Kegels & Incontinence: The Truth

Since I opened Physio Borealis in 2013, I have been sharing my passion and knowledge about pelvic health on the Physio Borealis’ Facebook page. In addition, I thought it would be great to write a blog, so I can share more in depth about different subjects.

Wondering about the first topic I would like to write about, I immediately thought of that one question that we always get asked as Pelvic Health Physiotherapists:

“I have urine leakage problems – shall I do Kegels?”

I am going to answer very honestly: I don’t know.

Why don’t I know? Because – like any other symptom – if I don’t know the cause of it, it is impossible for me to give you an appropriate treatment for it. As simple as that.

To illustrate my point, let’s review three typical cases.

WARNING: I may lose your attention along the way, and I am truly sorry about this. But for those who make it ‘til the end, it will give you a taste of how complex urinary incontinence can be, and why physiotherapists who specialize in Pelvic Health need extensive training to help people with those issues.

So let’s start!! All of these cases consulted for symptoms of urinary incontinence with sneezing, jumping and running.

 

NEW YORK, NY – NOVEMBER 01: The Professional Women division of runners cross the Verrazano-Narrows Bridge at the start of the TCS New York City Marathon on November 1, 2015 in New York City. (Photo by Mike Stobe/Getty Images)

 

CASE #1

Story

28 yo female, long distance runner, nulliparous (fancy medical term to say that she has never given birth).

When she started training for marathons a few years ago, was told by a friend that she should keep her abs and pelvic floor tight while running “to ensure a good posture”.

Following this advice, she developed incontinence with running, sneezing and coughing and it got worse over time, to the point of having to wear a thick incontinence pad during her runs.

When questioned about a stretching routine after her runs, she said that she sometimes stretch when she has time, but not on a regular basis.

Assessment findings

Lower body, pelvic floor, abs muscle tightness +++

Overactive pelvic floor, inability to relax on command

Running: foot contact on heels, upright posture, abdominal clenching, chest breathing, i.e. all the things that favour high impact on her bladder and pelvic floor…!

Treatment

Pelvic floor relaxation and stretching exercises

Abdominal muscles release

Breathing exercises (ribs, diaphragm)

 Advice on running gait to reduce impact on pelvic floor:

– Avoid pelvic floor and abs clenching !!!

– Avoid chest breathing – allow mobility in ribs and diaphragm

– Foot contact on forefoot instead of heels

– Posture slightly bent forward to decrease vertical impact on pelvic floor / bladder

**Thanks to Julie Wiebe, PT (check out her website…!) for all her great work and knowledge about the running athlete – you have been such a great resource for me to help my runners!

Prescription of a stretching routine after her runs for long term pelvic health and prevention

Outcome

After 6 weeks, symptoms were reduced by 80% – was wearing a liner during her runs (as opposed to a thick incontinence pad). After 3 months, she was symptom-free.

 

Comment: Indeed, having a “tight pelvic floor” is not a good thing! As any muscle in your body, you need full length and mobility in your pelvic floor for it to be functional. If this lady had started doing Kegel exercises, she would have made her condition worse by creating more tensions in her pelvic floor, which is the opposite of what she needed. It is not surprising that her issues started after following this advice from her friend (re: tightening abs and pelvic floor during runs – which is NOT the right thing to do!). She was overusing her pelvic floor, making it tight and fatigued. No wonder these muscles were no longer able to do their job!

I would also add that I rarely see long distance runners who stretch enough for the amount of running they do. Guess what: not only are they developing tight gluts, calves and hamstrings, but they also get tight in their pelvis! 

 

 

CASE #2

Story

Mother of 2 children. Started developing incontinence with coughing and sneezing while pregnant from her 2nd child who is now 2 years old. Recently started running again and noticed significant leakage issues.

Assessment findings

Pelvic floor muscles weakness and lack of endurance.

Decreased pelvic floor coordination on cough.

Treatment

Kegel exercises to strengthen the pelvic floor

Program combining long contractions to address endurance and short contractions to improve coordination.

Program was reviewed every 2 weeks to ensure proper parameters (position, repetitions, sets, load) and progress.

Integration of her pelvic floor abilities through functional activities (cough, lift, sneeze).

Outcome

After 4 months of physiotherapy, her pelvic floor was strong with great coordination and endurance. She had learned how to use it through her functional activities. She was symptom free while running, coughing and sneezing.

Comment: In this case, yes, Kegels were indicated! But we made sure that she was doing them properly with the right parameters – which is the key for Kegels to be effective 🙂


CASE #3

Story

Post menopausal woman – developed incontinence with coughing and sneezing as well as vaginal heaviness after a severe episode of constipation. Along with these symptoms, she was reporting onset of pain during intercourse.

Assessment findings

Bladder prolapse grade 2

Tight pelvic floor muscles especially at the opening of the vagina

Vaginal atrophy and dryness

Treatment

Pelvic floor stretching to normalize muscle length FIRST!

Recommendation to use lubricant during intercourse, paired with pelvic floor relaxation techniques.

Recommendation re: vaginal moisturizer.

Once length was normalized, pelvic floor strength was assessed to be weak. Kegels prescribed to strengthen and increase bladder support. Exercise program combined endurance/coordination exercises.

Advice re: vaginal heaviness/prolapse management (exercises to relieve pressure)

Education about constipation management

Outcome

After 6 weeks with home program to stretch the pelvic floor, intercourse was comfortable again.

Once she started on strengthening program, her incontinence and vaginal heaviness symptoms were reduced by 75% after 10 weeks.

She eventually consulted with a gynaecologist who prescribed a pessary (external bladder support) to use while exercising only.

Comment: This is a more complex case who presented with different pelvic floor issues, and the order of each intervention was very important here.

First, menopause is a risk factor for pelvic floor disorders. This is due to the hormonal changes and their impact on muscles elasticity and tone. In this case, she had been through a severe constipation episode which increased the pressure on her bladder and led to a prolapse (i.e. bladder descending into the vaginal canal), thus causing vaginal heaviness.

We talked about weak VS tight pelvic floor – but watch this: sometimes people can present both!!! It is not always one or the other (how simple would that be…!) When it happens, it is important to start by normalizing muscle length first by stretching it, and then we can address the weakness by doing strengthening exercises (Kegels).

What?! You are still reading?! Congrats!!!!

You qualify as a Pelvic Health guru!!!

I know, I know, this was a little long for a first post. But I hope it raised awareness about the complexity of urinary incontinence. Therefore, it is impossible to give everyone a “recipe” about how to go about it. A thorough assessment by a Pelvic Health Physiotherapist is needed to determine the problem and an appropriate treatment plan.

So next time you meet a Pelvic Health PT in a gathering, I hope you won’t ask if you should be doing Kegels 😛

(just my little joke here – no one ever asked me this in a social context…!!!! Hahaha!)

Yours truly,

 

Sophie Villeneuve

Pelvic Health PT

Leave a Reply

Your email address will not be published. Required fields are marked *