“I ask every single woman I treat if they ever have incontinence. They always get this deer-in-the-headlights look,” says Ann Wendel, PT, ATC, CMTPT, founder of Prana Physical Therapy in Alexandria, Va. “Most say no initially, but I go down the list: ‘So, you never, ever leak — even a tiny bit — when you exercise?’ They say ‘Um, no.’ I ask ‘How about when you cough, sneeze, jump, run, do a box jump, a double under, or you jump on a trampoline?’ Then they say ‘Well yeah, of course, I’ve had kids!'”
Do you consider peeing during deadlifts, rope skips or running a fact of your life, and more specifically, a fact of your lift?
I have news for you: You shouldn’t have to. You don’t have to.
“We’ve just got to keep educating,” says Wendel.
In this interview, she does just that, explaining what causes stress urinary incontinence (SUI) and listing several drills (including a great one in the accompanying video) to help prevent it.
Wendel goes on to point out that it’s not a one-size-fits-all approach, as the cause can be different from person to person, so it’s worth seeking out a practitioner willing to work with you to solve the problem. Wendel herself has offered to answer any questions you have in the comments section of this post.
JS: Judging by the conversations I have in the gym, leaking urine during workouts seems to be fairly common. Is this the case?
AW: Leaking urine during exercise — called stress urinary incontinence, or SUI — is common, but not “normal.” In the U.S., the national average of women who experience incontinence is 1 in 3. A 2002 study done by Thyssen et al. surveyed 291 elite female athletes competing in a variety of sports from basketball to ballet regarding their history of urine loss during participation in their sport or day-to-day activities.
A full 151 reported leakage of some kind. Of the 151, five discussed it with a medical provider, and only six got pelvic floor training. Can you imagine only 5 out of 151 athletes with an ACL tear seeking treatment? That would never happen! Incontinence is very prevalent in the athletic community, yet most women do not seek treatment because they are either embarrassed or they assume it’s normal because everyone else they know has the same issue.
As a physical therapist, I treat women every day who say that they leak urine when coughing, sneezing and exercising. The most common activities that lead to SUI are box jumps and double-unders (some women also experience SUI with deadlifts). In a physical therapy evaluation, women nearly always follow up admitting to SUI with a statement like, “Of course I leak, I’ve had two kids!”
While it is true that childbirth can be one of the factors that contribute to pelvic floor dysfunction, not all women experience incontinence after childbirth; and, it can be treated if it occurs.
JS: So, SUI is common; but, you say it’s not “normal,” right? Why is that? What does it indicate about your body?
AW: Any women’s health physical therapist will tell you that it is not OK to leak urine when working out (or coughing or sneezing). It is a sign that the whole system is breaking down, and the pelvic floor is just the place it shows the most at the time.
My colleague Julie Wiebe, PT, explains it this way:
“Incontinence is just one way of identifying a pelvic floor insufficiency. It is a signal that an imbalance in the deep core exists. The deep core is a closed-pressure system, and insufficiency in any component will impact the capacity of the whole. A female athlete may not be incontinent, but do they have any hip pain? Or low-back pain? How about osteitis pubis? Pain, joint instability and incontinence are all just signals that the system as a whole needs attention.”
In my own practice, I rarely have a patient that comes to me specifically for incontinence. Many female patients come in with complaints of low back, hip or knee pain. As part of my initial evaluation, I ask every woman if they ever experience any incontinence. Over half of the women will say no, until I press, and then they admit that they do.
What they don’t understand is that pain in the knee may be related to weak and/or uncoordinated pelvic floor, diaphragm and hip muscles. Chronic groin strains, IT band syndrome, trochanteric bursitis, low-back pain and patellofemoral syndrome are a few of the common diagnoses that female patients seek treatment for — and an integrated approach is necessary to identify the root cause of the issue and to successfully treat the problem.
If you experience incontinence with running, box jumps or double unders, STOP. Seek help from a qualified women’s health physical therapist, even if your gynecologist states that you don’t need physical therapy. Be an advocate for yourself and seek treatment. The Section on Women’s Health of the American Physical Therapy Association has an index of providers.
JS: What kinds of things cause SUI?
AW: There are many factors that can lead to SUI and/or pelvic pain.
- The muscles of the pelvic floor may be weak from being stretched during vaginal delivery or even from the weight of the baby during pregnancy. They may also be weak due to postural habits (standing with a posterior pelvic tilt) and lack of exercise.
- The muscles may be hypertonic (overactive) and unable to relax, which decreases the strength of the contraction when they do fire. So they are overactive, but weak.
- The pelvic floor muscles may be overactive but strong; yet, the client has stronger abdominal, back, diaphragm and glottis (voicebox) muscles. Women who leak while lifting a heavy load may be in this category — holding their breath leads to a rigid thorax, yet they can’t contain all of the pressure, so they either grunt/yell, leak urine, or sustain an abdominal hernia or herniated spinal disc. The pressure escapes the system through the weakest link. (For more on this topic, check out this post from Physio Detective on pelvic floor dysfunction.)
- The pelvic floor may have been damaged (think episiotomy, forceps, vacuum extraction of baby, cancer/radiation) and the scar tissue affects the ability for the muscles to contract properly.
It is important to work with a therapist who can evaluate your specific condition and treat you with appropriate exercises and manual techniques. The answer to pelvic floor issues and SUI is not always “more Kegels.”
