Why Having A Strong Pelvic Floor Isn't Enough

As a physical therapist, every day I treat women who say they leak urine when coughing, sneezing, and exercising (called Stress Urinary Incontinence or SUI).

Leaking urine during exercise is common, but it is neither inevitable nor untreatable.

The activities that most frequently lead to SUI are box jumps and double unders. Some women also experience SUI with deadlifts. In a physical therapy evaluation, women nearly always follow up admitting to SUI with a statement like, “Of course I leak—I’ve had two kids!”

While it is true that childbirth can be one factor contributing to pelvic floor dysfunction, not all women experience incontinence after childbirth. In the U.S., one in three women experiences incontinence. Though leaking urine is common, it's usually a sign of a larger issue—one for which doing more Kegels, or having a strong pelvic floor, isn’t always the solution.

Incontinence is very prevalent in the athletic community, yet most women do not seek treatment because they are either embarrassed or they assume it’s normal because everyone else they know has the same issue. A study done by Thyssen et al (2002) surveyed 291 elite female athletes competing in a variety of sports, from basketball to ballet, regarding their history of urine loss during participation in their sport or day-to-day activities. Of the athletes surveyed, 151 reported leakage. Of the 151, only five discussed it with a medical provider, and only six got pelvic floor training.¹

SUI can be treated if it occurs, but it’s a sign that the whole system is breaking down. The pelvic floor is just where the breakdown is primarily showing up at the time. Leaking urine is a clue that there is an imbalance in the deep core.

A few common diagnoses among female patients also alert me to the possibility of pelvic floor dysfunction:

• chronic groin strains
• IT Band Syndrome
• Trochanteric Bursitis
• low back pain
• Patellofemoral Syndrome

Why do I leak?

In order to identify the root cause of the issue and to successfully treat the problem, an integrated approach is necessary. Pelvic floor dysfunction is best treated by a team—the patient, her physical therapist, her OB/GYN, her coach/trainer, and possibly other professionals such as a Urogynecologist.

With the help and education provided by a growing number of Women’s Health Physical Therapists, active women now have a greater awareness of the help that is available for SUI. However, some misunderstanding still exists.

Many women believe that a “weak” pelvic floor is always the cause of urine leakage.

This simply isn't true. There are many factors that can lead to SUI and/or pelvic pain.

• Pelvic floor muscles may be weak from stretching caused by vaginal delivery or even from the weight of the baby during pregnancy. They may also be weak due to postural habits (standing with a posterior pelvic tilt) and lack of exercise.
• The muscles may be hypertonic (overactive) and unable to relax, which decreases the strength of the contraction when they do fire. So they are overactive but weak.
• Pelvic floor muscles may be overactive but strong; yet, the client has stronger abdominal, back, diaphragm, and glottis (larynx/voice box) muscles. Women who leak while lifting a heavy load may be in this category. Holding their breath leads to a rigid thorax, yet they can’t contain all of the pressure, so they either grunt/yell, leak urine, or sustain an abdominal hernia or herniated spinal disc. The pressure escapes the system through the weakest link.
• The pelvic floor may have been damaged (possibly by episiotomy, forceps, vacuum extraction of baby, or cancer/radiation) and the scar tissue affects the muscles’ ability to contract properly.

Kegels to the rescue! Right? Maybe not.

Just as many women believe that SUI is a result of “weak” pelvic floor muscles, many also typically assume they know exactly what they need to do to “strengthen” their pelvic floor: More Kegels!

Unfortunately, more Kegels are not always the answer to pelvic floor issues and SUI. Central stability (commonly called core stability) requires a balance of muscular strength and a neuromuscular strategy for engagement to meet physical demands. The respiratory diaphragm, deep abdominal muscles, spinal stabilizing muscles, and pelvic floor need to work perfectly together. Doing more Kegels does not address this necessary balance.

If not Kegels, then what?

The pelvic floor and central stability mechanism can be trained just like every other muscle group in the body. We know that for any muscle in the body, there is an optimal length/tension ratio; the pelvic floor muscles are no different. We also know that a muscle needs to relax fully in order to then generate a strong contraction. We wouldn’t walk around with our biceps flexed all day, and the notion of doing Kegels and constantly firing the pelvic floor is misinformed at best, and harmful at worst.

Work with a Women’s Health Physical Therapist

First and foremost, if you have SUI/pelvic floor dysfunction I strongly urge you to take it seriously. Be an advocate for yourself and seek treatment. Have an evaluation with a gynecologist or urologist, or consult with a physical therapist. Through evaluation, they can identify what is causing your issue and work with you to treat it.

