our old habits. One tendency worth mentioning in particular here that is very common is the overly squeezed glutes. It takes many reminders to finally be able to let go a little of those bigger muscles in order to find both a deeper sense of relaxation and a deeper source for strength.
Joanne (47) had never had physical therapy when she started yoga with me. She has had pelvic floor pain since she was 19 years old that included severe nerve pain in the vaginal area and external genitalia “stabbing sharp pain feeling like needles are poking you” and chronic yeast infections. After 12 years of suffering the non-stop stabbing pains she had found a holistic practitioner that was able to help her by changing her diet. The dyspareunia however persisted. “Intercourse feels like you are on fire… like someone is holding a flame to your skin”. Joanne had told me that normally when she has her yearly visit at the gynecologist they had to use a child version of specula on her and after the exam she would have about a week of severe pain accompanied by bladder infection. Not too long after joining the pelvic health yoga class she had a gynecology appointment. She told me that when the exam was about to start she could hear my voice from class reminding her to relax her buttocs. Along with the expanding breath she was able to relax enough for the doctor to use a regular specula and did not experience infections. The pain following the exam was reduced from the typical week, to a day. For me Julie’s story was huge. The reminder to relax the body and especially those places where we tend to clench – cannot be overemphasized.
Awareness to breath – When the body is relaxed can we begin to direct our attention to the breath (of course, when we direct our attention to the breath so can the body further relax). Placing the hands on the lower belly is a good place to start. Along with the rising of the belly we pay attention to the movement between our sitting bones, pubic and coccyx. When the belly fills gently, so does that lower space, and when the belly subsides, moving closer to the center of us, the center of the area between the four corners of the pelvic floor – the perineum, moves upward – energetically meeting the naval.
Quieting the mind – focusing on the breath and on the relaxation of the body allows the mind to quiet as well. Many of my pelvic health students walk through the door without much experience in yoga, impaciente with the idea of slow movement and eyes turned inwards, as they try to be ‘proactive’ about their well being and health. Before noticing any change in their pelvic health conditions they are amazed by how relaxed they feel and by the powerful effect of the quieting mind, hence calmer nervous system, and I suspect that more than anything, this brings them back to yoga.
Creating intention – Then do we begin to “work”. We imagine the sitting bones come closer with the expiration and moving away with the inspiration. We can then shift to focus on our pubic bone and tail. Eventually we seek the narrowing of all four corners – the gentle draw in and a rise with the outbreath, and a release and widening with the inbreath. We look for a steady pace, a muscular smoothness to match our breathing. We scan the body to notice that the glutes stay at ease and that no ‘tucking’ or locking of the groins occurs. When I began teaching these classes I was advised to never lead a ‘hypertension patient’ to do a kegel. I have found nonetheless, that especially for those persons, the use of just imagine – just create the intention, is extremely beneficial. If the focus on the breath is present and one can simply create the intention of watching both isuf and release happening, they are on a good path. The same is true in the reverse situation, and I remember myself clearly in it. When I tried to contract and lift and count till ten like the sheets of paper I received from midwives and doctors instructed, I realized, when it came time to relax, that there was nothing to relax… all that effort, all that squeezing, and no tone, no response. When I allowed myself to simply imagine the movement with clear direction in my set intention, then did I feel my body respond. Karol tells me ”The relaxation and the ‘only imagining’ allowed me to feel my pelvic floor as a whole for the first time”.
Rooting – Once our inner gaze is able to rest on the pelvic floor, we can accentuate the understanding of rooting. The increased awareness to everything that comes in contact with the ground especially but not only through the feet, allows us to draw a clear connection now between rooting down, and the echo flowing up created by this action in the pelvic region.
Expanding – The feeling of the energy moving both downwards and upwards both in and out at the base of the spine is key to then feeling that expansion at the seed – expand. I have been fascinated with the idea that when exhalation arrives and carries in it such a tremendous opportunity to relax further and let the weight go, then in fact something in us works in the opposite direction. I feel that with the understanding – from within, that everything carries few directions- widening and elongation, a deep yet wonderfully subtle sense of expansion reveals itself.
