Category Archives: Urinary Incontinence

How should urgency suppression strategies be modified for the tender or “hypervigilant” pelvic floor muscles?

Urinary urgency, frequency and incontinence are complex and involve the interactions of multiple systems (somatic, visceral and neurological). These three problems are treated commonly in pelvic physical therapy and women’s health physical therapy practices. Urgency suppression strategies were initially developed based on these systems- with the understanding that the pelvic floor muscles were not contributing their part to the system.  In my opinion, this was largely based on the understanding the incontinence/urgency occurred when the pelvic floor muscles were not strong enough to properly hold back urine. But, over time we have learned that this is not always the case. (See my recent post here).

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So, do the same urgency suppression techniques apply for a tender pelvic floor muscle group? Hhow should urgency suppression techniques be modified for the overactive, shortened or hypervigilant pelvic floor?

To understand this, I first need to introduce you to the standard urgency suppression techniques.

UST Traditional

Now, please don’t take this as “Jessica doesn’t think urgency suppression techniques work,” because that is simply not true. I use these in the clinic all the time—for my patients who are experiencing urgency or urge incontinence and have weak, under-functioning pelvic floor muscles. These techniques work for this population a few different ways:

  • Deep breathing facilitates the parasympathetic nervous system which helps to keep the walls of the bladder relaxed thus allowing the bladder to fill and decreasing urgency. This breathing also helps to decrease the emotional fear that a person may feel (“Ahh, I hope I make it to the bathroom!”) which also will calm urgency due to the impact this has on the brain.
  • Strong, quick, contractions are thought to stimulate the neurological connection between the pelvic floor muscles and the bladder. Basically, quick contractions tell the bladder “it is not yet time to empty” and the bladder relaxes its contractions (which make us feel the strong urge) helping to calm urgency.
  • Distraction/Visualization are ways to get the mind off of the bladder and on to something else. Remember when you needed to go to the restroom, but got busy and forgot you needed to go? This aims to utilize that same mechanism to calm urgency and allow postponement of the urge.

Sounds great, right? And it is—really great for people who are experiencing urgency and have weak, underactive pelvic floor muscles. But what about for the people having overactive/shortened/hypervigilant pelvic floor muscles?

My thought process is that these techniques have to be modified to allow them to be effective for this population. First, we will keep a few steps and here’s why:

Deep breathing & Distraction/Visualization: I actually love these (especially the calm breathing) for my patients with difficulty relaxing the pelvic floor muscles. I often find that people with overactive pelvic floor muscles tend to be in a sympathetic-drive state for their nervous systems. Remember, the sympathetic nervous system is the “fight-or-flight” response. People who have chronic pain or chronic urgency/frequency often will have a significant amount of stress and fear, and I find that this state of their system often facilitates poor breathing patterns and overall increased tension and poor force modulation (meaning, choosing the right amount of muscle activity for the current task at hand). My colleague, Seth Oberst, wrote an amazing post about this very thing recently (I could write an entire post applying all of that to the pelvic floor!). So, we’ll keep these steps—with an emphasis on slow, calm breathing, utilizing the diaphragm and emphasizing relaxation of the pelvic floor with the inhale and returning to baseline with the exhale.

But here’s where we modify:

Quick, strong, pelvic floor contractions: My issue with this component for the overactive or hypervigilant or shortened pelvic floor muscles stems from a few key points. Traditional “kegels” or pelvic floor strengthening exercises are contraindicated for people with pelvic pain (or in my mind, anyone who has a tender, hypervigilant or overactive pelvic floor). Performing quick contractions for this population often will create pain, worsen the patient’s symptoms and actually increase urgency. You heard that right. Did you know that the pelvic floor muscles can actually refer to the bladder? I have had many instances when examining a person’s pelvic floor muscles that he/she reported that even lightly pressing on certain muscles made him/her feel urgency. And we know that somatovisceral convergence (a muscle impacting an organ) is real, and does occur.  So, what do we do about this step?

We use this relationship in our favor.

Instead of quick, hard contractions, the person can perform deep breathing and pelvic floor drops (emphasizing complete pelvic floor relaxation). Although initially, some of my clients will worry that relaxing the pelvic floor muscles will “open the flood gates” this does not typically occur. Instead, relaxation of the pelvic floor combined with breathing will often calm down the detrusor (bladder muscle) activity and allow them to feel decreased urgency.

So, what do these new urgency suppression strategies look like?

 New UST

 What do you think? If you have a tender pelvic floor and/or pelvic pain, I encourage you to give it a try! Let me know what you think! As always, I would love to hear from  you!

~ Jessica

TBT: “Do you need to go potty?” 5 Tips to Improve Your Kiddo’s Bathroom Health

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Today’s throwback (yes, I know it’s Friday– I’m sorry, I was busy yesterday!) comes from a post I did a year ago on improving bathroom habits in children. This has been modified from my original post to reflect my most current thoughts and current practice patterns. Hope you enjoy! 

