stress incontinence

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Please read this health disclaimer before applying any of the information on the website.

This website and the information contained herein, is for people who have been examined by their medical professional, have been diagnosed with pelvic floor dysfunction and physical therapy has been ordered. Regular exercise is not always without risk. You are responsible for your own health and safety at all times. As such, by visiting and using the information on this website you are agreeing to the following:

You acknowledge and agree that you have been assessed by a qualified professional (i.e. your doctor) who has given you consent to take part in pelvic floor physical therapy and has ruled out more serious conditions that warrant further testing.

These exercises should not be painful. Please stop and seek the advice of your medical professional if you suffer any kind of adverse reaction to the exercises proposed on this website.

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Have you ever been laughing so hard you have literally peed your pants?!?! It is wonderful to laugh like that, however, we really do not want to walk around wearing pads just in case something cracks us up…This workshop is for those people who lose urine because of a sudden STRESS, like a cough, laugh or sneeze. Some clients have even given up exercises that they love due to embarrassing leakage or dribbling. This class will show you a powerful program to target this kind of condition and to give up STRESS once and for all!!

Hello, it's Annette again and welcome to the STRESS INCONTINENCE WORKSHOP!! I am so glad you are here!! This lecture is in PDF form, and I will go over it all in the videos, but not word for word – this PDF can be printed out at the end of the lecture if you would like to refresh your memory about the information I have provided in the lecture.

We will start our class by introducing you to the PELVIC FLOOR AND HOW TO PERFORM A POWERFUL KEGEL. Once you have this technique down, we will show you how to condition and exercise your pelvic floor to SPECIFICALLY TARGET your problem area. Let's start with a quick anatomy lesson:

FEMALE ANATOMY

MALE ANATOMY

PELVIC FLOOR ANATOMY

This may be an uncomfortable picture of our private parts, but I wanted to illustrate to you that it is the only thing between our innards becoming our “outards.” Imagine that you are sitting on this piece of paper (in fact, you can print it out with this lecture and do just that) with the pointy part forward. Just think of the responsibility of this wonderfully powerful group, who work in concert together, to keep all those delicate functions up and in! There they are, suspending our organs in our bodies against gravity trying to pull everything down and out. Chances are you never thought about this perfect hammock of warriors until something went awry – either you started leaking a bit or you started having pain down there. The reason these muscles are so incredible is because of the delicate balance of two types of muscle (fast and slow twitch – I'll get to that later) that are responding to what we want them to do (volitional) and what our brain and organs want them to do (autonomic).

Now pick the video of the pelvic floor and how to find it…

Basically, as you sit here in your chair or on an exercise ball, let's feel the boundaries of this pelvic floor everyone is talking about. Arch your back and roll forward, you can feel the anterior portion (pubic bone). Now start to have a rounded back or poor posture (don't ever have poor posture by the way). Some can feel their coccyx or tail bone, which is the posterior portion of the floor. To the left and right sides are those bony sits bones that you can feel if you rock to one side and the other. This can be called your saddle area, all the places you would have pressure on while riding a horse. Delicate tissue, nerves and muscles are in this area and they have a BIG job to do!

OK, now that you know what your pelvic floor looks like and where to find it, let's move on to the video called “Performing a Powerful Kegel.”

HERE WE GO – WE ARE REALLY GOING TO DO THIS – A POWERFUL KEGEL

Now, most of you have heard of Kegels or have tried them in the past without much luck. Kegels are usually described as clenching your urinary sphincter area, the one that you would use to stop and start your flow of urine. Some may have suggested finding these muscles while on the pot, as this would be an obvious cue to those who have trouble, however, it is not recommended to perform Kegels in this way due to the interrupting of the complex physiological process of elimination. If you must try it this way to see if you can stop your urine, only do so a few times a month. I have found it much more helpful for people to concentrate on contracting the anal sphincter. The reason for this is that those muscles surrounding that area are generally more powerful and have more sensory information in them. Remember every muscle down there works as a team, so as you think about your anal sphincter the whole floor will pull up and in.

Now pick the video for how to perform a powerful kegel…

So let's try it. Here is a weird but effective visual – please do not actually try this, as it would be an uncomfortable and awkward discussion at the ER. Let's say I put a stack of 10 pennies on your chair before you sat down here for this class (and for some reason you have thin enough clothes on, or no clothes on, to do what I am going to ask next). Now try to pick up one penny with your anal sphincter, the one that you would pucker if you had to pass gas in a room with just you and me and I know it was not me. It's important that you do not push the pelvic floor toward the actual floor – so never push out and down, even when performing a bowel movement. Remember, gravity is trying to pull everything down and out of you, and you would like to keep things up and in. You also want to act like no one can tell that you are actually doing this, so if you are contracting your glutes and are moving up and down – that is not a Kegel. Also, if you are holding your breath or contracting your abdomen at all, keep practicing. Just your sphincter should be contracting. Do this a few times to get the hang of it.

