Saturday, February 06, 2016

Tired of wearing black pants? Let's talk about exercise incontinence

Although this article is a bit embarrassing to write, my hope is that it will be a catalyst for others to get closer to their own solutions for incontinence.  Catalyst for further exploration, not a cure.  It is a conglomeration of what I learned as a physical therapy patient, as a personal trainer, through my 200 hour yoga teacher training, during my MELT hand and foot training, and through trial and error.  Scope of practice warning:  I'm not a doctor, nor am I a physical therapist. This article is intended to tell you about a few things that helped me so you might consider whether they'd be helpful to you.  See a women's health professional.

Here's a fantastic article from a physical therapist that might also help.  I agree with what she writes and I don't think any of the additional things that I write are in conflict with her statements.

It was a typical day in 2012 when I stuck a mini pad into my underwear and went to my martial arts class.  There was a lot of running and jumping in class, so it was habit for me to be prepared "just in case."   It was a bit inconvenient, but live-able.  I'd been doing the mini-pad in the underwear "just in case" for 30 years, since high school gymnastics, too embarrassed to ask my mom and years before Google existed. 

When I got home from taekwondo and changed my clothes, my heart stopped. The mini pad was gone.  

Gone.  My mind raced with all the horrible possibilities of where that pad might have exited my pants.  Somewhere between my car, the parking lot, during class, or at the grocery store, the devil-pad had slipped out of my undies, un-noticed, and wiggled out the loose legs of my uniform.  I was so deeply mortified, I didn't go back to taekwondo for two weeks, and it was months before I went to the grocery store after class.

There's nothing like humiliation to spark the desire for change.

Although I'd had a little experience and education in Kegel exercises related to childbirth, they'd never fully cured my occasional stress incontinence, and the problem was relatively minor so I'd just lived with the mini-pad ritual.  But now, I started googling stress incontinence in earnest.  I also went to a lovely physical therapist who specialized in women's health through an OB/GYN department.  God bless Cindy G. of Kaiser Permanente, her woman-positive practice, her assurances that I wasn't alone, and for her little biofeedback machine!

Here are some things I've learned, the combination of which has helped me.  Your mileage may vary.

1)  How are your feet, calves, and shoes? (my opinion as a personal trainer)

Our feet are the first line of defense against incontinence.  When our feet are strong and flexible, we can reduce the amount of force we create each and every time we land.  I tell my training clients to step and to land "softer than a cat in a ninja suit," rolling from toe, through the ball of the foot, to the heel, and then continuing past that to softness in the knees.  To make this work for you, check how well your toes move, how well you can twist your mid-foot, how much flexion you have in your ankle joint, and how quietly you can jump and land.  Stretch both groups of your calf muscles (this is a good idea whether you suffer with incontinence or not).  The better you can cushion your landing, the less stress you'll place on your pelvic floor in the first place.

2)  How is your spinal and pelvic posture? (my opinion as a personal trainer as reinforced in my yoga teacher training)

Our pelvis can be thought of as a bowl, with the tailbone and pubic bones at the bottom and the "waist" at the top.  If the pelvic bowl is in neutral, you could pour water into it and it wouldn't fall out front, back, or either side.  If the bowl is tipped too far forward, with the tailbone sticking out, imaginary water in the bowl would spill out the front of the bowl.  Similarly, if the bowl is tipped backwards, water would spill out the back.  Exercise physiologists argue a bit about how to find perfect "neutral" (source:  Tom Myers, from episode two of his webinar, "BodyReading: Visual Assessment of the Anatomy Trains Webinar Series," which can be found at, but this image should give you a basic idea of the pelvic bowl and the idea of neutral.

A person's pelvic position can directly affect the amount of force placed on the pelvic floor, and thus the urethra.  With a neutral pelvis, the internal organs are weighted more over the pubic bone and less over the pelvic floor muscles.  When the pelvis is tipped backwards, the weight of the internal organs is weighted more heavily on the pelvic floor.  Posterior pelvic tilt is common in American culture where we tighten our butts, pressing the the hips and legs forward - perhaps the origin of the term "tight ass?!?"  At any rate, it doesn't do any favors to the pelvic floor.

The pelvis can also be tilted side to side, such as with a difference in leg length.  That's a problem because the muscles will pull and tense in different amounts on different sides of the pelvis.  

3)  The pelvic floor is really complex.  (paraphrased summary of what I learned from my PT)

Kegel exercises are a small subset of what's going on down there...

There are oh, so many muscles, in oh, so many layers, and they're all intricately connected by fascial tissue.  My PT said that's why she went into women's health, because it was complicated enough to be truly interesting while also life changing.  So don't feel bad if you're trying to do Kegels and they're not working to improve bladder control.

There are several sets of muscles, all of which should be contracted, and with a little practice, you can feel the difference between them.  There are muscles that surround the clitoris, there's a sphincter near the opening of the urethra, there are muscles that contract the vagina, and muscles that contract and lift the anal sphincter upwards.  The urethra (tube that goes from the bladder to the outside of the body) is connected to the front side of the vagina through connective tissue, contractions of the vagina are very relevant to continence.