As you may know, I have advanced training in working with children with bowel and bladder dysfunction in pelvic physical therapy. Often times, this is shocking to many people to hear as most of us are somehow under the impression that children don’t have these sorts of problems. But the truth is, these problems are SO common in children! Amazingly, there are many easy things parents can do to make huge differences for their children!  I often here my adult patients say,

“But you don’t understand, I’ve been constipated since I was 5 years old– it must run in my family! ” 

What if we changed the habits of our children early to promote healthy bowel and bladder habits? Could we truly make a difference for them later on in their lives? Could we prevent them going in to their physical therapist and having to say statements like the one above? I believe we can do just that!

Here are your 5 tips to start making those changes today!

1. Encourage adequate fluid intake (mostly water!) and fiber intake!

The average person should consume 5-8 8-oz cups of fluid per day–and your child is no different! Fluid is SO important for both the bladder and the bowels! For the bladder, having adequate fluid decreases the risk of urinary tract infections, encourages normal bladder urges, and allows for a normal light colored urine instead of a dark concentrated urine. As an aside, taking in too many sweet sugary drinks, caffeinated drinks, and carbonated drinks will actually irritate the bladder and is something we want to try to avoid. (Note: Remember this if your child has difficulty with bed wetting!). For the bowels, adequate fluid allows for a soft stool that is easy to pass! If your child is not getting enough water, he or she will likely have a  more firm stool as the intestines have worked to absorb the fluid your child needs for normal bodily functions. Many a patient has been “cured” of constipation simply by drinking more fluid!

Fiber is also very important to encourage a good bowel consistency. The American Academy of Pediatrics recommends children take in between their age + 5 and their  age +10 grams of fiber per day (i.e. a 5 year old would need between 10 – 20 grams/day). There is some debate in this, so check with your pediatrician to get their recommendations. Good fiber sources include fresh fruits and vegetables, whole grains, oatmeal, granola, seeds and nuts! For good recipes for your kids, check out Gina’s recipes from Skinnytaste.com that are “Kid Friendly” here. Also, one of my favorite books for parents, Overcoming Bowel and Bladder Problems in Children, has a wonderful index of fiber-filled kid recipes!

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2. Encourage your child to listen to his or her normal body urges.

This goes for both the bladder and the bowels as well! Quick lesson on anatomy and physiology–We have a normal reflex in our colon that helps us hold our stool to empty at an appropriate time (Yay!). Unfortunately, if a person holds stool for too long, the normal colon response to help us poop is dampened–meaning it won’t work as well! For the bladder, over suppressing bladder urges can cause problems with emptying that bladder, daytime accidents and frequent urinary tract infections. Many times, children become distracted with playing, watching TV, etc. and will hold off on going to the bathroom when they do have that urge. Parents should try to be aware of how long it has been since their child has urinated, and try to encourage a frequency of at least once every 2 hours (this will vary some depending on the age of the child).

3. Get your kids moving! 

I’m sure you’ve heard it in the news these days that children need to get moving more! But, to take a new spin on it, encouraging your kids to move more will actually help keep their bowels more regular! Yes, it’s true, exercise is a stimulant to the bowels. So, encourage your kids to get outside and play, ride their bikes, do family walks and games– the more your kids move the better!

4. Help your child develop a bowel routine 

This one ties in perfectly with our last point. Here’s the scenario:

“8 year old Mary is not a morning person. Mom has a hard enough time getting Mary out the door in the morning, and this often means eating a bagel on the way to school. After Mary gets to school, she often needs to go #2, but is too embarrassed to go and holds it the whole day.”

Unfortunately, kids like Mary often develop constipation from over suppressing those urges! The sad thing with this is that if a child suppresses urges for bowel movements, the stool will often become hard and may even cause pain when the child does go to the toilet. Over time, children can end up with overly stretched colons and may even need to use laxatives/medication for a period of time to loosen the stool and help the colon return to it’s normal position. All of this can be minimized by building a routine for your kids in the morning (or evening) to help encourage a normal bowel movement.

This video from the Children’s Hospital in Colorado helps to shed more light on bowel problems in children:

We know that the colon LOVES consistency, so try to encourage your kids to spend some time (at least a few minutes) on the toilet at the same time each day. We also know that the colon loves fluid (hot especially), hot food, and exercise! So, a good bowel routine would look like this:

“To help Mary’s bathroom habits, Mom started waking Mary up 30 minutes earlier. Mary starts her day with a warm bowl of oatmeal, then plays with her pet dog.  After they play, Mary heads straight to the bathroom to have a BM.”

Yes, building a routine takes some extra time–but it is well worth it to prevent constipation in your kiddos!

5. Encourage proper toilet positioning and breathing on the potty

Yes, there is a right way to sit on the toilet. For children, most toilets are too tall and this makes it difficult for them to relax the muscles around the anal canal to help them poop without pushing hard. Kids will compensate by straining, but over time this can be very detrimental to their pelvic health. To help them out, get a small stool to go in front of your toilet seat which will help encourage them to fully relax their muscles. Encourage them to lean forward and relax on their knees. This will help straighten out the rectum to encourage easy emptying.

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Image from our good friends at squattypotty.com. Check them out!