FAST KEGELS – Now, the pelvic floor is made up of slow twitch fibers (think long distance running) AND fast twitch fibers (think Usain Bolt). To work on those speedy muscles, let's use our penny analogy again (just imaginary pennies, please). Now try to pick up 6-10 pennies one at a time as quickly as possible. It may be hard to do this at first, as those quick fibers may have not been asked to partake in this pelvic floor game lately, but you will get better with practice! If I asked you to sprint across the yard, you may not move as fast as you have in the past, unless you are being chased by a knife wielding cheetah and you happen to be coming home from the meat store. Think of snapping your fingers- work up to doing it this fast. Try ten now.

Now, back to the lecture!

WHAT SHOULD HAPPEN

The bladder and it's communication with the brain is a very intricate and complex sequence of events. These events typically happen with little or no acknowledgement from us – it happens AUTOMATICALLY. Here is what SHOULD happen:

Urination (micturition) involves processes within the urinary tract and the brain. The slight need to urinate is sensed when urine volume reaches about one-half of the bladder's capacity. The brain suppresses this need until a person initiates urination.

• Once urination has been initiated, the nervous system signals the muscle that surrounds the bladder to contract into a funnel shape and expel urine. Once empty, pressure falls and the bladder relaxes and resumes its normal shape.
• The average bladder can hold up to 2 cups of urine before it needs to be emptied. It is normal to pass urine 5-7 times during a 24-hour period. Eight times is normal as we age, waking once at night.
• Urine should flow easily without discomfort in a good and steady stream until empty. Now, let's talk about how to handle your specific issue: URGE AND URGE INCONTINENCE!

HOW TO STOP STRESS INCONTINENCE

This class is for people who struggle with a small or large amount of leakage with any kind of stress on the bladder, typically things that catch you by surprise like a cough, laugh or sneeze. Many people have some leakage during plyometric or bouncing exercises and have decided that they should just go back to walking, or stopping exercising altogether. Of course, you have tried Kegels without success. However, have you honestly ever tried a consistent, daily strengthening program of a certain type of Kegel for 8-12 weeks? Are you willing to try to get rid of this pesky problem once and for all?!?! Let's do it!!

Most people are told to do Kegels a few times per day at stop lights or during commercial breaks of their favorite show. I'll use the analogy that I tell all my clients – would you expect to get stronger in your biceps, strong enough to make a difference in your ability to lift heavy items or improve the tone or look of your shoulders, if you had a one pound weight in the passenger seat of your car and you picked it up during stop lights and belted out a few!?!? I'm thinking this exercise program is not going to get you to a “which way to the beach” physique. But that is how we expect our occasional Kegels to tone and strengthen the only muscle group between your insides and the floor.

For stress incontinence or leakage, things seem insurmountable. The intra abdominal pressure that is generated from a sudden cough, laugh and especially a sneeze is incredible. That, coupled with gravity already pulling organs south, it is a lot to ask the pelvic floor to keep it all in check. It's muscles vs liquids, people, and guess who wins out if there has been past trauma down there, especially deliveries that warranted one of the main anchors for all other muscles down there – the perineum – to be cut, or worse, torn (all of you should give a silent bow to the girls with THAT post-partum tale).

That is where this workshop comes in. I will teach you how to perform a Kegel on steroids, for sure, AND target the fast twitch muscle fibers needed to catch those sudden, quick stressors on your pelvic floor. SO, BETTER, STRONGER, FASTER is what I am talking about. Our muscles are made up of fibers that have different responsibilities. Some are set up to move quickly, some are in it for the long haul. Think of it this way. We have to develop our Arnold Schwarzenegger strength fibers AS WELL AS our Usain Bolt speedsters down there to beat this. So here we go.

If you have read or practiced How To Perform A Powerful Kegel already, you know where your pelvic floor is and how to contract it. (Take a moment to watch the video or read the explanation NOW if you have not already done this). To develop your fast twitch fibers, the ones that are going to help with that leakage that occurs with cough, sneeze, bouncing exercises, we have to perform FAST KEGELS. So, let's imagine again that I have set up a stack of pennies on your chair and you sat on them (not a nice party trick, so please do not actually try this!!! The pennies are imaginary!!).

