Urinary Incontinence – more common than you think

At the 2012 London Olympics, almost half of the athletes competing were women. As women’s participation in sports continues to increase, the importance of understanding common women’s health issues in the sports environment becomes more important for all clinicians. Urinary incontinence is an unspoken problem of the female athlete, and of women in general. Here’s what you should know about why it happens. If you just want to cut to the chase and just learn how to treat it, skip to the exercises at the end.

THE PELVIC FLOOR:
Think of the pelvis as the bowl-shaped arrangement of bones, including the flat bone in your lower back (sacrum), all the way around both sides to the pubic bone in front. To understand how complicated the strength in this area is, we need to realize that there are 30 muscles involved, mostly attaching the pelvis to the lower extremities. The pelvic floor muscles (PFM) form the bottom of the bowl and help support the bladder, uterus and rectum. To function normally, the pelvic floor needs to be able to both contract to maintain continence and relax to void urine.

The pelvic floor can be weak due to muscles being too tight or too lax. In order for the pelvic floor to function well, muscles of the pelvis and lower extremities have to be balanced in their tension. Individuals with low back pain have a significant decrease in pelvic floor function compared to individuals without pain. Because of the interdependence of back, pelvic and leg muscles, pelvic floor problems can originate from the low back, sacrum, hips, knees or ankles. Later in this article, we’ll talk about ways of improving awareness and control of the PFMs.

PELVIC FLOOR DYSFUNCTION (PFD):
This refers to any impairment of muscles, nerves, or connective tissue, or cooperative function of all of these, that interferes with normal pelvic floor function — i.e., proper bowel and bladder function, back/pelvis stability, and sexual function. The main complaints people have when there is dysfunction are incontinence and prolapse. Today, we will address the incontinence issue and in a later article, we’ll address prolapse.

INCONTINENCE:
Urinary incontinence occurs in many women, but most are too embarrassed to talk about it. It is defined as involuntary loss of urine and has wide ranging consequences, including decreased involvement in social situations and overall decreased quality of life. It is common in the general population and affects many young female athletes, whether or not they have experienced childbirth, which generally increases incontinence. Even in the young female population, aged 15 to 39, over 50% have incontinence, but only 20% seek help. Women typically wait 8 years before telling a physician.

Incontinence can be described as stress incontinence or urge incontinence. Stress incontinence is the involuntary loss of urine with increased abdominal pressure, which exceeds the forces that close the urethra, the path for urine to exit the bladder. Examples would be leakage with running, jumping, coughing, sneezing or laughing.

Urge incontinence, on the other hand, is the loss of urine with a strong urge from bladder overactivity or instability. This is more of a nerve interpretation problem than a strength problem. It is caused by inappropriate nerve signals to the bladder or from the bladder, poor voiding habits such as frequent voiding or an imbalance of muscles in the area of the bladder. In the female athlete, urge incontinence can develop from imbalance of certain abdominal muscles relative to others, imbalance of muscles at the level of the upper inner thighs, or low back problems, since that is where the nerves to the bladder originate.

“Research shows that pelvic floor exercises are the most effective way to reduce stress incontinence problems in women” (Bo and Herbert, 2013).

Here’s how to do them:

ACTIVATE YOUR PELVIC FLOOR MUSCLES (KEGELS)

Please keep in mind that Kegels are not appropriate for all conditions. Be sure to talk with a trained Physical Therapist before attempting these exercises.

HOW TO DO A KEGEL:

• Start lying down with your knees bent and supported with pillows. Once you’ve gained awareness and can feel the contractions you may perform exercises either sitting or standing.
• Place your hand on top of your pubic bone. Tighten and draw in the muscles around the anus and the vagina. You will feel the muscles lift up towards your pubic bone and squeeze the openings shut.
• Think about trying to stop the flow of urine, but do not actually do these when going to the toilet.
• Try to lift UP and IN, (not pushing down and out). Keep your legs, buttocks and abdominal wall relaxed. Breathe normally.
• You can feel the action of these muscles if you insert a finger in your vagina when you perform a contraction. You should feel a tightening around your finger and the muscular vaginal walls squeezing up and in.

There are two types of exercises, quick contractions and endurance contractions, generally held 3-10 seconds and completed 30-80 times per day. Your physical therapist will help determine the appropriate exercise for you. It is also helpful to perform Kegels when lifting, coughing, and sneezing. They can also be performed during sexual activities to enhance enjoyment.

And the best thing about Kegels? Once you know how to do them properly, you can do them privately anywhere, and anytime. So, what are you waiting for? Improved pelvic floor function can change your life. Get started TODAY!

OTHER PHYSICAL THERAPY CAN HELP!
In addition to the Kegel exercises, other methods can help establish a normal and balanced pelvis and re-educate the pelvic floor muscles in relationship to the other core trunk muscles to help improve incontinence. Gradually increasing pelvic floor strength can be done with the use of biofeedback. Education on proper bladder habits and a review of fluid intake and diet need to be considered when addressing bowel and bladder dysfunction. Manual therapy by a physical therapist can help improve muscle balance of the spine and hips. Modalities such as electrical stimulation can be considered to stimulate muscle contraction using internal electrodes for stress incontinence or to inhibit unwanted bladder contractions for urge incontinence.

Stay tuned for other important info about pelvic floor issues, including the very common problems of bladder and uterine prolapse. Remember, these are common problems. Help is available if you start the discussion with your physician.

References:

1. www.feminist.org/sports/olympics.asp
2. Meyers WC, Kahan DM, Joseph T, et al. Current Analysis of Women Athletes with Pelvic Pain. Med Sci Sports Exerc. 2011 Aug;43(8):1387-93.
3. Bø K, Borgen JS. Prevalence of stress and urge urinary incontinence in elite athletes and controls. Med Sci Sports Exerc. 2001 Nov;33(11):1797-802.
4. Nygaard I, Thompson FL, Svengalas SL, et. Al. Urinary incontience in elite nulliparous athleses. Obstet Gynecol. 1994; 84:183-7.
5. Delancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170(6):1713-20.
6. Lee DG. Stress urinary incontinence and the pelvis. 2011. Available online at http://dianelee.ca/education/article_stress_incontinence.php.
7. Brubaker, L. and Saclarides, T. The Female Pelvic Floor: Disorders of Function and Support. F.A. Davis, 1996
8. Lee DG, Lee L, Vleeming A. The Pelvic Girdle, An Integration of Clinical Expertise and Research. Churchill Livingstone; 2010.