Urinary incontinence, the pelvis, and training

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A client came in recently, slightly irritated. “Jenn, you aren’t going to believe the commercial I recently saw. You are going to be upset.”

Intrigued, because this client knows me well and she knows very few things phase me, I went ahead and bit. “What?”

“One of the feminine hygiene companies is making incontinence products targeted towards younger women. Just what women need—to be told they need to spend more money on products when they could get stronger and save themselves the money and the embarrassment of peeing themselves.”

A little background. This client had two children via C-section. One of her main goals when she started seeing me was not to pee herself when she got older. We work on things. No leaking has happened in the 13 years she has worked with me. In the last two years, she found out both her stepmom and her sister struggle with urinary incontinence (UI). When she asked me what they should do, I told her they should both get referrals from their doctors to a pelvic floor physical therapist. I also told her I don’t think it’s a topic that’s talked about often enough. I train a lot of women who have had children, and I care about their total body strength, including the strength of their pelvic floors.

At some point, she looked at me and said, “I am beginning to think you’re right about why women take so long in the bathroom—they are cleaning themselves up as discreetly as possible.” (Women in the bathroom used to perplex me until I started realizing the sheer number of women struggling with incontinence. I have become more patient and understanding in recent years when waiting several minutes for a stall.)

After our session, which involved a lengthy discussion about the importance of strength and some challenging deeper abdominal exercises (for her), I began a search of urinary incontinence and exercise on my lunch break. What I found was interesting and (in my opinion, anyway), article worthy. Let’s start with the obvious.

Vaginal birth and UI:

One of the risk factors for UI is denervation of the pelvic floor muscles. Denervation means there has been a loss of nerve supply to a specific area. Nerves provide sensory and motor information to a body part—if you can’t feel an area, it’s more difficult to control that area. One of the things associated with denervation to the pelvic floor is vaginal birth, so it shouldn’t come as a surprise that statistics show up to 37.9% of women experience UI, even after 12 years of child birth. Hence, UI products.

It’s not that cesarean delivery guarantees you won’t have UI, but the odds are less. Risk of pelvic organ prolapse is also less during a cesarean delivery; however, it is surgery, and there are a host of other factors that increase following C-sections.

As an aside, I have found training women post c-section is related to different concerns than working with women post vaginal birth. I will speak more about this in a later post.

Female athletes:

It’s a problem that extends beyond vaginal births. An observational study published in the European Journal of Sports Science found the prevalence of UI in high impact sports athletes was 70%. At the risk of stating the obvious, Chances are low the 82 out of 118 women surveyed reporting had given birth, which makes this number seem really high.

A meta-analysis examining the prevalence of urinary incontinence in female athletes found female athletes had a 177% increase of presenting with UI when compared to sedentary women. The researchers suggest physical exercise places women at higher UI risk because of increased intra-abdominal pressure that’s generated during high-impact activities, but aren’t we designed to run and jump and climb? And if we are designed to do those things, shouldn’t our pelvic floors respond by getting stronger?

Curiously, a literature review by Steenstrup et.al, (2018), found that while data is limited, sedentary lifestyle also appears to be a risk factor for UI. It appears it is difficult to escape UI risk if you are a female.

Menopause:

Lest you think the issue disappears with age, in China, more than 20% of women between the ages 45-59 experience stress urinary incontinence (SUI). SUI refers to leaking during elevated abdominal pressure, which happens when you cough and sneeze.

Data collected from a questionnaire given to women between 1995-2005 found that of 1339 women reporting UI, 61% did not seek treatment because 73% believed the UI wasn’t “bad enough,” and 53% believed UI was “a normal part of aging.” This begs the question: how many women struggle with UI and don’t report it? Hence, products aimed at women specifically for UI.

And don’t forget about the men…

Prostrate cancer happens. One of the treatments for prostrate cancer is a radical prostatectomy (removal of the prostate). When the prostrate is removed, risk of UI increases.

And maybe UI just happens. A survey of 23,240 Danish men found 1657 reported various forms of UI. Granted, this is a lot lower than the numbers reported for women, (7% as opposed to 20% or more reported in the sections above), but it’s not insignificant.

Implications for movement professionals and personal trainers:

So at this point I think we can all agree UI is a bit of an issue, probably one that’s bigger than many of us realize. What can movement professionals do?

As always, creating a line of open communication is key. If any of your clients shy away from a higher impact exercise without offering an explanation, respect there might an underlying issue she/he doesn’t want to discuss. If, at some point, if someone does share with you she’s struggling with leaking, encourage her to get a referral to a pelvic floor physical therapist.

Here’s what we know: pelvic floor muscle training has a positive effect on UI in women. In men with UI following a prostatectomy, research showed improvement in UI following a strengthening program that included kegals, squats, supermans, and bridging; interestingly, hip extensor strength and endurance was significantly higher in the continent group. Women who regularly exercise have stronger pelvic floor muscles mid-pregnancy than women who are sedentary. Ankle position facilitates greater contraction of the pelvic floor muscles.

Let’s look at this another way. Getting strong will effect the entire body, all of the way down to the skeleton. Your pelvic floor muscles are no exception; if you load the pelvis in a variety of ways, the muscles that support the pelvis will get stronger.

