The NHS estimates that between 3 and 6 million people in the UK suffer from some type of urinary incontinence. Although it is more common in women, men can also suffer from this condition. In this article we will look at a few of the reasons for urinary incontinence and outline some of the solutions to it. We will discover how Peter prepared for his prostate operation; how Anne resolved her back pain—whilst learning that growing older didn’t have to include wearing incontinence pads; how Clara found freedom to leave her house again; and how I learned to run and jump without worrying about peeing my pants.
Six months after the birth on my second son I was teaching an aerobics class at the most exclusive health-club in town. I’d arrived late because my elder son had fallen down some steps outside and cut his lip, and because of my lateness I didn’t have time to go for a pee before the start of the class. As soon as I’d taken that first jump, I knew I’d made a terrible mistake. I felt a pressure in my pelvic floor and then wetness in my pants. It was only slight at first, but with every jump I felt it spread. I remember the music booming out as I shouted instructions to the twenty participants who were trying desperately not to look at the dark patch creeping down my legs. By the end of that sixty-minute class my light-grey jazz pants had a dark stain that ran down my inside leg from my crotch to my mid-thighs. I clearly remember my walk of shame through the open-plan gym as I left the club that day. It was a Saturday morning and packed with people who expected their aerobics teachers to have a pelvic floor made of steel. I looked down at the floor and made a beeline for the exit, hoping that no one would come near enough to notice the stale smell of urine.
This was a classic case of urinary stress incontinence and now—having been in practice for over twenty years—I’m aware of how easy it is to resolve this problem. But at the time I was only in my first year of osteopathic study and hadn’t been introduced to Pilates. I was a busy mum, with little time to myself, and during the previous three years my pelvic floor had suffered from two pregnancies, two difficult labours, and three cuts from big episiotomy scissors. I knew I needed to do pelvic floor (Kegel) exercises, but I wasn’t exactly sure how to find that pelvic floor—and I didn’t really believe that squeezing my vagina however many times a day would make any discernible difference to my leaking bladder.
It was only when I started practicing Pilates that I learnt about the pelvic floor. I discovered that it is a muscular sling at the base of the pelvis that supports our pelvic organs and that it helps us expel unwanted substances from our body. (The next time you go to the loo, consider how your pelvic floor relaxes to allow you to pee, fart or poo. Also, observe how your pelvic floor tightens just before you cough or sneeze—this helps increase the pressure inside your abdomen so that you can force out any foreign object from your lungs or throat.) Stress incontinence is extremely common and can affect both women and men. Frequently occurring after pregnancy, it can also be associated with excessive coughing, weight gain, lowered oestrogen levels, and prostate or gynaecological surgery
I mentioned earlier that I’d initially had problems finding my pelvic floor. Sometimes I felt as if I were simply pulling in my tummy or squeezing my bum and thighs. Occasionally I think I was just lifting my eyebrows. Eventually I resorted to locking myself in the bathroom, away from the children. I sat on the loo, put my fingers up my vagina, and drew in the muscles as if I were trying to stop myself peeing. I could feel a very slight tightness and lifting sensation just up from the opening of my vagina. My fingers gave me extra feedback to know I was doing the exercises in the right place. I could relax my tummy, thighs and bum … even my eyebrows. I held it for a breath and then relaxed it. This was the start of my pelvic floor rehabilitation routine. Whilst a little basic, it did the trick and soon I could isolate the muscles without needing the feedback from my fingers.
Admittedly this isn’t everyone’s experience. Anne came to see me at my practice last year because she had pain in her tailbone. She is 60 years old and, after retiring as a head teacher, she now spends her time eating and drinking with friends, going to the theatre, and reading. She has no children and when I asked her about her activity level she told me firmly she was ‘not the sporty type’. I asked Anne about her pelvic floor and she admitted she wore a pad most of the time. ‘This is just what happens when you get older’, she told me . I felt her pain might be related to her weak pelvic floor and abdominal muscles and when I asked her to contract these muscles, she admitted she didn’t really know how. For Anne, it was necessary for me to do an internal examination to show her their location. She contracted against my fingers and I was able to tell her when she was using the correct muscles and when she was not.
Returning to my own experience, once I’d started Pilates, I began regular pelvic floor exercises. I initially did them when I was lying in bed—I found this was the easiest way to isolate them—but soon I’d progressed to exercising my pelvic floor whilst sitting, standing, and even walking. (A word of warning—it is important not to try to hold your pelvic floor in all the time. This simply fatigues the muscles and then if you cough or jump they can’t suddenly contract. I’ve treated young women who suffer from stress incontinence because they hold their pelvic floor muscles too tightly. Contract the muscle, breathe for a breath or three, and then relax it.) It took a few months of being disciplined for me to resolve my problem. I did my exercises every day and gently increased the number and duration of the contractions. I ensured I could breathe while doing them and I also did some quick draw-in/releases as well as the slower ones. I remember the excitement of running my first half marathon totally dry.
