Getting to the Bottom of Pelvic Floor Issues

If you pee when you run/jump/cough/laugh/sneeze, we’re talking to you. Read on to discover how to avoid bulky pads and (yikes!) adult diapers.

“Ladies, who pees a little when they laugh?” a celebrity spokeswoman asks a stage full of backup dancers. At least half the women shrug and raise their hands. “Uh-huh, ya see?” the woman says to the camera before launching into a sales pitch for her favorite urinary incontinence pads — aka adult diapers.

This commercial is just the latest to claim that incontinence happens to everyone — no big deal — in order to sell products designed for an issue that, according to the Urology Care Foundation, affects about one in three women. But pelvic floor expert Dr. Julie Sarton, DPT, WCS, says that this kind of thinking, which is intended to be de-stigmatizing — empowering, even — is actually counterproductive. “Urinary incontinence is common, not normal,” she asserts.

Pelvic Floor 101

Found in both men and women, the pelvic floor is what Sarton refers to as a group of “forgotten” muscles, and no one talks about them until there’s a problem. “These muscles stretch across the bottom of the pelvis, like a taut, flexible trampoline,” she says. “They anchor at the pubic bone in the front, wrap around the vaginal and rectal openings, and attach to the base of the spine.”

Working together, the muscles of the pelvic floor perform four distinct functions. First, they play a supportive role by holding up the organs like the bladder, uterus and rectum. Second, they work in concert with the abdominal wall muscles to stabilize the core, which is crucial to everything from standing to walking and lifting weights. Third, they play a sexual role, allowing for intercourse and contributing to orgasm in women and men. And last, they keep us continent by acting as a sphincter, contracting to control urine and feces.

The medical community recognizes a few different types of urinary incontinence, but if you leak when force is applied to your pelvic floor (say, during a sprint or during double-unders), that’s considered stress urinary incontinence (SUI). “The problem is that the intra-abdominal pressure and the forces coming from above are exceeding the forces from below,” Sarton explains.

It’s logical to think that if you’re leaking, you have to strengthen your pelvic floor. That’s possible but is not always the case. “Part of it can be a coordination and timing issue,” Sarton says. “Maybe the muscles are strong enough, but no one’s really taught them to, or they’ve lost the ability to, be able to fire at the appropriate time.” It’s also possible for the pelvic floor muscles to be too tight to function properly.

Causes of Dysfunction

It’s not uncommon for women to experience SUI during pregnancy and after childbirth: The extra weight of a growing baby, changes in your center of gravity, the production of relaxin (a hormone that causes the ligaments to relax) and giving birth can mess with the pelvic floor’s ability to manage pressure. But SUI isn’t limited to new moms: Women of all ages and athletic backgrounds — dancers, gymnasts, volleyball players, weightlifters — can experience SUI.

Dr. C. Shanté Cofield, DPT, OCS, founder of TheMovementMaestro.com, says that seemingly simple factors like improper breathing patterns, bad body mechanics and poor posture can be to blame. For example, athletes who stand and train with an overly arched lower back “put the pelvic floor, the diaphragm and the abs in a disadvantaged position,” she says. “This means you can no longer control that intra-abdominal pressure very well.”

Even if you stick to lower-impact workouts like yoga and Pilates, bad alignment cues can negatively impact your pelvic floor rather than strengthening your middle — for instance, the cue about pulling your bellybutton to your spine that some instructors use to direct students to draw in the abdomen or “scoop” the belly. “Think of a tube of toothpaste: If you hold it upside down with the hole at the bottom and squeeze the middle, the pressure goes either up or down,” Cofield says. “When it goes down, that’s when we have these incontinence issues.”

Seeking Help

Contrary to what the adult diaper industry would have you believe, SUI isn’t something women should just accept. Pelvic floor physical therapists like Sarton and Cofield specialize in assessing and treating women with incontinence, as well as other issues like sexual pain and frequent urination. Yet many women put off seeing a pelvic floor physical therapist because they’ve been told that their symptoms are nothing out of the ordinary. In certain geographical areas, access also may be an issue. (Sarton advocates for the inclusion of pelvic floor assessments in annual OB-GYN visits). Some women also may harbor feelings of embarrassment about their symptoms or anxiety over the appointment itself.

Sarton and Cofield reassure that a visit with a pelvic floor physical therapist should look and feel a lot like any other physical therapy session. Appointments begin with a thorough history that includes the patient’s symptoms, goals and other questions regarding their typical bathroom habits (e.g. “How often do you urinate?” and “Do you get up in the middle of the night to use the bathroom?”). There’s typically an educational component on the pelvic floor and its various functions, and then the therapist moves on to the physical assessment.

The therapist will first observe how the patient stands and moves, focusing on her posture, breathing patterns and general mobility. Next, they’ll conduct an external exam by palpating the pelvic area, then (with the patient’s consent) an internal exam, often with a three-dimensional model placed on the patient’s abdomen so they can follow along. The internal exam is similar to a gynecological exam but with more participation on the patient’s part. The therapist may instruct the patient to contract and release her pelvic floor or ask her whether she feels pain or pressure as she palpates different muscles. “If the muscles are in a really unhealthy state and there’s a lot of hypertonicity — muscle shortening where it’s too active at rest — you can have some discomfort or pain,” Sarton says. However, the exam itself should not be painful. “A good physical therapist should be able to communicate so effectively with the patient so that if there is discomfort or pain, we can modify immediately to make it as pain-free as possible,” she says.

Intervention

If you visit a pelvic floor physical therapist for SUI, expect to go home with a list of exercises to do on your own. “We want our patients to become the CEOs of their own bodies,” Sarton says. “We give them the tools, then the patient has to take the baton and run with it.” Follow-up visits gauge progress and dictate future treatments.

And what happens if you do nothing? Does SUI ever go away on its own? In some cases, postpartum women find that once their tissues heal and they stop breast-feeding (which lowers vaginal estrogen, which can then decrease tissue integrity), their symptoms may go away. But if you haven’t given birth or it’s been months since you stopped nursing, any kind of leaking should be checked out. “If you ignore it, it’s likely to continue and likely to get worse with time,” Sarton says.

Bottom line: If you have SUI, adult diapers are not categorically your fate. Take control of your continence and get an assessment with a pelvic floor professional, and in a few months, you could be hammering out those double-unders with no fear.

Pelvic Floor Myths

Here, we dispel some commonly believed theories about the pelvic floor.

Doing Kegels (contracting the muscles that stop the flow of urine) will solve incontinence. 

Oftentimes, pelvic floor dysfunction is caused by hypertonic (shortened and overactive) muscles, so in that case, repeatedly contracting them won’t solve anything. Additionally, Kegels aren’t functional; they isolate the pelvic floor rather than training it to work in concert with other muscles. “When it comes to normal, symptom-free movement, our body does not use any muscle in isolation; the pelvic floor is no different,” says Dr. C. Shanté Cofield, DPT, OCS. “If we want it to function in its normal integrated fashion, we must train it accordingly.” Only do Kegels if you’ve been directed by a therapist to do so.

You should pee before you jump rope/run/lift so you don’t leak. 

This may lessen the amount of leakage but won’t stop it completely. “You never fully empty your bladder,” Cofield says. “You always have some residual, reserved capacity in there, so that doesn’t stop it.”

You probably need surgery. 

Surgery should never be your first option, Cofield says. She prefers taking an aggressive but noninvasive approach to treatment at first. “Because if your dysfunction is caused by poor positioning or poor breathing patterns, surgery won’t fix that,” she says.