A brief note about the physiology and anatomy:

Muscle tone and strength maintain your structural integrity. When the muscles of the pelvic floor are stiff and/or stretched out, the muscles fibers are less able to generate power. The majority of the muscles that comprise the pelvic floor are made up of slow twitch muscle fibers, so contraction during urination is initiated by a small number of fast twitch fibers. These muscles are affected during denervation, but with the appropriate exercise and pelvic floor training stimulus, can be strengthened. Kegels are a low level activity, and while they may be appropriate to begin to improve coordination and awareness of the pelvic floor, in a movement and strength setting, the structure of the pelvis should be challenged in a way that stimulates strength and mobility.

*Please note: I opted not to discuss breathing, but breathing is also a low level activity that can improve awareness of pelvic floor contraction and relaxation.

The muscles that support the pelvis should be trained in different positions. If someone doesn’t have the ability to move the pelvis in isolation, chances are slim the pelvis is going to participate in an integrated way during movement. From a practical perspective, it’s less about anterior or posterior pelvic tilt being bad, and more about the ability to being able to move the pelvis both directions, as well as laterally and rotationally. Basically, if you can channel your inner burlesque dancer, you have good access to mobility in the pelvic region.

Putting theory into practice:

How many positions can you perform a pelvic tilt? Can you do it in supine? Quadruped? Tall kneeling? Half kneeling? A squat? A lunge position? A plank? Seated? Long sitting? You own the movement when you can translate it into a wide variety of positions.

External rotation:

Strengthening external rotation of the hip may increase pelvic floor muscle strength, possibly because of the orientation of muscles such as the obturator internus and piriformis. The piriformis is actually one of the muscles of the pelvic floor; it’s also one of the rotator cuff muscles of the hip, so it stabilizes the femur in the socket during movement. It’s not only implicated in UI, it’s also implicated in non relaxing pelvic floor dysfunction, which can involve pain during urination and sexual intercourse (different topic for a different day, but worth noting).

Putting theory into practice:

External rotation should be strengthened progressively. There is so much value in ground work and different floor transitions; I frequently use the floor work from the MovNat system and squat variations from the GMB elements program to work on external rotation. I also using breathing techniques and isometric holds to feel movement in the pelvic floor. If someone struggles with external rotation, teaching the basic clam shell exercise creates awareness and the ability to isolate the movement of external rotation. Like Kegels, these are a low level movement and clients/students should be progressed to more dynamic movements fairly quickly.

The shin box/seated 90/90 exercise is an excellent way to teach external and internal rotation at the hip. A wide number of variations and transitions can be implemented from this position once basic points are covered. Prone frogger is also an excellent exercise for isolating external rotation at the hip joint. Both the seated 90/90 and the prone frogger are ways to build awareness and strength in the muscles of the pelvis and the pelvic floor.

Ankle position:

How you use your feet and ankles affects how you experience work in your pelvis and hips. Have you ever cued someone to push through the heel when stepping on to a step in order to get the person to feel the gluteal muscles more? Or maybe you’ve cued the pressing of the big toe and arch into the floor while staying centered in the heel in order to help someone feel the adductors. Your feet and your hips works together to create movement; it shouldn’t come as a surprise that ankle position impacts pelvic floor activity.

Think about what happens when women wear high heels. What position does their pelvis naturally move to accommodate the motion? Anteriorly, right? Again, this isn’t about anterior or posterior pelvic tilt being better or worse, but it should make sense that ankle dorsiflexion or a neutral ankle improves resting activity in the pelvic floor muscles. Try this: come into standing on the balls of your feet. Try and contract your pelvic floor on your exhale. Now, lower your feet to the ground. Try and contract your pelvic floor on the exhale. Which was easier?

Now, in a standing position, move your pelvis into an anterior pelvic tilt. Contract your pelvic floor. Move your pelvis into a posterior pelvic tilt. Contract your pelvic floor. Which variation was easier?

Putting theory into practice:

Our pelvis should be able to move anteriorly and posteriorly. Our ankle should be able to plantar flex and dorsiflex. If you are working with someone who struggles with UI, early on in the programming, work on ankle mobility and create awareness from the feet to the pelvis by utilizing a variety of positions while working on the feet in a flat position. Conveniently, squats, squat walks, and low lunge variations strengthen the hips and pelvis while also improving ankle dorsiflexion. You can also spend time simply working on foot exercises barefoot in order to create more mobility in these areas.

A brief note about the female athlete and UI:

I noted earlier female athletes appear to have a higher incidence of UI than their sedentary counterparts. This is probably (like all things), multi-faceted, but I do wonder if more restorative, mindful interventions surrounding the pelvis and the feet would help? Slowing down a little bit and paying attention to feeling how different areas move can create awareness, down regulate the nervous system, and improve overall coordination. While gravity, force, and pressure all play a role in the function of the pelvic floor, so does having access to a variety of positions and balanced strength. I couldn’t find any meta-analyses that looked at these types of interventions, and it’s an area I think that deserves further study. Strength happens from the inside out.

Urinary incontinence is a topic that’s considered taboo. It affects men and women of all ages and athletic capabilities. Creating programs that strengthen and mobilize the pelvis, hips, ankles, and feet in a variety of ways, utilizing isometric holds, and knowing who the pelvic floor physical therapists are in your area so you can refer out are all excellent ways to help clients deal with an issue that can decrease overall quality of life.

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