I had the most embarrassing incident two years ago when I was presenting at a fitness workshop in Green Bay, Wisconsin.
I peed my pants.
Worse than that: I was photographed with other industry leaders, there was a visible a wet patch on my leggings on the published photo — a photo which was posted all over social media. There I was, with my muscles all buffed, wearing my cool workout clothes, and with a wet patch right at my crotch.
I was horrified.
I couldn’t work out what the heck was happening to me, but I needed to understand why I had started leaking so unexpectedly and almost 10 years after having kids, when I previously had no incontinence issues.
My first port of call was to a pelvic health physiotherapist. I feel that we are very lucky that some physiotherapists are specializing in this field, and consequently changing the lives to so many women, who might have experienced unwanted dribbles in their knickers for years before consulting.
My physiotherapist identified some issues that might be causing my incontinence, by performing an internal examination on me and getting me to perform Kegels. That tactile feedback made me understand what a Kegel should feel like, where I should be feeling it, and why I might not be activating my pelvic floor muscles correctly — mind blown! I had previously been doing Kegels completely wrong, yet with these physical cues I was able to fully understand what I needed to work on.
Curious to know if you’re doing them correctly? Read the article here: How to Do a Kegel the Right Way
I reached out to my female clients and asked them if any of them had incontinence issues. The answer was a resounding YES! Most found it too embarrassing to discuss with friends and partners, nevermind their gym trainers, and some even resigned themselves to just putting up with the issues. I believe that somewhere along the line there is an assumption that, as we age, we should expect some kind of urinary incontinence. Unfortunately, this is far from the truth.
In order to get more answers, I turned to the expertise of Dr. Meryl Alappattu, a physical therapist, assistant professor, expert on pelvic floor dysfunction, and contributor to the Coaching & Training Women Academy Pre- & Postnatal Coaching Certification.
AMANDA THEBE: Firstly, can you please explain the difference between stress urinary incontinence and urge urinary incontinence?
MERYL ALAPPATTU: In the case of stress urinary incontinence (SUI), leakage will occur when there is an increase of intra-abdominal pressure. This could be for example when you cough, sneeze, laugh, run or jump.
Urge urinary incontinence (UUI) happens when involuntary leakage is associated with urgency — if you don’t act quickly you risk leaking, and the urgency can be triggered by external factors: starting to pull your pants down, putting your key in the door, or hearing running water. Another typical behavior associated with UUI is referred to as “toilet mapping”, i.e. systematically locating the nearest toilet before doing anything else.
Stress and urge incontinence may also occur together. This is known as mixed urinary incontinence.
AT: If a person identifies with either SUI or UUI, what are the therapies available to them?
MA: A common conservative treatment option is individualized care provided by a pelvic health physiotherapist. A clinical exam performed by a physiotherapist may include assessing the hips, lower back and pelvic floor area to identify dysfunction that may be contributing to incontinence.
With UUI, we can intervene behaviorally by teaching people to recognize the triggers that cause their incontinence, and to retrain themselves to recognize what is a normal schedule for urinating. If you have just urinated 30 minutes ago, for example, and not consumed any more water, you probably shouldn’t need to go for another two to four hours. For people with SUI, we identify what specific activities or behaviors (e.g. coughing, lifting, laughing, etc.) are associated with their leakage and build a treatment plan targeted at decreasing leakage with these behaviors.
AT: I have heard that it is not a good idea to stop your pee mid-flow because it can confuse the pelvic floor muscles, is this correct?
MA: Correct. We use this method clinically as a way assess an individual’s ability to use their pelvic floor muscles to stop urine flow (i.e. a rough measure of pelvic floor muscle strength and coordination) and to give patients an idea of how to contract their muscles for a specific function ie stopping urine flow. Keep in mind that this is a baseline assessment and NOT something that people should be doing regularly as a way of exercising the pelvic floor muscles. Pelvic floor muscle exercises should be done away from the toilet.
How to do a baseline test
While you are sitting on the toilet, stop your pee mid-cycle — this is called the stop urine test. This is also used with patients initially to help them to recognize how to do the stop the action mid-stream. You will get one of the following results:
- Your flow will stop completely = you have good strength and coordination of your pelvic floor muscles to stop the flow.
- The contraction will slow down your stream but doesn’t stop completely = you may have fair coordination and strength to stop the urine flow mid stream.
- Nothing happens, your flow just continues = you may need some help recognizing and strengthening these muscles.
AT: Does perimenopause impact urinary incontinence due to hormonal disruption?
MA: We don’t completely understand the extent of the relationship between menopause and incontinence. A recent longitudinal study examined factors associated with developing urinary incontinence across the stages of menopause. These authors found that weight gain, anxiety, and diabetes — rather than estradiol levels — were associated with more frequent urinary leakage. We also need to look at a lifestyle fix, as everything is connected. Increased BMI through weight gain and obesity, and increased stress and anxiety are both associated with the development of incontinence, but each patient should be have their unique issues identified.
AT: What do you think of Kegel weights and the jade egg for incontinence therapy?
MA: I do not recommend putting jade eggs in the vagina. Certain celebrities and media have popularized the jade egg to help detox and cleanse the vagina and vulva. There is no evidence that jade does any of this and more importantly, vaginas and vulvas don’t require detox and cleansing.
If pelvic floor muscle strength is an issue, there are several medical-grade vaginal weights that may be used under the supervision and direction of a licensed physical therapist who specializes in urinary incontinence management. Kegel exercises are not necessarily the answer to all incontinence issues Using vaginal weights doesn’t make sense if you can’t perform a pelvic floor contraction on your own. A patient would need to be trained specifically by a professional how to use the weights properly to be effective.
AT: What do you think of surgery to prevent leakage?
MA: For people who have failed conservative treatment for leakage, surgery may be a good option. This is where your pelvic health physiotherapist should have a strong collaborative relationship with your OB-GYN, urologist, and other members of your health care team. If you’re considering surgery for issues with leakage, your surgeon may want you to first try conservative treatment for incontinence, and treatment by a pelvic health physiotherapist is one such option. If you decide to move forward with surgery, some surgeons may also recommend treatment by a pelvic health physiotherapist for strengthening of the pelvic floor and surrounding musculature prior to surgery. Incontinence can have a huge impact on both men and women’s quality of life; the decision to have surgery is a personal one.
The Next Steps
You may use one of the resources below to find a pelvic floor physiotherapist in your area:
- Australian Physiotherapy Association
- Canadian Physiotherapy Association
- Chartered Society of Physiotherapy (United Kingdom)
- Physiotherapy New Zealand
- Section on Women’s Health, American Physical Therapy Association
If incontinence is an issue for you, you need to find a team of professionals who will work together to support you. This team might include your OB-GYN, urologist, primary care physician, and pelvic floor physiotherapist, as well as a fitness professional who’s knowledgeable about pelvic floor issues, and can tailor your exercise program accordingly.
Remember that it is important that you keep advocating for yourself: what you are experiencing should not impact your quality of life, should not stop you living your days to their fullest, and is not considered normal. There are professionals who can help you and you deserve their help.