Below are instructions on the exercise sequencing and position that is right for you, stress incontinence sufferer. We will do a beginner's version in sitting that will be reviewed in the Generalized Strengthening Video below. Once you get fairly good with those in sitting, then you can perform these in standing. Some instructions before you start. While sitting on a chair with cushion or exercise ball, pick up with your anal sphincter 6-10 imaginary pennies one at a time as fast as you can (these are the fast Kegels we practiced in the video above). Try not to throw the pennies down so to speak, and do not bear down or hold your breath. These are called quick flicks and you should try to work up to feeling like you are doing them as quick as you would snap your fingers. This will work on those Usain Bolt muscle fibers that will eventually be fast enough to catch your sudden losses of urine due to stress. Please be patient with yourself. If you wanted to sprint a 50 meter dash, let's face it, most of us would be fairly slow at first, because we just don't run around quickly these days! But eventually, your pelvic floor will get faster, because you are training it to work faster.

When we will add our hips into the mix, as our legs are strong and fast and are wonderful helpers to overcome weaknesses in our pelvic floor. Think of a hammock between two trees. As your hips squeeze together or separate, the pelvic floor moves up and down – it has no choice. This way when you perform a contraction, it is like a KEGEL ON STEROIDS! BETTER, STRONGER, FASTER!! Once you are able to perform the sitting portion of this sequence without leakage, or you feel as if you are stronger and faster, you can move on to the standing portion. Again, none of these exercises should be painful!!

DO THIS SEQUENCE DAILY – IT SHOULD TAKE YOU BETWEEN 7-10 MINUTES !

SITTING ON A BALL OR CHAIR WITH CUSHION, feet in neutral and knees about hip-width apart – try not to hold your breath.

1. Pick up with your anal sphincter 6-10 imaginary pennies one at a time as fast as you can. Try to contract your pelvic floor powerfully and quickly. Now hold your pelvic floor up and in for 10 seconds, rest for 10 seconds.

2. Squeeze your knees together comfortably and perform 6-10 quick flicks. Now hold your pelvic floor up and in for 10 seconds while squeezing your knees together, rest for 10 seconds.

3. Squeeze your knees apart comfortably and perform 6-10 quick flicks. Now hold your pelvic floor up and in for 10 seconds while squeezing your knees together, rest for 10 seconds.

4. Pull your pelvic floor up and in (anal sphincter) AND HOLD while you bounce gently 10 times. Rest for 10 seconds.

Do this sequence, numbers 1-4 above, ten times (you may have to work up to this – do what you can)!

IF YOU ARE ABLE TO PERFORM THE ABOVE WITHOUT LEAKAGE, OR THESE ARE VERY EASY FOR YOU – TRY THE SEQUENCE IN STANDING

Now, let's try this sequence in standing!

1. While standing, feet hip's width apart, toes out slightly, perform 6-10 fast Kegels. Now hold your pelvic floor up and in for 10 seconds, rest for 10 seconds.

2. While standing gently squeeze your knees together while performing 6-10 fast Kegels. Now hold your pelvic floor up and in for 10 seconds while squeezing your knees together, rest for 10 seconds.

3. While standing, feel pressure in the balls of your feet as you imagine you are moving the front portion of your feet away from themselves (you should feel your bottom muscles kick in). Perform 6-10 fast Kegels in this position. Now hold your pelvic floor up and in for 10 seconds, rest for 10 seconds.

4. Now, bounce gently in standing while holding your pelvic floor up and in. GENTLY is the key word here – please do not perform if you are experiencing any pain. Do 10 of these.

Do this sequence, numbers 1-4 above, ten times (you may have to work up to this – do what you can)!

ADVANCED STRESS RELIEF EXERCISES WITH BALANCE

1. While standing, HOLDING ONTO SOMETHING IF NEEDED, place your feet heel to toe as if you are walking a tightrope, perform 6-10 fast Kegels while breathing in. Now hold your pelvic floor up and in for 10 seconds while breathing out, rest for 10 seconds and breathe normally. Switch sides.

2. While standing, HOLDING ONTO SOMETHING IF NEEDED, place your feet heel to toe as if you are walking a tightrope squeeze your thigh to the other thigh, perform 6-10 fast Kegels while breathing in. Now hold your pelvic floor up and in for 10 seconds while breathing out, rest for 10 seconds and breathe normally. Switch sides.

3. While standing, HOLDING ONTO SOMETHING IF NEEDEDD, place your feet heel to toe as if you are walking a tightrope squeeze the balls of your feet into the floor (you will not be moving however you will feel the muscles of your bottom kick in – this should not be painful), perform 6-10 fast Kegels while breathing in. Now hold your pelvic floor up and in for 10 seconds while breathing out, rest for 10 seconds and breathe normally. Switch sides.

4. While standing, HOLDING ONTO SOMETHING IF NEEDED, place your feet heel to toe as if you are walking a tightrope squeeze your thigh to the other thigh, perform 6-10 quick adduction motions with your legs. You can attempt to perform your quick flicks at the same time, however this is difficult at first. Now hold your pelvic floor up and in for 10 seconds while performing the quick adduction motions with your legs while breathing out, rest for 10 seconds and breathe normally. Switch sides.

