Exercise and Incontinence
Why do I leak when I play sport or exercise?
Activities that increase abdominal pressure such as jumping, running, skipping and lifting weights can cause the small leaks of urine known as stress incontinence (SUI)
This will happen if the forces in the abdomen are greater than the forces within and around the urethra to create what is called the urethral closure pressure. The urethra is the tube we pass urine through from the bladder. If you imagine it like a straw which is open when fluid passes through but closes flat when there isn't.
Several factors determine how well the urethra stays closed :
- the pelvic floor muscles as they tension the fascial/elastic tissues behind the urethra.
- the ligaments around the urethra attaching it to the pubic bone
- the internal urethral sphincter - at the base of the bladder, blending with the bladder muscle (detrusor) and therefore made of smooth muscle
- the external urethral sphincter which surrounds the middle part of the urethra and contracts to help close it. This is one of the muscles we aim to strengthen with the cue "stop the flow of urine" or, for men "shorten the penis"
- the blood flow in the urethral walls
- the hormone oestrogen which helps to keep the urethra plump and the walls 'sticky'
These forces combined are called the continence mechanism and, if equal, the urethra stays closed and you don't leak.
If the abdominal pressure is greater - you leak.
It isn't always about getting stronger pelvic floor muscles, sometimes all you need to do is adjust your exercise and breathing techniques - see below.
Just to confuse things, the cause can also be because your pelvic floor muscles are too tight or overactive. If muscles are tight, shortened and overactive they can't respond properly when needed and won't be able to contract effectively and again, you may leak.
If this is the case, the treatment is NOT doing pelvic floor exercises or kegels, rather it is being taught how to relax and lengthen the muscles.
It's so embarrassing - what can I do about it?
There are many strategies to use and it is not all just pelvic floor exercises or kegels.
- First of all - DO NOT stop exercising! You may just need to adjust the intensity back to a level where you don't leak until you have trained your continence mechanism better.
- For most women, stress incontinence responds extremely well to pelvic floor exercises and is the recommended first line of therapy.
Building strength in the pelvic floor helps it to tension the elastic tissues that support the bladder neck and help to close it under pressure as well as supporting the bladder neck. - Breathing in rhythm with your pelvic floor reduces downwards presssures and the chances of leaking.
You should EXhale through the EXertion phase of an action eg as you lift. This reduces intra-abdominal pressure. - Build endurance in your pelvic floor and continence mechanism. You don't just run a marathon with no training, you build up to it. Do the same with loading your pelvic floor. Gradually increasing loads just like you would grade your exercise for the rest of the body.
This is also where pelvic floor weights can help. Used regularly they help to build muscle endurance. They can also be used as biofeedback during exercise to help you learn how to control abdominal pressures and co-ordinate your breathing. - Check your technique - often women who exercise a lot are very dominant in their outer layer of abdominal muscles, the six-pack and the obliques, which can create a lot of internal pressure. Losing that 'tummy grip' will lead to better overall exercise technique as well as less leaking. You can check your pelvic floor exercise technique with something as simple as a pelvic floor educator, and use it to see if you can hold a contraction whilst continuing to breathe.
- Some women, despite good training, may still leak because their continence mechanism (pelvic floor muscles plus elastic tissue and urethral closing factors) just aren't strong enough to counteract the abdominal pressures. This is where pessaries and urethral support devices can be very helpful. See a pelvic floor physio experienced at fitting a pessary if you also need pelvic organ support or you can try Contiform urethral support whilst exercising.
I've never heard of it happening to anyone else, is it just me?
It happens to many people, especially females but most are too embarrassed to talk about it. You are definitely not alone.
Research has shown that over 30% of Australian women over 45 report that they leak during physical activity, and 13% of 18-23 year olds say it happens to them too, even when they haven't yet had children One study showed that 26% of yoga instructors leaked whilst teaching!
Whatever sex or gender you identifiy with, if you have a bladder and a urethra you may at some stage leak with exercise.
Maybe I should just give up, or switch to another sport.
Exercise is vital to our overall health so stopping exercise because you are leaking is often what women do but it is the one thing you shouldn't do!
In fact, obesity is an independent risk factor for stress incontinence and many of us put on weight if we don't stay active which causes a vicious cycle. Don't get caught in that cycle.
Some good steps to follow are:
- Get a proper assessment with a pelvic floor physiotherapist or your gynaecologist (and ask them to refer you to a physio for ongoing guidance)
- Keep exercising but reduce intensity to a level where you don't leak - remember this is temporary until you build endurance and strategies.
- Find some alternative exercises that you enjoy and that give you that exercise hit you are after until you can build back to what you were doing.
- It may be as simple as using a pessary or a urethral support device whilst you continue doing what you love but make sure you also address the pelvic floor issues at the same time.
Stress incontinence shouldn't be a barrier to exercise, but it often is.
I've been wearing pads, but is there anything else I can do?
Wearing pads to exercise is a sign that things are not working properly so first step is to see a pelvic floor physiotherapist or your gynaecologist for a check up. A pad can be a good temporary option but wearing a pad and not addressing the underlying problem is not a good option.
However it is better to wear a pad and keep exercising whilst you work to find a solution rather than stopping exercise all together!
Pessaries and urethral support devices are other options but looking at exercise and breathing techniques are essential.
Try to find a trainer who understands the demands of exercise on the pelvic floor, and preferably one who works in conjunction with a pelvic floor physiotherapist. If any exercise makes you feel that you leak, or gives you a feeling of heaviness in the pelvis or vagina (signs of prolapse, read more here) then you need to modify that exercise, or find an alternative until you have done Step 1 above - had an assessment.
I'm a fitness professional. What can I do to help my clients?
This is an important issue for fitness professionals, who may be losing clients regularly without knowing why.
If someone stops coming to sessions it may be because they are either leaking or having symptoms of prolapse. Regularly running to the loo just before class or during certain exercises like skipping are also signs that someone is having pelvic floor issues.
Screening your clients to identify any issues before starting a program is essential. There is a good screening tool on the Pelvic Floor First website .
There is one specific for females and one for males
Recommendations:
- If your client is of child-bearing age or beyond then the chances are she has experienced some form of pelvic floor dysfunction. For most women strengthening of the pelvic floor muscles and retraining their co-ordination will overcome stress incontinence.
- Check out the resources available on Pelvic Floor First . There are many excellent resources on this site for fitness professionals
- Talk openly about the function of the pelvic floor
- Attend new training opportunities for fitness professionals through the Australian Fitness Network, as part of a joint initiative with the Continence Foundation
- Include lower impact alternatives in your workouts and give people the choice of which level to work at without judgement
- Becoming known as a personal trainer who understands the needs of your clients and how to adapt programs accordingly is a great way to grow your business and not lose clients because their pelvic floor issues are getting worse with exercise.
The material presented here is intended as an information source only. The information is provided solely on the basis that readers will be responsible for making their own assessment of the matters presented herein and are advised to verify all relevant representations, statements and information. The information should not be considered complete and should not be used in place of the advice of a health care provider. Pelvic Floor Exercise does not accept liability to any person for the information or advice provided , or for loss or damages incurred as a result of reliance upon the material contained herein.
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