Connecting – I am touched when Sabrina says “Now I have every class mini revelations, sometimes it’s not so much something new but almost a brief moment where there is a more definitive connection. And I know that there are more moments to come where I will feel more of these connections”. Sabrina (in her 30s) started my pelvic health classes (and shortly after joined my morning Vijnana Yoga classes) with chronic pain in the lower abdominal area that included constant cramping and sometimes stabbing pains. She had hip surgery in 2011 and is not certain about both what caused the pain that lead her into surgery (traumatic injuries during cheerleading and triathlons did not help) nor that she had ever recovered. Suffering chronic constipation, lower back pain, hip joint pain, pain during intercourse and difficulty emptying the bladder. For Sabrina to feel a sense of connectedness in her body along with the significant diminishment of symptoms, is a lot. Connecting is hard to explain but in those precious moments when students achieve this, they report feeling whole again, unbroken, no longer divided. It is through the ability to see their pelvic floor on all its connections, unseparated from relaxation, expansion, the mind and breath, that they are able to feel connected.
So much goes into teaching yoga especially when there is so much vulnerability that brings the students to class in the first place. To pay attention to the alignment and give the right cues. To be alert enough and attentive enough in order to tap in to exactly the words that the students in that room in that moment need to hear. To pretend at times that you are talking only about the body, when they know, and you know, that it is so much beyond. The body speaks so fiercely so convincingly and reveals so much. The locked pains begging to be released. The principles, the asana, pranayama it all blends in and yet, it is so very simple as well.
Simple postures to start from
Variation of Apana Vayu – https://youtu.be/gqXQeQIIkmU
Laying on the back with knees bent – a block between the knees (or blanket, towel or soft ball) is helpful in finding a stronger sense of midline. Laying down on the back with a neutral spine, paying attention to the weight of the sacrum, the feet and head, watching the breath and gradually slowing it down. With the exhalation adding on to the gentle rise of the center of the perineum, a gentle squeeze of the block. The inner thighs and pelvic floor muscles are directly connected and if the spine and groins remain calm, as well as the glutes, one can begin to sense that connection very clearly.
Setu bandhasana – either keeping the block between the knees or thighs, or without if the connection between the inner feet and sitz bones is established. Root down to allow the sacrum to float up, working to stabilize the pelvis. Try reversing the breath – a few times lifting up as you inhale and lower as you exhale and gather the pelvic floor muscles inward and up, and a few repetitions of the exhalation happening while lifting and the pelvic floor muscles releasing with the lowering of the sacrum.
Supta Baddha konasana – this is an excellent posture to start moving from. Laying on the back with the feet touching, as you exhale press the feet a little more firmly toward each other and down and away, notice the rippling through the inner thighs, perineum and area above pubic bone allowing it to hollow. Keep a steady pace in breathing and movement. When inhaling relax the legs completely and come back to a heavy tail. After several repetitions find neutral again. Now, as you breath out feel as if there is a magnet on the top of the inner thighs drawing them towards one another. With the inhalation the legs open out again. https://youtu.be/w_0CpUM918I
On hands and knees – this is yet another excellent posture to start moving from. One of my favorite exercises is keeping the spine neutral here while being aware to the backs of the feet, shins and hands. As you breath in allow the belly to simply relax down, allow the space between your sitting bones, pubic bone and tailbone to relax as well – expanding outwards. With the exhalation make the sound shhh… as if soothing a baby. Along with that sound draw the naval gently up toward the spine and simultaneously gather the pelvic floor muscles inward and upward to meet the naval energetically. After several repetitions find a gentle cat and cow. A block between the knees will remind the body of the midline we are striving to find. Combine all previous exercises and breath here into a smooth organic movement of both larger muscles and the deeper ones as well. https://youtu.be/kFwkl_Q82JE
Preparation to Virabhadrasana iii and Trikonasana from hands and knees – from hands and knees extend one leg back keeping the pelvis stable and both sides of the torso long. Keep the front ribs hugging in as you allow the leg to float up off the floor with the memory of something to squeeze gently between the top of the inner thighs. Focus is on non gripping – non slacking, searching for a flow that runs through the entire body. Then place the foot back on the floor and open the pelvis side ways. With the one foot planted on the floor find the alignment of trikonasana in the upper body and arms, and the balance in the pelvis.