Here are a couple of pictures that I found helpful.  Don't read them if you're bored, but I'm putting them here so I can get back to them.



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4)  Strength of the pelvic floor contraction  (paraphrased summary of what I learned in PT, with some helpful tips from yoga)

Just like strength and endurance of your other muscles, strength and endurance of the pelvic floor are both relevant.  First, the strength of the contraction.  What I was taught about Kegels while pregnant with my first child 14 years ago was this.  Imagine that you're urinating and mid-flow, the doorbell rings so you have to stop peeing really fast.  It was a decent enough instruction, but really only worked on the muscles around the urethra and vagina.  

What I learned from my PT in 2012; In order to have a strong contraction, tighten the muscles near the top of the clitoris like you're bringing them down towards the urethra, tighten and lift the muscles of the vagina closest to its entrance like you're picking up a grape, and lift the muscles surrounding the anal sphincter as though preventing the passage of gas or semi-solid objects.  Tighten them all.

Another way to think of this is from a yogic perspective - Mula bandha, aka "root lock."  I first learned this in kundalini yoga about 20 years ago in a "sat, nam" chant, which is done in a seated position (lotus, half lotus, easy pose, rock pose).  In the exhale (sat), there is a strong lift, like you have a golden flame at the base of your tailbone and you are drawing that energy up your spine, by tightening your root muscles.  In the inhale (nam), allow all of the muscles to completely release.  There's a temptation to push them out, but just release and relax.  If you google "kundalini sat nam" or "sat kriya," there are lots of explanations, but the above paragraph is how I was taught and I believe is the most helpful way to think of the sat nam chant in service to strengthening our continence.  It's also got a beautiful meaning in and of itself, about the seed of our internal truth.

I thought I had a strong pelvic floor contraction.  And then I got hooked up to a machine to test how many muscle fibers were firing.  There's some decent technology to measure the strength of your pelvic contraction that don't require anything to be inserted internally.  My PT hooked me up to a biofeedback machine with little electronic pads that stick on the skin above the target muscles, and a little light would go on when I had tightened the muscles enough to measure with the pads.  Then as I got better at it (neurally and muscularly), she could turn the sensitivity down so that I had to contract harder to get the darned light to turn green.  

5)  The duration (endurance) of the pelvic floor contraction is important (paraphrased summary of what I learned in PT)

The ability to hold a pelvic floor contraction is important.  After I had a strong PF contraction with all the muscles firing (step 3 above), I started being measured with an external biofeedback machine while going up and down stairs (pretty easy) and then jumping (oops!!!).  What I learned was that although I got a good strong contraction when I took off from a jump, I wasn't holding that contraction through to the very end of the landing.  Note:  Landing from a jump includes the toe-ball-heel + knee bend of the initial landing, all the way until the legs re-straighten.  There's still a lot of downward force until the jump and land are totally done.

6)  Avoiding liquids does NOT help!  (articles, experience)

In high school and college, I would allow myself one glass of milk in the morning for my instant breakfast drink, and then I wouldn't drink again until after gymnastics or drill team practice.  That strategy doesn't work.  One of the articles I read while writing this blog mentioned that the reason it doesn't work is because concentrated urine can be irritating to the bladder.  This makes sense to me now, because it sure didn't make sense to me at age 16 how I could have almost no water in my system, yet still leak a few drops during a dismount from the high bars or a ballistic tumbling pass.

7)  And in fact, there's evidence that chronic dehydration can make things worse (from my MELT education).  The earth needs wetlands in order to absorb water.  When we put too much pavement over too many surfaces - what happens with it rains?  Flood!  Healthy, elastic tissue (including but not limited to connective tissue and muscle) absorbs and transports water.  And worse, dehydrated cells don't just forego water, they tend to spread / collect like sediment, and eventually die without the ability to get nutrients and flush waste.  The answer to this is to drink small amounts of water throughout the day AND to work on the hydration and elasticity of your connective tissues.  How does one hydrate connective tissue?  I am sure there are several ways, but the way I know of and am trained in is MELT.  If you're in the Portland, Oregon area, message me.  The sequences that helped me in particular are the soft ball foot treatment, the SI joint shear, and the inner thigh glide/shear.

8)  Scar tissue from c-sections and other surgeries can alter the lines of pull of connective tissue, and the lines of pull of connective tissue can affect the urethra's ability to close evenly and stay closed.  Nobody told me this after my first or my second c-section.  Thanks a lot!!!  The good news is, massage therapy can help tremendously in working out and breaking down scar tissue.

Good news!  No more pads for me.  I exercise hard, and often.  I sweat buckets, so there are still classes where I am drenched all over, including the pants.  But at least now, 99% of the time, it's just sweat.

My hope for you is that you keep exploring, that some of these ideas resonate with you, and that you find a professional you find safe to address these questions with.  After taking my MELT training and seeing the effects of scar tissue, my bias is towards trying as many non-surgical methods as possible.