This blog was originally posted on drlaurenkeller.com and has be adapted by the author for this website.
Must I pee when I sneeze?
We know that abdominal bracing and diaphragmatic breathing is beneficial to core strength and stability because “as one inhales, the diaphragm moves downward in unison with the abdominal muscles and pelvic floor to eccentrically contract and regulate the volume of the abdominal cavity. By regulating the volume, the intra-abdominal pressure is also controlled.” Now, let’s focus on the other beneficial aspects of proper breathing and bracing, pelvic floor strength.
I commonly hear women say “I don’t like to do that movement because I will either pee my pants or fart.” Unfortunately, many women are told this is normal and to be expected because they gave birth. In fact, “at three months postpartum 34.3% of women admitted to some degree of urinary incontinence…” (Wilson, 1996). The thing is, it may be common but it is not normal. An article from 2001 stated that “the data are highly suggestive that leaking urine may be a barrier to physical activity, especially among mid-age women.” No woman should have to worry about exercising, sneezing, coughing, yoga or jumping rope for fear of losing control of their pelvic floor musculature and peeing their pants or farting.
Vaginal vs. Casearaen
There’s a thought that urinary incontinence must be more common in vaginal births because the baby is coming through the birth canal. In fact, a study from 2007 done by Press showed that “Although short-term occurrence of any degree of postpartum stress urinary incontinence is reduced with cesarean section, severe symptoms are equivalent. This begs the question of why is the rate of urinary incontinence the same among all women?
Breathing & Incontinence
In 2006, an article was released in the Australian Journal of Physiotherapy that concluded “unlike obesity and physical activity, disorders of continence and respiration were strongly related to frequent back pain. This relationship may be explained by physiological limitations of co-ordination of postural, respiratory and continence functions of trunk muscles.” This relates back to the connection the diaphragm has with the pelvic floor and all abdominal musculature – they must work in unison to provide stabilization. This was further addressed when Smith found in 2014, the “relationship between BP, incontinence, respiratory problems, and GI symptoms in which the presence of one symptom is associated with the development of another.” Difficulty with optimal breathing and pelvic floor control (urinary leakage or farting) actually go hand-in-hand.
The importance of the diaphragm
The diaphragm, which works with the pelvic floor and abdominal musculature is important when looking at the cause of urinary incontinence. In 2015, Park released an article stating that “Diaphragmatic motion and contraction of the PFM correlate with breathing.”
It is improper breathing patterns altering the pressure on the pelvic floor that leads to incontinence. You see, “during normal respiration, or in the event of coughing or any other physiologic diaphragmatic alteration, a symmetric change in the pelvic floor can be observed…it also ensures the steadiness of the human trunk and maintaining urinary continence during respiration and coughing” ( Bordoni, 2013)
In the Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders by Laycook and Haslam, they focused on breathing in order to improve urinary incontinence. They state, “it is considered essential to maintain co-activation and breathe in a slow, relaxed manner” and the use of isolated breathing patters is dysfunctional.” They further stressed the need for intra-abdominal pressure by stating “co-activation of the abdominal, erector spinae, diaphragmatic and pelvic floor musculature is essential to developing the intra-abdominal pressure for spinal stability.”
Improving the leak
A study done by Hung in 2016 focused on treating urinary incontinence by retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. The results showed that “both amount of leakage and number of leaks were significantly lower in the training group (p < 0.05) but not in the control group. More aspects of quality of life improved significantly in the training group than in the control group.” This is great news for many women because it highlights the fact that many don’t have to continue peeing their pants or farting if they do specific exercises to help strengthen the abdominal musculature, pelvic floor and diaphragm activation.
Dynamic Neuromuscular Stabilization (DNS) focuses on the inherent movement control system in the brain in order to activate the body’s stabilization system through proper use of the diaphragm. Functional progressions, which were created using DNS principles, focus on moving through a functional position. Laycook stated that “to improve performance, muscles are best trained with movements as similar as possible to the desired work. Therefore, exercise is most appropriate in a functional position.” This is important to remember because all exercises given to improve the pelvic floor should be done in movements that mimic ordinary function.
Results of exercise
We know that peeing your pants when you exercise or sneeze is not normal and we know that the functional movements based off of DNS principles will improve the leakage. It’s also important to look at the long term effects because let’s be realistic, nobody wants to put in a ton of work and not see results. Dumoulin in 2014 released an article stating that, “the review provides support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress and any type of urinary incontinence.” In 2000, Morkved released a study showing there was not only statistically improvement in urinary leakage at 16 weeks postpartum, but exercise can improve leakage at 12 months postpartum too.
The gift of normalcy
While it may be common, peeing your pants when you exercise is not normal. In fact, it is a sign that you need to work on breathing and core stabilization. In order to find someone who can appropriately help you navigate this concern, it is important to find someone trained in DNS or a women’s health physical therapy.
Lauren Keller, DC, DABCA