Alignment and Asana
We know as yoga teachers that alignment is a key element in feeling good in our bodies. It is essential for students to understand how we are linked and that everything affects everything else. An injured knee results in leaning more on the other leg which may result in a painful ankle, slightly twisted torso that may affect the neck and jaw that may cause headaches, etc. It is my experience that ‘force fixing’ will not yield positive results, however awareness and acceptance of where we stand right now, can slowly bring the shift we are looking for. The fabric of our alignment delicate and sometimes elusive in finding, but when a connection is made, we can feel it clearly and as with the mind – our bodies yearn for it. In the context of pelvic floor health I chose three main connections to focus on as I see a direct correlation between our attention to the feet, ribs and jaw to the pelvis.
The pelvic-feet connection
Sabrina tells me that thanks to yoga “There are moments where I realize that all I need to do is just plant my feet more firmly into the ground… I’m not trying to keep myself upright from just my pelvic floor anymore… I can use my feet”. The understanding from within of the role of the feet is powerful and so is the connection to the pelvis. Many times during class I try to make this connection for students. When standing I will refer mostly to the center of the heel and the connection to the sitz bones energetically reaching down, or heavy towards the heels. An image of the heels tailing down to the earth is also helpful. But on the back with the knees bend, if I realize that the feeling of midline isn’t there, meaning there is no connection for the person of the space between the sitting bones and the inner heels, I will emphasize that. Sitting in Virasana in another excellent place to feel this connection – the vitality given to the base of the pelvis by the tops of the feet rooting down and the heels pressing slightly inwards as if pushing the sitting bones closer. In almost every single posture including in sitting for pranayama, a mental drawing of the pelvic-feet connection can be established and very significant. For example Dhanurasana. While the feet reach back in space away from the chest that is expanding and lifting, it is valuable to watch what the pelvic floor is doing. While the feet move in a certain direction watch the hammock hanging from the four corners of the pelvic floor, or the pelvic diaphragm, gently move in the opposite direction and slightly inwards to support gently from within. People with a slacking pelvic floor may be pushing down on it in effort rather than utilizing its strength for the asana. People with very contractile pelvic floors are most likely overdoing it when in effort and may need the reminder to allow the feet and thighs to take the load. Another example; Malasana, a deep squat (can be modified with blanket folded under the heels or sitting on blocks if there are knee injuries. This posture is not recommended if there is prolapse or a heavy feeling at the pelvic floor). While inhaling allow the pelvic floor to completely relax or as it is called – pelvic drop. Even for people who think of themselves as slack or weak and therefore have fear around letting go of those muscles, allow the pelvic floor to really relax downwards here without fear (not to be confused with pushing or bearing down. Just realising). As you exhale, root the feet down with much intention until you feel the energy rising in the opposite direction and the echo of the downward action clearly rebounding back up. For people who have no tone this will not come naturally. It is important to know that they will need to hear this instruction in order to slowly make that connection.
While it has been clear to me how meaningful the rooting of the feet into the ground and the activation of the feet out in space was in relation to feeling then the pelvic floor respond and the pelvic bowl aligning itself properly in relation to the feet, I was unaware of the reverse being significant as well. Mark (mid 30s) is a strength and conditioning coach for the local football team, an extremely demanding and athletic job. He reached out because he was aware of the pelvic floor not functioning or ‘doing its part’ in his training. After our first private session he said he felt much better (the sense of new vitality that I spoke about before) and when after the second lesson he continued reporting improvement in almost everything he did, I inquired for more details. Mark told me he felt a significant improvement in all the physical activities he was doing including weight lifting, chin ups, one legged squats etc. He also reports walking being easier now, like he is propelled forward rather than dragging the legs under. But I was especially touched and even surprised when he talked about how acutely aware he has become of his feet. He reported feeling suddenly a new bounciness that he was missing and his running had suddenly improved as well. I guess I should have understood by now that of course the subtle pelvic floor work would reflect back at the feet as I expect the feet work to reflect back on the pelvic floor. Nonetheless I had not been aware of it until this student who has much more body awareness than the average new yoga student, had pointed it out.