Then, and most importantly, make sure they have time. Encourage them to read a book or magazine and give their colon a few uninterrupted minutes to “do its thing.” I recommend they spend this time doing slow breathing (Potty Yoga) and relaxing. If they feel like they need to push, encourage them to breathe while they push to avoid the typical valsalva maneuver we often see. Learning this will help them so much both now and in the future! For more information, read this excellent post from my colleague, Jenna Sires, called “Are you Pooping Properly?

What have you tried to help encourage good bathroom habits for your kids? Are your children having problems not addressed above? Feel free to comment below! Here’s to a healthy upcoming generation!

~ Jessica

Throw-back Thursday: When “Kegels” are not appropriate for Urinary Incontinence

For the next few weeks, I plan to re-blog/update every Thursday a previous post originally written by me when working in Greenville, SC for the Proaxis Pelvic PT blog (http://proaxispelvicpt.wordpress.com), in hopes of building a comprehensive library of posts at jessicarealept.com. Selfishly- I like having them all in one place since I often refer patients who come to see me in Atlanta for pelvic PT to my old posts to read as “homework.” 

That being said, today’s post is one published a while back here, originally titled, “Yes, you have incontinence. No, I do not necessarily want you to do Kegel exercises.” It has been modified/updated for you today 🙂 Enjoy! 

~ Jessica 

Recently, I was fortunate to evaluate a nice middle-aged woman referred to me by her urogynecologist for urinary incontinence. When we first sat down, she looked at me and said, “I’m not sure why I am here. My doctor specifically told me that I have a strong pelvic floor. I really don’t think you can help me.” I smiled. I hear this same thought process on a weekly basis (See my previous article on common misconceptions of pelvic physical therapy) You see, at some point the world became convinced that from a musculoskeletal perspective, stress urinary leakage is always due to a weak muscle. And the best way to fix a failed muscle is to strengthen, strengthen, strengthen. But, if that’s the case, then why do I have so many patients walking into my office telling me that they have done “Kegel” exercises and still leak? Why would a patient like the one above have a “strong” pelvic floor that cannot hold back urine? Why is urinary leakage associated with low back pain and pelvic pain- disorders that we know can often include tight and irritated pelvic floor muscles?

Now, as a caveat to this article, let me say now that it is sometimes totally appropriate for a person to start a pelvic floor strengthening program. In fact, the person with a truly weak, overstretched, poorly-timing pelvic floor will likely be prescribed a strengthening program. With that being said, the truth is that the majority of patients referred to my clinic for evaluation of urinary incontinence are not issued a traditional kegel exercise program. My colleagues and I actually tend to be surprised when we evaluate a new patient who truly needs to start a true “strengthening” program for their pelvic floor at the first visit. The reason behind this is that Stress incontinence is not simply a failed muscle, but a failed system.

The urethra is supported within the continence system by fascia, ligaments, as well as muscular structures. When a downward force is applied to this system as occurs with coughing, sneezing, lifting, bending, etc, these structures function in a coordinated way to compress the urethra and prevent urine from leaking. In fact, Hodges et. al. in 2007 examined musculoskeletal activation occurring when a person performed an arm movement and found that the pelvic floor muscles pre-activated to prepare the body for movement. This helps to demonstrate that our pelvic floor muscles function as a member of the anticipatory core team. This team requires optimal and coordinated function of the diaphragm, the deep abdominal muscles, the deep low back muscles as well as the pelvic floor muscles. My awesome colleague, Julie Wiebe demonstrates that relationship very well in the video below (Note: Julie has an AWESOME blog/website- read more of her stuff here):

When any of these structures are not functioning well, leakage can occur. Now, the tricky part here is that optimal functioning requires both strength, flexibility and proper timing. A tight irritated muscle then becomes equally as dysfunctional as a weak over-stretched muscle. And, a strong, flexible muscle that doesn’t have the right timing contributes to a very dysfunctional system.

So, treatment for incontinence then must include retraining and reconditioning the system to ensure its proper functioning—which for me includes a bit of detective work to truly identify the faulty components. And, when it comes down to it, typically does not include doing 100 kegel exercises a day. More often, it includes learning to relax the pelvic floor and teach the pelvic floor to be a working team member– learning to coordinate the pelvic floor with the diaphragm, eliminating trigger points and restrictions which may be inhibiting this function, and then retraining the motor control of the lumbopelvic girdle as a system.

So, for now, take a deep breath and relax. We’ll save Kegels for another day.

For more information, check out the following:

I hope you enjoyed this throw-back- please feel free to share any thoughts or questions below!

~ Jessica

Interview on PT for Urinary Incontinence in Greenville News

A few months ago, I had the opportunity to be interviewed for a story in the Greenville News on Urinary Incontinence.

Many women (and men too!) don’t realize that there are effective non-surgical options for UI. My hope is that articles like this can help spread awareness and encourage people to be proactive in seeking out help! Women’s Health and Pelvic Floor Physical Therapy can make a huge difference for people struggling with these problems!!

Enjoy the article here! Will be added to our News page for future viewing!

Happy Thursday!