The Gist: What are Urinary and Fecal Incontinence?
Also known as: leaking, peeing when you sneeze, can't "hold it", I pass gas during yoga
Incontinence is the involuntary loss of urine, gas, or stool, often associated with sneezing, laughing, exercise, or the inability to make it to the toilet in time.
There are three common types of incontinence. Stress urinary incontinence (SUI) is the involuntary loss of urine with increased pressure on the muscles of the pelvic floor (PFM). Causes include, but are not limited to, coughing, sneezing, jumping, and exercising. Urge urinary incontinence (UUI) is the sudden and strong urge to use the restroom and the inability to hold your urine until you make it to the toilet. Mixed urinary incontinence (MUI) is a combination of both. Bowel incontinence is the involuntary loss of gas or stool.
The Anatomy of Incontinence
One of the functions of the pelvic floor is to keep you continent. Your deep pelvic floor layer is responsible for supporting your organs (bowel and bladder), and your sphincters (anal and urethral) are responsible for stopping the flow of urine, gas, or stool. Together they work to give you conscious control over the bowel and bladder and the ability to delay voiding. When contracted, the deep layer lifts and supports the organs and the sphincters shut the openings. When the muscles relax, voiding happens.
Incontinence occurs when there is some disruption to the support of the bowel and bladder or the inability to control the sphincters. It can be a coordination issue, meaning your body is unable to time a contraction correctly, or a strength issue, meaning you do not have the muscle strength to delay voiding.
Who gets Incontinence? When does it occur for women?
During pregnancy, the load on the pelvic floor muscles (PFM) increases as the baby grows inside the pelvis. Imagine someone sitting on your abs and trying to do a crunch. This is essentially what is happening to the PFM during pregnancy. So, as the baby gets bigger, it becomes more challenging to contract your PFM both quickly and strongly enough. This means that when you cough or sneeze, your PFM may activate too late or with not enough force to prevent leakage. Furthermore, the growing baby is putting pressure on your bladder, which increases the feelings of needing to go. Incontinence can also be present postpartum.
During a vaginal delivery, the PFM may tear as it stretches and contracts. This trauma to the muscles can result in a patient having difficulty reconnecting with or "finding" the PFM, which can lead to muscle guarding (overactivity) or loss of tone (underactivity), both of which result in incontinence (urinary or bowel). Even if there is no significant tearing, it does not mean that the PFM did not undergo trauma during delivery and they can still be overactive or underactive. Sometimes, incontinence is related to something other than pregnancy, like a history of pelvic trauma or various pelvic pain conditions.
Incontinence can also present later in life during menopause for women experiencing vaginal atrophy, or a weakening of their pelvic floor muscles.
The Origin Way: Physical therapy for Urinary and Fecal Incontinence
At Origin, we look at your entire history, not just your most recent pregnancy and delivery, because leaking during exercise years ago is still relevant. We take a comprehensive approach that includes not only addressing the pelvic floor, but your pelvic girdle, core, and even the way you breathe. If you can manage the pressure on your pelvic floor, you can help control the forces contributing to your incontinence. Your physical therapist will also ask you about your voiding schedule and may ask you to keep a bladder diary.
Just because you are experiencing incontinence, we do not assume your pelvic floor lacks normal tone. It could be too tight because it is working beyond its ability, or your incontinence could be linked to poor coordination. If that is the case, your pelvic floor must be downtrained, or taught to relax, before it can be strengthened with kegels and other exercises.
Imagine if you were trying to do a bicep curl, but your biceps was spasmed so much that your hand was almost touching your shoulder. That's what it's like trying to do a kegel if your pelvic floor is overactive.
A typical plan of care involves manual therapy to the pelvic floor, re-education of the pelvic floor,and coordination exercises. We will also work through appropriate strengthening, lengthening, power, and endurance exercises for the pelvic floor. We progress you at your pace and get you back to the activities that you want to do without leaking. Vaginal weights or trainers may be used if your Physical Therapist thinks it's the right course of treatment for you.
How long does it take?
Results can be seen after just a few visits as you relearn how to coordinate, release, and contract your pelvic floor. True strength gains, like any other muscle group, will take a few months. Returning to higher level activities like running or jumping without leaking may also take a couple months.
What to expect in the future
Like any other muscle group, you need to exercise your pelvic floor to keep it strong. You may have to keep up with your exercises in some capacity in the future in order to prevent a recurrence. Symptoms may increase again if you don't do your exercises for a few months, and improve once you've resumed. You may experience symptoms during subsequent pregnancies, but you can return to similar exercises.
Additional Reading and Sources
Gonzales, Alicia L. BSc*; Barnes, K. Lauren MD†; Qualls, Clifford R. PhD†; Jeppson, Peter C. MD†; Prevalence and Treatment of Postpartum Stress Urinary Incontinence, Female Pelvic Medicine & Reconstructive Surgery: April 9, 2020 - Volume Publish Ahead of Print - Issue - doi: 10.1097/SPV.0000000000000866
Szumilewicz, Anna, et al. "Prenatal High-Low Impact Exercise Program Supported by Pelvic Floor Muscle Education and Training Decreases the Life Impact of Postnatal Urinary Incontinence: A Quasiexperimental Trial." Medicine, Wolters Kluwer Health, Feb. 2020, www.ncbi.nlm.nih.gov/pmc/articles/PMC7015656/
Dasikan, Zeynep, et al. "Pelvic Floor Dysfunction Symptoms and Risk Factors at the First Year of Postpartum Women: a Cross-Sectional Study." Contemporary Nurse, U.S. National Library of Medicine, 7 Apr. 2020, www.ncbi.nlm.nih.gov/pubmed/32216721
Sigurdardottir, Thorgerdur, et al. "Can Postpartum Pelvic Floor Muscle Training Reduce Urinary and Anal Incontinence?: An Assessor-Blinded Randomized Controlled Trial." American Journal of Obstetrics and Gynecology, U.S. National Library of Medicine, Mar. 2020, www.ncbi.nlm.nih.gov/pubmed/31526791
Qi, Xiaowen, et al. "The Effect of a Comprehensive Care and Rehabilitation Program on Enhancing Pelvic Floor Muscle Functions and Preventing Postpartum Stress Urinary Incontinence." Medicine, Wolters Kluwer Health, Aug. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6736454/