The pelvic-rib connection
In my interview with Sabrina she tells me she always loved yoga and when she finally had to give that up as well due to her injuries and constant pain, it was a big loss. But… she says reflecting back “I had been practicing it “all wrong”… The things that I used to be complimented for in yoga classes, you would correct… postures that looked impressive and beautiful exterenly didn’t feel good from the inside. The days I can get into postures and feel my ribs move, those are the days I feel so good”. When I first saw Sarah in class I was puzzled. Her range of motion big but limited by pain, she stood tall but felt locked in certain places. mostly I noticed that there was barely any movement in the rib cage when breathing. While her abdominals would 20 inflate on the inhale it was virtually impossible for her to direct the breath to expand the ribs. Even though she came to yoga to help with her pelvic issues, it is clear from the quote above that we figured that without the ability to soften the rib cage and to find a way to expand and narrow, the pelvis would be much less reluctant to respond as well. On the other hand I have Andrea. While Sabrina is struggling with hypertension, Andrea is working towards finding tone in the pelvic floor. Her tendency is to stand with the ribs sticking out in the front and the abdominal underneath the ribs contracting forcefully, her buttocks held out behind and clenched. Alison works out and runs and would be considered very fit however the ribcage being out of alignment was inhibiting her from finding her deep core strength not from the top of the abdominals but all the way from the bottom. In order for the base of the pelvis to engage, the front ribs must soften. I also see it like this: when we lift the ribs it is as if there is no trust in the power of the pelvic floor. The ribs are thrusting out trying to ‘help’ the pelvic floor lift. Once the ribs learn to soften, the message sent to the perineum is one of trust. This allows a connection between the abdominopelvic cavity and the thoracic cavity. Andrea says “yoga tapped in to exactly what I needed. I am superficially strong but now can do plank from a sense of wholeness. I also had trouble breathing to the extent that I thought I had asthma…”. Seeing the shift in her practice I was amazed how much improvement she had made both in her capacity to breath and in gaining pelvic tone, mostly by working on the alignment of the ribcage.
Standing poses are wonderful in finding this connection. In warrior i & ii, triangle and tree (and later in the more challenging postures as well) there is an opportunity to find balance through the pelvis – heavy tail and sitz bones, and if we keep the groins deep and relaxed we will prevent any extra ‘tucking’. Then allow the ribcage to rest over the pelvis. Spine is long and chest is broad, the ‘lift’ created from the rooting of the feet. The instructions here really wouldn’t be any different than in any other yoga class. However I find that contrary to other styles of yoga, in Vijnana Yoga the language embeds the reminder of deep groins, unclenched glutes and ribs at ease, and is therefore naturally supportive of persons who are dealing with pelvic floor dysfunction.
For many people I see, the overly tight abs keep them essentially weak at the core. Just as with overly tight pelvic floor muscles. A connection needs to be made between the breath on all its dimension and movement and freedom in the ribcage, the abdominals and the pelvic floor. We are seeking to be in sync. This will help gain proper function.
The pelvic -jaw connection
The first time I truly experienced in my body the deep connection between the jaw and the pelvic floor was at the birth of my daughter Rohan in 2007. My yoga teacher Noga Barkai had recommended Ina May Gaskin’s book Spiritual Midwifery. In the stories of this book it came up again and again that for the pelvic floor to open up, the lips, tongue, mouth and jaw, need to relax as well. During labour I repeated the sound OM and when that vibration wasn’t sufficient in managing the intensity I began to sing. Then, remembering the book, I kissed my partner with an open and soft mouth and tongue between contractions and the effect in dilation was immediate and quite magical indeed. For years after that especially when teaching prenatal yoga classes, I emphasized this relation and it felt very right to go back to it when I began teaching pelvic health classes and workshops. So many people report feeling tension in the jaw but what is reassuring is that by being aware of that tension students are able to consciously relax the jaw and notice the reflection in the pelvic floor relaxing as well. There is fascinating material on the early Embryo connection between the two. Around day fifteen to the creation of an embryo, two depressions form; one becomes the oropharyngeal membrane that eventually forms the mouth and the other is the cloacal membrane that eventually forms the openings of the urinary, reproductive and digestive tracts. Even as the spine develops, they remain connected. While the physiological aspects of our early development are certainly interesting, in the context of a yoga practice what matters to me is the awareness to this connection. I find that while it would make sense that persons with overly tight pelvic floors would have tight jaws, it is very common for people with lax pelvic floors as well to tighten up their jaw, perhaps as a way of compensation.
