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By Sophia McLean – Certified Pelvic Health Physiotherapist
Leaking urine, gas, or stool can be frustrating, disruptive, and isolating, yet it happens to 1 in 3 women and 2 in 9 men. The formal word for leaking is incontinence, and it is typically associated with childbirth and aging. However, it can happen throughout the lifespan for a variety of reasons. Like pain, leaking is common but not normal. While leaking can have different levels of bother depending on the situation and person, it’s presence is a sign that something isn’t in working order and is worth taking care of. Leaking is often very treatable with conservative management such as pelvic health physiotherapy, regardless of how long it has been happening.
There are different types of urinary (bladder-related) incontinence:
- Stress urinary incontinence (SUI) occurs with mechanical “stress” or pressure, such as coughing, sneezing, laughing, jumping, gagging, running, etc. Essentially, the muscles around the urethra (tube leading out of the bladder), called sphincters, aren’t able to counterbalance pressure on the bladder, which allows the escape of urine.
- Urge urinary incontinence (UUI) has to do with leaking in response to the urge to pee, often on the way to the bathroom. In this case, either the muscles aren’t able to hold a full bladder and/or the bladder muscle is overactive.
- Mixed urinary incontinence (MUI) is, as the name implies, a mix of both SUI and UUI.
- Functional incontinence occurs when circumstances limit one’s ability to get to the bathroom on time, such as mobility issues or surgery.
Non-bladder related incontinence occurs with gas and stool:
- Gas incontinence typically happens due to lack of muscular control around the anus. The anal sphincters should squeeze in response to the presence of pressure, like with yelling, laughing, walking, or changing positions.
- Fecal (stool) incontinence can occur because of the same pressure control issue, and/or from lack of robustness of muscles that provide mechanical support to the rectum.
Regardless of the type of incontinence you might have, it comes down to a pressure management issue. Leaking is an escape of pressure through the path of least resistance in the system, and the solution is to optimize the resistance in the system so that pressure is managed well. Specifically, as the bladder fills with urine, the rectum fills with gas or stool, and/or you do an activity that causes increased pressure through your torso, the pelvic floor muscles need to have adequate power, range of motion, endurance, and response time to counterbalance that increase in pressure.
Often people attribute leaking to weak pelvic floor muscles and do “kegels” to resolve it. However, there is much more nuance to consider. For instance, the pelvic floor muscles don’t work on their own. Good pressure management requires adequate function of and coordination between pelvic floor muscles, the diaphragm (breathing muscle), the deep core in the abdomen and back. Other muscles that attach to the pelvis, like the gluteals, also play an important role in this dynamic system. Similar to a sports team, each player has to perform at its best individually and be coordinated with (every other member of the team).
In addition, the pelvic floor can be weak for two reasons: because it has low tone (it is more lax, loose, and is not as robust as it could be) or it has high tone (it has too much tension or tightness). Either way, the pelvic floor muscles lack range of motion, and therefore optimal performance. The common prescription for a weak pelvic floor are kegels. However, when pelvic floor muscles have high tone, the important thing to do before kegels is to normalize tone. In addition, research studies show most women don’t perform kegels correctly without guidance. Thus, it is best to be assessed for an appropriate rehabilitation program to treat your symptoms.
Still, there are a few things you can consider if you are dealing with any type of incontinence:
- Brain-body connection: The first step is being more connected to and aware of your pelvic floor. Sit on a small rolled up towel (long ways like a saddle) so that you have pressure against the space between your legs. Start relaxed, let go of your belly and legs if they are holding any tension. Bring your awareness to what is contacting the towel. Now, picture a marble sitting at the opening of your anus. Use your muscles to gently wrap around the marble and lift it gently up into the pelvis. Then use your muscles to place the marble back down and melt completely back into the towel. Signs that you might need extra guidance for this movement include: extra muscle involvement (squeezing your legs, clenching your butt cheeks), not being able to fully lift OR fully relax, and pain or discomfort when you activate the muscles.
- Posture: If you think of your torso as a balloon full of air, you want to sit and move in ways the keep the air balanced throughout the balloon. For example, if you tend to slouch often, the top of the balloon (your rib cage and midback) presses downward, increasing the pressure going through the bottom of the balloon (the pelvic floor) and outward through the sides (your belly). While perfect posture is not the expectation, sitting in optimal posture most of the time can keep the pressure balanced through the system.
- The Knack: If there is a consistent pattern to when you leak urine, such as position changes, coughing, sneezing, bending, etc, you can voluntarily activate your pelvic floor muscles to provide counterpressure for the activity or movement. This is different from squeezing or bracing your whole body – you want to specifically have the pelvic floor muscles lifting and holding.
- Diet and water intake: Muscle performance aside, proper diet and fluid intake can often help incontinence issues. For instance, if your urine is too concentrated (you don’t drink enough water or drink a higher ratio of non-water fluids like coffee), the bladder lining becomes more sensitive, contributing to more urgency or activation to get it out. In addition, if your stool is not formed, it is harder for the sphincters to manage and control the loss of stool. Lastly, if your diet contributes to frequent bloating or gas, this puts more pressure through the system as a whole.
Regardless of the type or cause of incontinence, leaking can often be resolved by pelvic floor physiotherapy, which helps to assess the tone of the muscles; get a baseline for strength, endurance, and coordination; assign appropriate exercises to restore optimal muscle function; and guide you through helpful lifestyle changes (diet, water intake, bathroom habits, and/or exercise). Incontinence is not something you have to or should live with, and we at The Mama’s Physio would consider it a privilege to work with you to make that possible.
Forget, Marie-Josee and Sheila Zelmer. “Level 1: The Physical Therapy Approach to Female and Male Urinary Incontinence.” Pelvic Health Solutions. Vaughan, ON, May 2019.
The Cameron Institute. “Incontinence: The Canadian Perspective.” The Canadian Continence Foundation, December 2014.