Urinary incontinence is often dismissed as a normal part of aging that only affects women in the peri to post menopause transition and beyond. Surprisingly it does affect 10% of women in their later teens and 20-30 % of women age 20 to 30. This number climbs to 40 % of women aged 40-50 who experience urinary leaking.  And without any intervention the number of women who leak will climb to 1 in 2 women by the age of 65 and older.  In addition to the hassle of wearing pads, buying incontinence underwear or changing clothes, incontinence negatively affects sleep, social interactions, and sexual health as well as increasing anxiety and depression.

From a healthy aging perspective, woman who leak urine are more likely to reduce their physical activity levels or stop all together to avoid leaking. This reduction in physical activity coincides with losing muscle mass and bone density due to decreasing estrogen in midlife as well as increased risk for heart problems post menopause.  The quick takeaway here is that muscle mass, bone health and heart health are all improved with physical activity. Meaning the body needs more exercise not less in midlife. Managing urinary leaking in women really is a health priority.

Challenging Societal Norms: From Aisle to Lifestyle

 

Urine leaking is something that our society thinks is normal. Have you noticed the long aisle of incontinence products in the grocery store? However, managing incontinence goes beyond wearing pads and changing clothes. It really is a commitment to understanding your body and making small changes over time that with a consistent effort will make a difference. For those of you who are time and fun challenged, this may seem very overwhelming however the argument presented in this blog post is a shift in perspective— from viewing incontinence management as a necessary burden to recognizing that small changes, such as doing 5-10 minutes of targeted exercise most days, can offer a liberating alternative to wearing incontinent pads.

Diving into the Types: Stress, Urge, and Mixed Incontinence

Let’s look at the 3 different types of incontinence before we talk about how to treat the problem of urinary leaking. And find the liberating part of treating urinary leaking with exercise.

Stress Urinary Incontinence (SUI):

 

SUI is defined by leakage of urine with coughing, sneezing, jumping, and/or laughing. Leakage occurs when weak pelvic floor muscles and the inner abdominal muscles can’t manage an increase in intra-abdominal pressure that comes with coughing, sneezing, jumping, and/or laughing. Sometimes there is laxity in the pelvic floor fascia so that the fascia cannot support downward pressure of the abdominal and pelvic floor organs during increased activty or with coughing, sneezing or laughing, contributing to stress incontinence.

Urge Incontinence (UI):

 

UI results from a bladder that sends an urgent uncontrollable signal (‘urge’) to pee several times during the day and night. Sometimes called an overactive bladder, this sudden bladder urge can occur without leaking, however it demands attention right away. Urinary urge incontinence can occur for several reasons.

  • Overactive pelvic floor muscles or increased abdominal muscle tension contribute to the sensation of having to go pee. Holding your belly in all day, grinding your teeth with resulting jaw tension, and always gripping your bum muscles are examples of muscle tension that can contribute to urinary urge.
  • Increased pelvic floor muscle tension can result from urinary tract infection with women of all ages continuing to feel the urge to go pee even when the UTI has cleared.
  • Constipation is a big contributor to increased bladder urge and incontinence.
  • Reduced estrogen during the perimenopause to post menopause transition is also a significant cause of increased bladder urge and bladder frequency ( both of which are symptoms of the Genitourinary Syndrome of Menopause (GSM).
  • Managing what triggers your bladder triggers can go a long way to reducing bladder urge. As we age, the bladder can become more sensitive to caffeine, bubbly water and drinks, alcohol and sugar. And many women have bladders that are sensitive to being cold so dressing warm can really help reduce leaks.

 

Mixed Incontinence

Mixed incontinence means that you have both SUI and UI. Stress incontinence is more common, is more straight forward to diagnose and usually responds to treatment in a shorter amount of time. Urge incontinence is not as common as SUI, however it more negatively affects quality of life and often takes longer to have lasting results from treatment.

 

Assessment: Unveiling the Pelvic Floor’s Role

 

The pelvic floor plays a pivotal role in holding urine until it is socially acceptable to let it out. Assisted by the breathing diaphragm and the transverse abdominals, the pelvic floor manages pressure during activities like coughing, sneezing, laughing, or jumping.

Consideration of breathing patterns in the assessment of pelvic urinary leaking is key. Hunched shoulders, and shallow breathing can contribute to the likelihood of leakage, as can habits like clenching the jaw, holding the belly in, or gripping the glutes. Failing to allow the inner core to do its job by limiting rib expansion during inhalation can lead to a situation like the inflated balloon gripped tightly (Fig 1). Increased downward pressure and, essentially, resulting in stress urinary incontinence (SUI).

 

Figure 1: Downward pressure from squeezing a balloon.

 

Recognizing that the pelvic floor operates as part of a larger system (Figure 2), assessing the isolated muscle groups is key.  Evaluation of the  joint mobility of the thoracic and lumbar spine, hips, and rib mobility also ensures that all parts of this interconnected system can play their part.