pranayama, Bandha and Vayus
Once a person has more of an awareness to the lower region of the body and how it directly correlates to our natural and slightly lengthened breath, they can practice pranayama, bandhas and vayus with a new level of subtlety. Three forms which I find particularly helpful:
Kapalabhati: Clara loves Kapalabhati. She has severe scoliosis, injuries in knees, shoulders, neck and extremely tight hips. She is also overly contracted in the pelvic floor muscles which resulted in several years of urine leakage and what brought her to do semi private yoga classes with me. She tells me over and over how much she appreciates kapalabhati “It is so special. It is helping me so much… and is calming and strengthening and meditative”. Once we have established in our body the notion that exhalation brings with it Isuf it is then interesting to let that thought go and just watch what happens in the pelvic floor in kapalabhati. These are not what we call quick-flicks (A quick action of Isuf training the muscles to be able to gather spontaneously when inner abdominal pressure is created such as in sneezing). Rather, we allow the pelvic floor to respond to the abdominals pulling in. If the top of the feet root down and we can feel that energy streaming up the inner thighs, our body already knows that the ‘state’ of the pelvic floor isn’t the one of complete release and opening but rather something that is already more ‘collected and hugged upwards’ – in a very gentle way. What most of my pelvic floor health students really need to focus on, is how to let the belly then ‘go’ with each inhalation. This ability to relax the abdominals while staying in alignment, and then find again the draw in, allows the pelvic floor work to be very presente but not in the center, which is why I think Clara finds this particularly calming and meditative.
Uddiyana Bandha on hands and knees: The first time Lisa (our local pelvic floor specialist who is my student as well and has prolapse herself) practiced this in my morning class, she lifted her eyes at me and said with excitement “this is exactly what my pelvic floor needs!”. With the lifting of the diaphragm that comes with the rooting down of hands and top of the feet, we can distinctly feel how the pelvic diaphragm is being gently called up. Allowing the back to respond with a baby cat and the head to drop, makes it clear that the bandah holds in it both the gathering of the energy powerfully inwards but also how this ‘trapping’ flows in the body. The 23 focus is on uddiyana bandha but it is clear here how it is linked to pada bandha and hasta bandha from the bottom, and mula bandha, and jalandhara bandha from the edges.
Apana vayu & Samana vayu: For my pelvic floor students I have been teaching Apana Vayu slightly different than described in the book Vayu’s Gate – Yoga and the Ten Vital Winds. Instead of saying to contract the anus slowly and gradually, I tell the students to create a suction feeling from deeper in the rectum. Because of the sensitivity of many of my students I want to avoid them squeezing the anus too strong or the glutes, but more that the sphincter will respond to the movement in and up of the rectum. With the inhalation expanding and releasing to the front part of the pelvic floor, pouring the inbreath bellow and above the pubic bone. In Samana Vayu, finding the compactness of the energetic draw in three fingers below the navel with the exhalation, with the inhalation breath to the area above allowing expansion. Then as suggested in the book, we gently practice apana vayu and samana vayu together to form a mini mula bandha. The gentle combination of these two vayus that gives a solid sense of support, holds much of the essence of all the awareness work but is much too subtle for most beginners, as at first they typically have very little access to the area. Adding prana vayu is of great value to make the deeper alignment connection, and when students are ready they appreciate that and even report that they can now feel more sensation and blood flow in the pelvic area and that along with the prana vayu they feel apana and samna clearly present.
How it is no longer about the pelvic floor
When I ask Karol in the end of our interview how she would summarise the ways yoga had benefited her, I am surprised. She talks about how the breath makes her feel connected to her whole self, how she now knows to distinguish between simply telling herself to relax and really relaxing. She talks about how her headaches have reduced significantly and how she no longer needs antidepressant medication nor anti anxiety medication like she used to in the past. She says she feels overall so much better, that she learned to be patient with her body and how she is getting so much more out of the classes than she ever imagined. She says she no longer feels divided, it is like she got her body back. Finally I ask her about her pelvic floor. And it is such a beautiful moment for me when she pauses and then says that her pelvic floor is now just a part 24 of her. She doesn’t have any symptoms anymore – no heaviness, bulging or dragging feeling or that sensation as if you are sitting on a rubber ball from her prolapse. But she keeps coming to the pelvic health class. Karol says “yoga is teaching me the tools to getting myself back to where I need to be.”