GENTLE is the key word here – please do not perform if you are experiencing any pain.

Do this sequence, numbers 1-4 above, ten times (you may have to work up to this – do what you can)!

It will take some time for you to get better, stronger and especially quicker, however I would imagine you are getting the picture – to combat difficulties with quick actions like a cough, laugh or sneeze – we need to practice and develop those muscles that are responsible for the fast stuff. Please be patient and give this some time – you will notice the improvements soon!

SOME TIPS BEFORE AND AS YOU TRY THIS

1. I recommend that clients wear some protection, i.e., some form of adult undergarment, to help with the confidence factor when starting this technique. If your bladder “knows” it is secure, it will behave better, and you will have some time to develop the skill.

2. Please DO try this at home for some time before you try it in the middle of Lowe's (although, yes, if you are heading into the hardware store and are reading this and sprinting to make it to the restroom – TRY IT NOW!!). You should be confident you have some control. Heading out to your induction into your high school hall of fame may not be the time to give this a whirl. Start to tackle that “Garage door Opening” urge moment on a day you don't have a dinner party planned at your home with 18 of your closest guests coming in a half hour. Remember, your central nervous system and brain are supporting actors here. Chilling out is central to your success.

3. Once you are noticing your success, it is important that you do not “mess” with your bladder in other areas. For example, waiting 4-5 hours to use the restroom at work and then wondering why your system is cranky is on you. Conversely, using the restroom when you do NOT have to go starts to signal the bladder to contract at a lower and lower volume. Try to drink enough fluids so that you are voiding every 2-3 hours or so.

4. Have a little fun with this – some of my clients have had a “Me vs Bladder” win ticker when they first start out. Sometimes they “win” and are able to calm the urge, and sometimes the bladder wins. You will get better and better at it.

5. Occasionally, the urethra will have a little bit of urine still in the pipe, or the bladder feels as if it has not fully emptied. This is called a Post Void Residual and may be complicit in that feeling of urge. My recommendation is to, after your initial voiding, stand up (if you are normally sitting) or sit down (if you normally are standing) to retilt the bladder. Do this a few times and try again (never push out). One could also, while standing, bend your body at your waist forward and backward a few times. Think of it this way: if a pen had a bubble of water in it, to coax the water out you would gently rock the pen back and forth. This can help the post void to mechanically drip out without straining.

TIPS TO MAINTAIN GOOD BLADDER/BOWEL HEALTH

Take your time when emptying your bladder/bowel. Make sure you empty your bladder completely each time. Do not rush the process!

• Do not avoid going to the bathroom for long periods of time. Ignoring the urge for more than 4-5 hours between daytime voids may be convenient but not healthy for your bladder.
• Avoid going “just in case,” or more often than every 2 hours. It is usually not necessary to go when you feel the first urge. Try to go only when your bladder is full. Retrain your bladder to perform on a schedule.
• Maintain a good fluid intake. Try to drink 4-8 8oz glasses of water per day unless otherwise advised by your doctor.
• Limit the amount of caffeine, citrus foods, and alcohol you consume (see “Common Bladder Irritants” below).
• Avoid constipation. Never strain when defecating. Let things come out naturally.

If you try to push everything SOUTH when you are going and the rest of the time you want things to stay NORTH, well, gravity is going to win eventually.

COMMON BLADDER IRRITANTS

The things we eat and drink affect our bladder and its “behavior.” Common irritants include caffeine, alcohol (sorry), chocolate (sorry again), carbonated beverages, cranberry juice and citrus fruits and juices, tomato products, processed foods, artificial sweeteners and spicy foods. There are also some studies that suggest that quitting smoking, in addition to all the other reasons why one should, stopped stress incontinence symptoms almost entirely.

I usually will not suggest a diet change to my clients (at the risk of being stabbed if I take away their morning coffee) unless we have tried the exercise programs or techniques above and have had limited success. There may be a dietary component that is irritating the bladder in some way, and perhaps trying to eliminate one item from the list would further their success.

BLADDER TRACKER KEEPER

Often times, it is helpful for people to track the food or liquids they consume and how often they had an urge or leakage episode. Please click on the BLADDER TRACKER KEEPER below if this sounds like something you would like to log to see how you are doing in the coming weeks.

BTK – CHART

BLADDER TRACKER KEEPER VIDEO

BTK – INSTRUCTIONS

GENERAL STRENGTHENING FOR THE PELVIC FLOOR

For an easy strengthening program for your pelvic floor, please see the GENERAL STRENGTHENING FOR THE PELVIC FLOOR video below. This is a gentle program that can help any type of pelvic floor issue.