You may have heard murmurings at practice, the gym, in yoga, or maybe you’ve got your own experiences to share, of people describing incidences of urine loss while exercising. This is called Stress Urinary Incontinence (SUI) and is described as a loss of urine associated with a stress to the body causing increased intra-abdominal pressure, such as running, jumping, lifting, etc. Picture a full tube of toothpaste with the cap off, an event causing increased intra-abdominal pressure would be like squeezing on that tube which forces the toothpaste to leak out of the bottom. Now picture that same tube of toothpaste with the cap on, squeezing on it doesn’t cause leakage because the appropriate systems are in place to prevent that leakage from happening. In this analogy, the cap represents your pelvic floor muscles. When these muscles are functioning appropriately they help to maintain continence by contracting with adequate force in order to close the urethra and prevent leakage of urine.
So why do so many athletes experience SUI? Many people have preconceived notions about who experiences pelvic floor dysfunction. While there are certain risk factors that can put a person at risk, here at PHRC we know that pelvic floor dysfunction can affect people of all ages, genders, backgrounds, and activity levels. Being an athlete doesn’t automatically prevent you from having pelvic floor dysfunction, and depending on your specific sport or activity you may be more at risk. Just like anyone, athletes may have muscle imbalances or impairments that can lead to SUI. Their issue can be any number of things, but most commonly we see athletes dealing with muscle tightness and/or inability to control their pelvic floor muscles. These impairments coupled with the increased intra-abdominal pressure caused by their sport can lead to SUI which can limit both the athlete’s performance and quality of life outside of their sport.
Athletes tend to push their bodies to accomplish incredible feats using training programs to build strength and develop motor control. Motor control can be described as a person’s ability to initiate and direct muscle function and voluntary movements. That said, strength and motor control are not developed equally in all parts of the body. People get better at what they practice and most athletes spend a lot of time honing in on their specific sport or skill and very little time working on their pelvic floor muscle function. Depending on what your sport is, you may be putting significant stress on your pelvic floor muscles. For example, people who do high impact sports that involve lots of jumping such as gymnastics or trampolining are much more at risk for SUI than someone who plays golf. System failure occurs when a load exceeds the tissues capacity to function properly. Therefore, if the load you are putting on your pelvic floor exceeds their ability to function too close to your urethra, you’ll experience an involuntary loss of urine.
So what can an athlete do to help their pelvic floor function more properly and prevent this leakage? Well, for starters, breathe. When you breathe in the diaphragm contracts and descends which pulls air into your lungs. Think of your core like a balloon filled with air, the top of balloon is the diaphragm, the sides are the core muscles, and the base is the pelvic floor. When the diaphragm descends it acts as a force that’s pushing on the top of the balloon, and the air inside the balloon has to go somewhere so it expands into and stretches the sides and the base of the balloon. You’ll notice during good diaphragmatic breathing that your abdomen will rise and fall. What you may not notice is your pelvic floor muscles also moving; they expand and drop as you inhale and then they naturally come back up as you exhale. Keep in mind that the diaphragm and the pelvic floor muscles have a parallel movement pattern so when you breathe in both the diaphragm and the pelvic floor descend. This movement of descending or dropping causes a relaxation of the pelvic floor muscles.This is a great way to perform a natural stretch to those tight pelvic floor muscles and to develop some awareness and motor control which can help them function more properly. For more information on diaphragmatic breathing and instructions on how to practice, check out Nicole’s blog.
What should I not do, you ask? Kegel. Yes, you read correctly. Kegels have been pitched as this one size fits all approach to pelvic floor dysfunction but that’s just not the case. If your pelvic floor muscles are too tight and generally sit in a state of contraction, then strengthening is not the appropriate response. Imagine doing bicep curls from full elbow extension to full elbow flexion, you can generate a lot of force and build strength in this case. Now imagine doing bicep curls when your elbow can’t extend past a 90 degree bend. You’re not going to build strength through such a limited range of motion and in fact you’ll only make that short muscle even tighter. If our goal is to get those muscles to relax, then strengthening is not going to be the appropriate intervention. For more information on why Kegels aren’t good for your tight pelvic floor, check out Liz’s blog.
Who can help me with this issue? Find a local pelvic floor physical therapist to do an assessment. Your therapist can help to determine the underlying cause of your leakage and help you overcome these impairments with manual therapy, exercises, and lots of patient education. Your session will be individualized and they can provide sport specific tips. Improving your pelvic floor function can help to reduce the leakage you’re experiencing during exercise, improving both your performance and your quality of life.
As a final note it’s important to remember that you are not alone in this. In 2018 a systematic review of literature studying the prevalence of urinary incontinence in athletes found “the prevalence of UI varied from 5.56% in low-impact activity to 80% in trampolining.1” All this is to say that if you or someone you know is experiencing urinary incontinence with exercising it is an incredibly common dysfunction and there is something that can be done to help!
References:
- de Mattos Lourenco, T.R., Matsuoka, P.K., Baracat, E.C. et al. Urinary incontinence in female athletes: a systematic review. Int Urogynecol J (2018) 29: 1757. https://doi.org/10.1007/s00192-018-3629-z
FAQ
What are pelvic floor muscles?
The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.
What is pelvic floor physical therapy?
Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.
What happens at pelvic floor therapy?
During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.
What is pudendal neuralgia and how is it treated?
Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.
Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.
What is interstitial cystitis and how is it treated?
Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.
Who is the Pelvic Health and Rehabilitation Team?
The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.
How many years of experience do we have?
Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.
Why PHRC versus anyone else?
PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.
Do we treat men for pelvic floor therapy?
The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.
Do I need pelvic floor therapy forever?
The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.