Amannda (74) has had multiple abdominal surgeries due to bilateral mastectomy and tram replacement, after the birth of her son 42 year ago she suffered such a severe tear that the rectal sphincter needed to have surgery and a very deep episiotomy that left her with very little pelvic tone and damaged nerves. She has been wearing pads for 42 years as she has daily urine leakage and in the past had suffered fecal incontinence as well. When I ask her how is yoga helping her she says “Doing yoga is really important in terms of my mental health. Can’t imagine, not doing it…”. Like everything else she tried, yoga isn’t making her leakage disappear. Nonetheless, “The yoga is not just an exercise or not just a tightening but helps me to move with a greater degree of ease without the fear of leakage”. Anne lives with the constant threat of her leakage, but she says yoga has given her the strength and ability to get from one position to another with more flow between movements, less fear and with an awareness of breath that is significant to her.
Joanne says “I may never be able to have pain free sex, but I can see strides being made.”
For Karol and others who come to the pelvic floor health yoga class with conditions that have developed over the past few years like prolapse or stress incontinence, the class stops being just about the pelvic floor because they see real improvement in most of their symptoms. For persons who have suffered however decades of dysfunction, like Amanda with leakage or Joanne with hypertension, the classes may not offer a magical healing power. But with yoga being an holistic approach that is inclusive of all of our being, and everything we are, students gain a new sense of empowerment and control, both physically but as importantly, mentally and emotionally.
In this paper I was hoping to convey that at times connections are not able to be made on their own or without the lense being directed right at the issue. The dot of the pelvic floor, for whatever reason, is sometimes just not there – to be connected. I asked Sabrina if she thinks she would have benefited in the same way just taking my morning classes and she nods no. “The specificness of working on the pelvic floor makes me feel more whole… this is where the resistances are…” It was me who encouraged her to join the regular class, and I do this often when I feel that a student would now benefit more from a complete practice. But first, a foundation has to be laid, here it is that of extra attention to the pelvic floor.
Coming from a background of dance one of the things that was most challenging to me when I started practicing Vijnana Yoga (before it was called that) in Jerusalem in 2003, was the feeling as if I had to constantly ‘hold back’ from the maximum of my range of movement and ability to stretch. It is also one of the things that made me instantly fall in love with this way of practicing yoga and moving. Because really the ‘holding back’ wasn’t holding back at all, but rather, a constant pulsing between the drawing in and the moving out. There is always what is beyond us to reach for and also that that is inside us to sink into. This is also in a way how I view the focus on the pelvic floor. The exploration of one’s own range and the deep stability and the never ending pulse between them.
(1) Stein Amy, Heal Pelvic Pain (McGraw-Hill Education: 2008), 2.
(2) Mathias, S. D., Kuppermann, M., Liberman, R. F., Lipschutz, R. C., & Steege, J. F., Chronic pelvic pain: Prevalence, health-related quality of life, and economic correlates. Obstetrics & Gynecology (1996), 87, 321–327.
(3) A few books I have in particularly learned a lot from and enjoyed reading, are: Pelvic Power: Mind/Body Exercises for Strength, Flexibility, Posture, and Balance for Men and Women, by Eric Franklin. The Female Pelvis Anatomy & Exercises, by Blandine Calais-Germain. The Better Bladder Book: A Holistic Approach to Healing Interstitial Cystitis and Chronic Pelvic, by Wendy L. Cohan. Heal Pelvic Pain: The Proven Stretching, Strengthening, and Nutrition Program for Relieving Pain, Incontinence,& I.B.S, and Other Symptoms Without Surgery, by Amy Stein.
(4) Stein, Heal Pelvic Pain, 15.
(5) Ibid, 14-20.
(6) Later on, the physical therapist had instructed Karol to stop doing any kegels. To deal with the prolapse her body had naturally tightened especially in the back part of the pelvic floor in order to support the growing pressure. When adding kegels, which the Gynecologist had confirmed she was doing correctly, squeezing her vagina over and over, the muscles became overly tight, which caused more weakness.
(7) Kassai Kathryn and Perelli Kim, The Bathroom Key, Put an End to Incontinence (Demos Health: 2007) 23-30
(8) Holleman Dona and Sen-Gupta Orit, Dancing the body of light the future of yoga (Pegasus Enterprises: 1999) 38-39.