Even if your gynecologist states that you don’t need physical therapy, seek help from a qualified women’s health physical therapist. The Section on Women's Health of the American Physical Therapy Association has an index of providers.

It is important to work with a therapist who can evaluate your specific condition and treat you with appropriate exercises and manual techniques. As you can see from the scenarios mentioned above, if the muscles are hypertonic or the issue is a result of holding your breath, Kegels in isolation won’t solve the problem.

My best recommendation is, of course, that you work with a physical therapist specializing in pelvic health to get a thorough evaluation, diagnosis, and plan. If you are hesitant and feel that working with a physical therapist for your pelvic floor is a little embarrassing, we assure you that you have nothing to be embarrassed about. Your long-term health and well-being are of utmost importance. Working with a qualified professional will give you an opportunity to learn more about your body and what you can do to help it perform optimally.

That being said, below are a few generalized suggestions for improving the function of your pelvic floor muscles:

• Learn to completely relax, as well as lift and contract, your pelvic floor. Learn to integrate your entire deep central stability system by coordinating your breath with your pelvic floor contraction. Constant tension in the pelvic floor muscles is just as problematic as weak muscles. Integrating your breath with your pelvic floor contraction helps you to manage your intraabdominal pressure (IAP) to prevent the downward force of your exhale from overpowering your pelvic floor. Check out the video in this article for more information.
• Practice functional movements integrating the breathing and relaxation of the pelvic floor muscles. You can start with bodyweight squats, done daily, several times a day even. Once you’re comfortable in this position, integrate the pattern of being relaxed on inhale and contracting the pelvic floor on exhale into your functional activities—lifting children or lifting heavy bags of dog food, etc. For some women, strength may show a measurable increase after several weeks of training, provided that the correct techniques are utilized (this is where evaluation by a professional comes into play).
• Strengthen your glutes. Strong glutes are integral to your deep central stability system. Women who stand in a posterior pelvic tilt (tucked, flat butt) tend to have weak glutes.
• Stretch and practice mobility drills for your hamstrings, calves, and adductors (groin muscles). When the pelvic floor is weak, women often use the glutes and adductors to keep the bladder closed (instead of the sphincter muscle of the bladder). Many women I work with tell me that they cross their legs when they sneeze to avoid leaking urine. This conscious and subconscious gripping with the adductors can lead to increased tension in the muscles and “tight” muscles. Learn to relax the adductors and fire the pelvic floor muscles.
• Train without a belt. When you rely on a belt to lift heavier weights, you are often pushing out or “bracing” against the belt. This generates a great deal of intra-abdominal pressure and the pelvic floor often can’t handle the pressure load. If you’re dealing with SUI, most of your training should be done without a belt, allowing you to truly integrate your deep stability system.
• Don’t let your ego run the show. If you are experiencing SUI, you will need to alter your training when you start working with your physical therapist during treatment. Allow your pelvic floor to be your limiting factor. Don’t lift heavier than you can manage without leaking. Train with perfect form, develop the true strength and stability you need, and then progressively increase the load.

If You Are a Coach or Personal Trainer...

If you are a coach, you spend infinitely more time with the women at your facility than any doctor ever will. Most gym members attend two or more sessions a week, adding up to over 100 hours spent in your facility per year. Contrast this with the 15 minutes women spend with their gynecologist per year.

SUI is probably an issue for many of your athletes or clients, even if they never mention it!

Some behaviors reported by my patients that may clue you in include:

• Wearing a sanitary pad every time they work out so that they don’t end up with wet pants.
• Avoiding certain exercises. They may say, “I can’t do double unders/burpees/box jumps/deadlifts.”
• Limiting intake of water to keep the bladder empty. This is a bad strategy that increases the risk of dehydration. Additionally, concentrated urine/dehydration can irritate the bladder and increase urgency.
• Running to the bathroom immediately before box jumps or double unders begin because they need to completely empty the bladder one last time before attempting these exercises.

Many women don’t feel comfortable discussing these issues with their coach or trainer. It’s important not to assume that women are receiving the care they need. You have the ability to address incontinence in your facility by talking about it, asking questions in your intake forms and during sessions, integrating proper central stability into your programming, and directing women to local resources such as women’s health physical therapists and gynecologists who understand the issue. You can even reach out to local physical therapists and sponsor them to give a talk at your gym.

Note from GGS: While pelvic floor dysfunction can show up in anyone, the risk is much higher for women who have had children, simply due to the extra stress on the pelvic floor muscle during pregnancy and childbirth.  If you've experienced any of the symptoms listed above, we encourage you to check out this resource. It will give you exercises to do and exercises to avoid to help you reconnect your core and pelvic floor, and make sure your entire core is functioning the way that it should.