Now, twenty years on, I don’t have a stress incontinence problem. I have done lots of training around pelvic floor issues and I regularly work with clients to help them resolve their problems.
Working with Anne on her back pain and stress incontinence was a little more complex than working on myself. We found that although her pelvic floor was weak and her awareness of the area poor, much of her tailbone pain was coming from tight muscles in the pelvic floor. I decided to try to alleviate Anne’s pain by working on these muscles via her vagina. It took time for Anne to trust me, but I’m sure she would tell you it was worth it. Because Anne had little awareness of her pelvic floor muscles, we chose to use small vaginal weights to give her more feedback. These weights are like little plastic tampons that you insert into your vagina. Initially, the weight was very light. Anne kept it inside her for up to 15 minutes each day, whilst she completed a series of pelvic floor exercises, squats and hip movements. As she grew stronger and more in touch with her pelvic floor, we increased the weight slightly and made the exercises more complicated. Eventually, after lots of disciplined exercise, the pain in Anne’s tailbone was resolved.
Clara came to see me because she felt imprisoned by her incontinence problems. Some time ago she had been travelling up north with her teenage children, her husband, and their pet dog. They were on the motorway at rush hour and the traffic was at a standstill. She suddenly felt a desperate urge to pee. She managed to grab the dog’s towel and had just thrust it between her legs when she felt the first trickle of urine. Of course, the kids had found it hilarious and spent the rest of the journey joking about mum needing nappies. She was mortified. This had subsequently happened on a number of other occasions and now she was terrified to leave the house at all.
Clara was struggling with ‘urge’ or ‘latchkey’ incontinence. This is not really a problem with pelvic floor muscle strength, but rather a miscommunication between the brain and bladder. Let’s say you are unlocking your door after having been shopping. In normal circumstances, you realise you need a pee, but simply contract your external urethral sphincter (pelvic floor) and the urge lessens slightly. With urge incontinence, just the thought of needing to pee contracts the muscle around the bladder (known as the detrusor muscle) and forces the urine out. As the detrusor muscle contracts, the internal urethral muscle relaxes. Unless your pelvic floor is extremely strong you will then wet yourself.
Just understanding this made life easier for Clara. I explained that her problem was resolvable, but that she needed to work at it. Initially Clara kept a diary of when she had the urge to pee and when she leaked. From this diary we made a schedule of loo visits. Gradually we increased the period between visits by 15 minutes at a time, until she could last for 3 hours. If Clara had an urge to pee between loo visits, she drew in her pelvic floor muscles three times to try to discourage her bladder from contracting; at first this wasn’t hugely successful, but with time and patience things really began to improve for her. In addition, she strengthened her pelvic floor by doing Kegel exercises and cut out all foods that might irritate her bladder. Clara can now leave the house with confidence and her kids have forgotten the embarrassing motorway incident (almost).
Peter was diagnosed with prostate cancer. The tumour was slow growing, but the surgeon wanted to remove as much of it as possible. Peter had never previously considered his pelvic floor (he actually thought that he didn’t have one.) His surgeon explained that urinary incontinence and erectile problems are sometime a side effect of prostate surgery and so any strengthening of this area before the operation might aid his recovery. During our session we talked about the anatomy of the pelvic floor and Peter practiced finding it. I put my hand externally on the area to feel the muscles contracting and to make sure he wasn’t just squeezing his bum. Peter placed his fingers in the soft tissue near his hip-bones and, as he drew in his pelvic floor, he could feel a slight tightening of his deep abdominals, which co-contract when the pelvic floor is drawn in. Peter and I wrote an exercise plan so that he could practice his pelvic floor exercises daily before his operation. For men, Kegel exercises can often help improve erections as well as resolve both urinary and faecal incontinence problems. Peter is sticking to his daily routine, which we hope will increase his chances of a swift recovery after his operation.
Urinary incontinence is not a life sentence. If you are struggling with it there are ways that you can get help. On the morning of Saturday 8th June, I will be running a two-hour workshop to discuss some of the different types of urinary incontinence. We will look at the anatomy of the pelvic floor and run through some basic exercises that you might find useful. The group will be small, and the cost will be £35. If you would prefer to discuss things in private or feel that you need help learning how to contract your pelvic floor, then do make an appointment with me, or a pelvic health physiotherapist.
To book the workshop or an appointment, please contact firstname.lastname@example.org. An appointment with an NHS pelvic health physiotherapist can be made via your GP. Emma Smith (a pelvic health physio at the RUH) also runs a private clinic from home. Please contact the studio for her email.