 

 

Figure 2: The inner core muscles ( courtesy of Burrell Education )

 

Genitourinary Syndrome of Menopause (GSM): Tending to Tissue Health

 

Assessment of the tissue of the vulva and lower vagina emerges as a crucial aspect of assessment, focusing on color, muscle tone and tissue mobility. As many as 85% of women may experience symptoms of GSM, a condition resulting from decreased hormones affecting the tissues of the vagina, vulva, urinary tract, and pelvic floor. The effects of GSM are broad, contributing to increased bladder urge and voiding frequency, urinary tract infections, vaginal dryness, and discomfort during penetrative intercourse due to vaginal tissue thinning.

Treatment and Results: Bridging Age, Stage, and Function

 

Regardless of age and the specific type of incontinence, the ability to control urine leaks is a function of pelvic, abdominal wall, and diaphragm motor control. It also relies on mobility of the spine and hips.

Pelvic floor physiotherapy has been shown to improve and indeed stop urinary incontinence when addressing the whole inner core system described above to ensure strong and mobile inner core and pelvic muscles.  Of course this means a 5-10 minute commitment of a daily or every other day targeted exercise program to address these muscles.

The reward is a reduction in urinary leaking.  A committed patient who is willing to be consistent with targeted pelvic floor and inner core exercises for at least 3-4 months will be rewarded with a reduction or complete cessation in urinary leaking. The benefits of which will be noticed in improved sleep, enjoyment of physical activity and  social gatherings without always wondering where the bathrooms are and an overall increased enjoyment of life. Of course, the pelvic floor physiotherapist will also explain that muscles stay strong and mobile when used and encourage the patient to continue with a targeted inner core exercise  program for life.

Part of the coaching will also encourage the patient to identify their own bladder triggers and make small changes to reduce the likely hood of leaking because of what we eat or drink. For example, when on vacation many patients may increase their coffee and alcohol intake resulting in unexpected leaking. Knowledge is power so a patient who understands their own body will more likely continue with an exercise program and recognize what their bladder will be triggered by and endeavor to avoid it most of the time.

Insights from Studies: What else can be done?

 

Improving Tissue Health for Urge Incontinence Related to the Genital Urinary Syndrome of Menopause (GSM):

 

The Genital Urinary Syndrome of Menopause (GSM) results in the tissues of the vulva and vagina thinning with reduced tissue mobility due to lack of estrogen. Increased tissue health can be achieved with a prescription for vaginal estrogen or DHEA (6,8,9) with lasting improvements for women with urge incontinence related to GSM. Increased blood flow can also be helped by targeted exercise of these muscles as well as using a vibrator on a regular basis for this purpose alone.

 

Lifestyle Interventions for Clinical Improvement:

 

Treating constipation through increased water and fiber, continued physical activity, and intentional bladder habits will also lead to improved bladder control. Pelvic floor physiotherapists can assist with addressing constipation and pelvic floor coordination.

 

Conclusion: An Liberating Approach for Controlling Your Bladder

 

The journey to freedom from urinary incontinence involves challenging societal norms–meaning not accepting that it is normal to leak. Putting the time in to learn about your bladder control and paying attention to what makes it leak allows you to make small changes that will have a positive effect on your bladder and pelvic floor.

A pelvic floor physiotherapist can be your incontinence coach by prescribing targeted exercises, explaining your body to you, and suggesting simple lifestyle changes to be made over time to reduce and stop leaking. And your pelvic floor physiotherapist can help you navigate the health care system to find noninvasive solutions to urinary leaking. For example, your physiotherapist can use information from reputable studies to support you to discuss treatment options with your primary care provider for symptoms of GSM.

My experience as a pelvic floor physiotherapist gives me the confidence to say that you can find liberation from urinary leaking and be able get on with the business of enjoying your life.

 

References:

 

1.The Prevalence of Urinary Incontinence – PMC (nih.gov)

 

  1. Prevalence and factors related to urinary incontinence in older adults women worldwide: a comprehensive systematic review and meta-analysis of observational studies – PMC (nih.gov)

 

  1. CJU27-I4_08_DrShaw.pdf (canadiancontinence.ca)

 

  1. Effectiveness of pelvic floor muscle training and bladder training for women with urinary incontinence in primary care: a pragmatic controlled trial – PMC (nih.gov)

 

  1. nams-2022-hormone-therapy-position-statement.pdf (menopause.org)

 

  1. Guideline No. 422b: Menopause and Genitourinary Health – Journal of Obstetrics and Gynaecology Canada (jogc.com)

 

  1. Pelvic floor muscle training for urinary incontinence in women | Cochrane

 

  1. You Are Not Broken: 212. Sex Med and Urology – Top Takeaways at the 2023 AUA conference on Apple Podcasts

 

  1. You Are Not Broken: 171. Vaginal Estrogen Show and Tell on Apple Podcasts

 

  1. You Are Not Broken: 197. 2023 Hormone Education 101 on Apple Podcasts

 

11. You Are Not Broken: 195. 8 Truths About Hormones on Apple Podcasts