If the muscles are hypertonic or the issue is with breath holding, Kegels in isolation won’t solve the problem. Central stability (commonly called core stability) requires a balance of muscular strength and a neuromuscular strategy for engagement to meet physical demands. The respiratory diaphragm, deep abdominal muscles, spinal stabilizing muscles and pelvic floor need to work perfectly together.
JS: This problem isn’t limited to women, right?
AW: Right. While we most commonly associate incontinence and pelvic floor issues with women, men also suffer from these issues and are less likely to seek help. Men with pelvic health issues struggle with incontinence, sexual dysfunction, pudendal neuralgia, pelvic and rectal pain, and prostatitis. Experienced physical therapists can address men’s health issues as well as women’s health issues.
JS: Say you’re not full-blown peeing your pants. What are some other indicators that pelvic floor stability is an issue?
AW: In a workout environment, a few indicators are:
- Avoidance of certain exercises (you say, “I can’t do double-unders/burpees/box jumps/deadlifts).
- Limiting intake of water to keep the bladder empty (bad strategy due to possibility of dehydration and the fact that concentrated urine/dehydration can irritate the bladder and increase urgency).
- Running to the bathroom immediately before box jumps or double unders begin (need to completely empty the bladder one last time before attempting these exercises).
JS: How can we improve the strength and function of our pelvic floors?
AW: Helping women (and men!) with pelvic floor dysfunction often requires a team effort. First, women and men with SUI/pelvic floor dysfunction need to seek treatment. I encourage anyone with these issues to have an evaluation with a gynecologist or urologist, and/or a physical therapist who specializes in pelvic health. Through evaluation, we can identify what is causing your issue and work with you to treat it.
Though each case is different, there are a few general suggestions I can make regarding things to do to improve the function of your pelvic floor muscles. We know that for any muscle in the body, there is an optimal length/tension ratio; the pelvic floor muscles are no different. We also know that a muscle needs to relax fully in order to then generate a strong contraction — we wouldn’t walk around with our biceps flexed all day, so the notion of constant firing of the pelvic floor is incorrect. Here are some pearls of wisdom:
- Learn to completely relax your pelvic floor. To do this, get into a deep squat and let your pelvic floor completely relax as you inhale. As you exhale, lift through the pelvic floor as if you were stopping the flow of urine. Do this 10 times, several times a day.
- SQUAT. A lot. Weak glutes are prevalent in women who stand in a posterior pelvic tilt (tucked bum). A posterior pelvic tilt causes the sacrum to move anteriorly, putting slack in the pelvic floor muscles. Strong glutes balance the anterior pull on the sacrum and restore normal lumbar lordosis.
- As much as you may love stilettos, they are not doing your pelvic floor any favors. High heels contribute to a posterior pelvic tilt in order to adapt to the torque at the ankles. As we know, posterior pelvic tilt is no bueno. Save the heels for special occasions.
- Stretch and do mobility drills for your hamstrings, calves and adductors (groin muscles). When the pelvic floor is weak, folks use the glutes and adductors to keep the bladder closed (instead of the sphincter muscle of the bladder). Many women I work with tell me that they cross their legs when they sneeze to avoid leaking urine. This conscious and subconscious gripping with the adductors can lead to tight muscles. Learn to relax the adductors and fire the pelvic floor muscles.
- For more exercise ideas, check out the book Primal Moms Look Good Naked: A Mother’s Guide to Achieving Beauty Through Excellent Health. I contributed a chapter on exercise for the deep abdominals and pelvic floor muscles.
JS: How often should we do these drills, and how soon can we expect results if we follow the plan diligently?
AW: Bodyweight squats with integration of breathing and relaxation of the pelvic floor muscles can be done daily — several times a day, even. We need to get comfortable in this position. Then we need to integrate the motor pattern of being relaxed on inhale and contracting the pelvic floor on exhale into our functional activities — lifting children or lifting heavy bags of dog food, etc. For some women, strength may show a measurable increase after several weeks of training (provided that the correct techniques are utilized — this is where evaluation by a professional comes in to play).
JS: Here’s a weird question: I’ve recently purchased a Squatty Potty — OK, three — for my house because I was intrigued by the promises of a healthier pelvic floor. Is this a useful investment on the incontinence front?
AW: Squatting deeply while you urinate or defecate allows the puborectalis muscle to relax. This in turn allows the anorectal angle to straighten, leading to easier bowel movements, without straining. Squatting also activates your glutes, which in turn bring the sacrum posteriorly, allowing the pelvic outlet to open. Squatting in a relaxed position helps the pelvic floor muscles to relax, decreasing the need to “push” to force urine out.
The habit of “hovering” over the toilet seat contributes to tension in the pelvic floor muscles. The Squatty Potty allows everyone (even folks with decreased hip and ankle range of motion) to relax with using the toilet, so that they can empty the bladder and bowels completely, without straining.
So, yes, I think that the Squatty Potty can be beneficial as part of your overall plan for pelvic floor health.
Let’s start a dialogue in the comments section!
Ann Wendel is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT). She utilizes trigger point dry needling as a treatment modality, along with Pilates, lifting weights, and nutrition and lifestyle consulting in her holistic physical therapy practice, Prana Physical Therapy in Alexandria, VA. She can be contacted through her website: Prana-PT.com.