Skip ** the Loo

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Dear Dr. Myrtle,

You’ve got to help us. My whole exercise class absolutely dreads the skip-rope exercises, because every time we jump, we pee our pants. Most of us are women with children, and we’re guessing our pelvic floors are too weak. Is there something we can do?


First, you’re not alone. Urinary incontinence (involuntary loss of urine) is very common for women, yet is severely underreported due to embarrassment. Thirty-nine percent of women aged 20-45 involuntarily release urine with coughing, sneezing, jumping or laughing (stress incontinence). Women over the age of 45 are even more likely to experience stress incontinence (51.2%), and further struggle with constipation and incomplete bowel movements (35%), and sexual penetration difficulties.

You’re on the right track with your exercise classes, too. The leading cause of stress incontinence is being overweight (BMI >30), since excess weight carried at the waist puts downward pressure on the bladder at all times. When you jump, your landing + gravity forces urine out. Increasing weight (BMI 40 - 80) makes the problem even worse. Pelvic floor muscles help to hold the urinary bladder, uterus and rectum in proper positioning, but over time pelvic floor muscles fatigue and the organs sag into the pelvic bone structure (pelvic organ prolapse), compromising their function. Pressure on the bladder internally, and loss of the coordination and strength of the pelvic floor muscles are the main causes of stress incontinence, although increasing parity (number of pregnancies) also plays a role.

Fortunately, pelvic organ prolapse is not necessarily chronic or progressive. Women who exercise weekly had far fewer bowel symptoms than those who did not, and women who lost an average of 32 lbs reversed the pressure on their bladder and experienced a reduction of incontinent episodes by over 70%. Smaller reductions of 5-10% body weight were also beneficial, and demonstrated lasting improvement for years.

So the question isn’t whether weight loss is a good thing (it is a good thing), but rather what activities you should go about while losing the weight. Improvement in bladder continence (holding your urine) is a strong motivator for women to continue their physical exercise program, because as they lost weight their bladders leaked less. As their bladders leaked less, they were able to be more active. Definitely a win-win.

Here are some strategies for exercising until you can jump without losing urine:

  1. Stop jumping. Your heart is in the right place, but the more you jump and lose urine, the more you are actually training your bladder to expell urine on pressure. It will not help you to keep repeating this jump/urine loss sequence. If you need a cardio substitute, substitute push-ups/upper body work instead.
  2. Start walking. Because impact-related exercise (jogging, jumping) is more likely to increase urinary pressure, weight loss strategies most preferred by women with stress incontinence include walking, cycling and weight resistance exercises.
  3. Retrain your core body muscles. You need to retrain the correct sequence of muscle engagement of your core body muscles before pressure occurs. For women who have experienced pregnancy, the muscles are stretched for months, and can lose their neurological coordination. This is particularly true with vaginal delivery, where the nerves can be compressed, leaving some moms without any urine control for a few days. It’s a little technical, but to hold urine in, one contracts the Transversus abdominus (Tr abdominus) first, and then the pelvic floor muscles engage. Ask your exercise specialist for some tips on how to do this.
  4. Get your exercise specialist to read this. I know people should know stuff, but consider that I also think people should know basic stuff about sex, too. So, make no assumptions: ask them to
    • first design a program which only works the Tr abdominus (TrA) while lying on your back. (Have them email me if they have questions.) Then,
    • engage the TrA,
    • hold for 5 sec, then
    • engage your pelvic floor muscles like a closing a zipper from your pubic bone to your tail, about 2 sec per zip.
    • Hold everything for 5 sec.
    • Relax all of your muscles.
    • Take a deep breath, which relaxes your involuntary pelvic floor muscles.

    It’s more important to work up for a longer length of the complete hold than to do a bunch of quickies. Don’t do quickies: leave that for some other activity.

    Also, once you can comfortably do this lying down, with 10-15sec holds, try doing this same exercise standing up. It’s much more challenging to engage the TrA muscle while standing. Always keep the sequence TrA first, pelvic floor group next.

  5. Don’t push when you urinate. Pushing and/or straining is something that feels right to some people, but you’re working the muscles backwards and doing more damage. If you feel that you haven’t emptied completely, take a deep sigh, relax and let it drain. Come back to the bathroom in 15 minutes if you still feel full, but don’t push.
  6. When you’re up for a challenge, try gently blowing your nose. Remember: TrA first==>Pelvic floor second==>then blow. How’d you do? This is a nice test for you to experience whether your muscles are getting stronger and under what circumstances. You’ll probably still lose urine to the unexpected sneeze, but not to controlled sneezing after a while. Once you’ve conquered that, try a gentle cough.
  7. It’s uphill from here. When you can engage these muscles standing, begin to engage them while walking up stairs or a steep incline. Take the elevator down, too, or at least gently walk down the stairs. You don’t want gravity undoing what you are trying so hard to retrain.
  8. Gradually add stresses (walking up stairs with TrA + Pelvic floor, etc.) as you can, but if you lose urine you’ve added too much stress. Work and exercise at the level of holding urine, not at losing urine. Avoid activities you know will cause leakage.

It will take time, but it does work for many women.

Good Luck, and skip the loo,

Dr. Myrtle

References:

Tubaro A. & Palleschi G (2005) Overactive bladder: epidemiology and social impact. Curr Opin Obstet Gynecol. Oct;17(5):507. van der Vaart CH et al (2002) The effect of urinary incontinence and overactive bladder symptoms on quality of life in young women. BJU Int. Oct;90(6):544. Bradley CS et al (2005) Pelvic floor symptoms and lifestyle factors in older women. J Womens Health . Mar;14(2):128. Ozel et al (2006) The impact of pelvic organ prolapse on sexual function in women with urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunction. Jan;17(1):14. Novi JM et al (2005) Sexual function in women with pelvic organ prolapse compared to women without pelvic organ prolapse. J Urol. May;173(5):1669. Bradley CS & Nygaard IE (2005) Vaginal wall descensus and pelvic floor symptoms in older women. Obstet Gynecol. Oct;106(4):759. Richter HE et al (2005) Urinary and anal incontinence in morbidly obese women considering weight loss surgery. Obstet Gynecol. Dec;106(6):1272. Hendrix SL et al (2002) Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. Jun;186(6):1160. Handa VL et al (2004) Progression and remission of pelvic organ prolapse; a longitudinal study of menopausal women. Am J Obstet Gynecol. Jan;190(1):27. Subak LL et al (2005) Weight loss: a novel and effective treatment for urinary incontinence. J Urol. 2005 Jul;174(1):190-5. Brown JS et al (2006) Lifestyle intervention is associated with lower prevalence of urinary incontinence: the Diabetes Prevention Program. Diabetes Care. Feb;29(2):385. Hay-Smith EJ & Dumoulin C (2006) Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. Jan 25;(1):CD005654.