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Incontinence impacts 25 million people in the United States and half of women over 50. As an adult wellness brand that sells bladder protection products, we’re well aware of the stress that incontinence can add to a person’s life.
We recently chatted with Yvette Fawzi, a physical therapist who specializes in treating pelvic floor dysfunction about the role that pelvic floor muscles play in urinary incontinence. Fawzi has practiced physical therapy since 1993 and Feldenkrais® since 2005 and has focused her practice on pelvic floor dysfunction since 2006. She follows a holistic approach to the body using a blend of Feldenkrais®, physical therapy and osteopathic techniques such as fascial counterstrain and visceral manipulation. Below, Fawzi helps explain what role pelvic floor muscles play in bladder leaks, what exercises can help, and when it might be time to seek help from a pelvic floor physical therapist.
Your pelvic floor muscles are a hammock or sling-like set of muscles that span from the tailbone to the pubic bone within the pelvis. These muscles support the bowel and bladder, and in females they also support the uterus and vagina. These are the muscles that relax and contract to hold back urine, feces, and gas or to release them.
The strength of your pelvic floor muscles are intimately connected with whether or not you experience bladder leaks. When your pelvic floor muscles aren’t functioning well, your internal organs lack full support—in this case, the bladder.
“When you contract your pelvic floor muscle, it sends a signal to the bladder to rest and fill,” says Fawzi. “And then when you go and sit on the toilet, you relax your pelvic floor muscles and then your brain sends a signal to your bladder that now it's time to contract and you can empty. When you're done, your pelvic floor muscles contract and send that signal to your bladder to relax.”
Fawzi says that, by strengthening the pelvic floor and simply increasing your awareness of the pelvic floor, as well as learning how to engage pelvic floor muscles, you can begin to minimize and prevent bladder leakage. “Even though incontinence is common, as we get older, it's not normal,” she says. Many factors can result in your pelvic floor muscles weakening over time. “But if your brain is reminded how to coordinate it with your abdominal muscles, then it starts using them.”
She notes that there are two main types of incontinence: stress incontinence and urge incontinence. Fawzi describes stress incontinence as “when you have stress onto the bladder, like when you lift [something] or cough or sneeze; that's downward pressure onto the bladder.” Urge incontinence, associated with overactive bladder, is a type of incontinence where the bladder starts contracting when it’s not supposed to. When this happens, the bladder muscles are effectively overriding the pelvic floor muscles, and then there's leakage.
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But how, exactly, do you strengthen your pelvic floor muscles? Through exercises called Kegels, which are pelvic floor contractions. Fawzi says that's where you engage your pelvic floor muscles to close around the openings in your pelvic area and lift.
There are two types of Kegel exercises you can do to strengthen your pelvic floor muscles, with each one engaging one of the two types of fibers in the pelvic floor muscles.
The first type of Kegel exercise is sustained holds. “You can either do a sustained hold—so you [contract the muscles and] hold for at least 5 seconds and then fully relax, and then you do a set of 10 a few times a day,” says Fawzi.
The second exercise is what Fawzi calls “quick flicks.” She says, “Those are kind of like your sprinter muscles. The sprinter muscle fibers are the ones that will give you a really strong contraction all of a sudden, but it's not something that you can sustain. So think about when you suddenly start running. It's just that little burst of energy. So those kinds of Kegel exercises are a quick contract, relax, contract, relax—like one second—and then you do little set cycles of five, three times a day or so.”
She says that when people are having a lot of urge—that sudden feeling of having to find the bathroom really fast—sometimes doing a few of those quick flicks can tell the bladder to calm down. “Running water is also a big trigger for people—so sometimes doing one sustained contraction for five to 10 seconds while they're washing their hands can be helpful as well.”
Fawzi says that, for stress incontinence, the first step is building up muscle—but the next step is learning to call those muscles into action. She says that when pelvic floor muscles are fully functioning, you have an anticipatory contraction of the pelvic floor muscles before you cough or sneeze. “It's this automatic, internal thing. But if your pelvic floor muscles are weak, if I know a sneeze is coming, I'll squeeze my pelvic floor consciously, and then it's prepared for that pressure coming. And then slowly, as you get stronger, it just becomes automatic.”
If you’re not practiced in being conscious of your pelvic floor muscles, it may take a bit of time to learn how to properly and fully engage these muscles to practice Kegel exercises. But Fawzi suggests a couple of approaches to gain confidence that you’re doing them correctly.
“The main thing when you're doing that contraction is feeling that ‘close and lift’ of the pelvic floor,” Fawzi says. “If you put your hand on your perineum, you might feel it actually lifting up a little bit.”
When initially starting Kegels, Fawzi says, “I usually start with people lying down with their knees bent so they can really be aware and feel the muscles contracting, kind of isolating them. And then, once they feel them lying down, then I want them to do them sitting or standing because that's a little bit more difficult, right.” She says that, if you want to take it to the next level, you could start incorporating Kegels when doing other exercises, like squats or lunges. “Oftentimes as your brain starts to become aware of your pelvic floor muscles, you start to incorporate it with any exercise [and] it becomes automatic,” she says.
A physical therapist can help instruct individuals on Kegel exercises, tailoring an exercise plan to an individual's needs and ensuring the exercises are being done correctly. Beyond this, Fawzi says that at her practice, “We look at the whole system, including posture and the strength and flexibility of the surrounding muscles, to make sure they are coordinating well with the pelvic floor and abdominal muscles especially during functional movements. Physical therapists also evaluate the pelvic floor muscles through an internal exam to make sure they are engaging properly.”
“It takes six to eight weeks to build bulk in a muscle, and it's the same goes for the pelvic floor,” says Fawzi. “But if you've been doing the Kegel exercises, and after about four weeks, you're not noticing any improvement, then it's probably good to be evaluated because sometimes there's a little bit of an imbalance in the pelvic floor. Sometimes you can have a very strong Kegel exercise, but just structurally, there are many things that have changed, and there's not a good closure around the urethra.” And if you’re losing urine while doing Kegels, that’s also a good indicator that you could be a good candidate for pelvic floor therapy. However, she notes that it can be helpful to start with an evaluation from your gynecologist before connecting with a pelvic floor therapist.