Incontinence advice

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With incontinence affecting one in three women, it’s time to take action. By Alix Johnson.

Do this exercise quickly: look over your left shoulder, then look over your right. No-one watching? Good, let’s get down to secret women’s business and talk about the awkward subject of weak pelvic floor muscles (PFM).

If you have ever had a young girl, perhaps your daughter, in your care you may recall asking her if she needed to go to the toilet before taking a car trip, and then encouraging her to go ‘just in case’. With the best of intentions, you may have been training her to suffer from problems with bladder control.

Far more commonly, the condition affects adult women – as many as one in three, according to senior lecturer in physiotherapy at Newcastle University, Dr Pauline Chiarelli, who wrote the bestseller Women’s Waterworks (George Parry, 2003, available at www.womenswaterworks.com).

This means, if you get three close girlfriends together for coffee, the probability is that one of you will leak a little from time to time, or enjoy less sensation when making love. The good news, also from Dr Chiarelli, is that with a little bit of work, the condition is completely reversible.

A core issue

You can’t see your pelvic floor muscles the way you can see, for example, your bicep or quadricep muscles, but they are easy enough to find. They’re a group of muscles that form a sling between the pubic bone and tailbone. When they are strong, they give you control over everyday bodily functions. They also keep your organs from moving out of place (known as prolapse).

“The pelvic floor is the base of the muscle groups that make up ‘core stability’ [balance in the trunk of our body]. The abdominal muscles are the cylinder and the diaphragm is the lid,” explains Anna-Louise Bouvier, physiotherapist and director of Physiocise: Movement for Muscles, a back rehabilitation program in Sydney’s North Shore. She adds: “A weak pelvic floor is linked to back pain and a strong pelvic floor to a flat tummy and core strength.”

According to Anna-Louise, of all the women who book a place her popular course, most have an issue with pelvic floor weakness, though few of them nominate this as the reason for coming. “The pelvic floor is essentially a trampoline that gets softer and softer,” says Anna-Louise. “After childbirth there may be trauma to the tissues, which is like a tear in your trampoline. Even when a pelvic sling operation is required (which is rarely), the muscles must be strengthened, like tightening the springs on the trampoline.”

A study published in the Australian and NZ Journal of Obstetrics and Gynaecology confirmed that exercises are the most effective course of treatment for all women, even when surgery or medication is also indicated.

Common causes

One of Sydney’s leading maternity hospitals, the Royal Hospital for Women, devotes a department to treating weak PFM. Sherin Jarvis, a pelvic floor physiotherapist at the hospital, says: “Most people immediately think childbirth is the main cause. However, many women in their first pregnancy can still have bladder control problems, so we can’t blame the delivery [alone]. Other important causes include being overweight or obese, chronic coughing, straining to open the bowel, heavy lifting and bad luck with genes.”

Genes play their role in determining whether you are what Anna-Louise and her team would classify as a ‘floppy’, meaning your body is flexible and bends easily. “Being flexible means having loose connective tissues and often fine skin, too,” she says. “It’s like having muscles wrapped in looser plastic wrap than people who are naturally stiff.” Looser muscles mean a pelvic floor that is prone to weakness, which is why the problem of weak bladder control is prevalent among young gymnasts.

So how do you know if your pelvic floor muscles are strong enough? While one leading expert reportedly boasts she can cease the blood flow to her partner’s ‘manhood’ during intercourse, experts suggest you needn’t strengthen the muscles this much (or test them in this manner). “If you are able to stop the flow of urine halfway then your PFM are working,” advises Sherin. “You can test your PFM this way very occasionally, but don’t do it often as it could cause other problems.” Certainly, don’t believe the urban myth that this is a strengthening exercise.

Telltale signs that you need to strengthen your PFM include: leaking small amounts of urine when you cough, sneeze, jump, play squash, tennis, or run (known as ‘stress incontinence’); feeling the need to urinate and having trouble holding it in (known as ‘urge incontinence’); feeling an abnormal bulge in the vagina (a sign of prolapse); decreased sensation for you or your partner during sexual intercourse; and urinating more often than is normal.

So what is considered ‘normal’ when it comes to toilet-trip frequency? Experts concur women should be drinking between one-and-a-half to two litres of water a day and needing to go to the toilet four to five times, and once at night. This is important: “Each urination should be at least 300ml, or the equivalent of a can of soft drink,” says Anna-Louise. “A tiny dribble is not right.”

If you do go to the toilet too often you could be training yourself for urge incontinence, which is what can inadvertently happen to young children who are encouraged to go often. It is like asking them to eat because you have cooked a meal rather than because they are hungry – soon enough they will learn to override their hunger signals. Likewise, the bladder has a setting mechanism that tells it when it is full. This tends to become reset at a third or half capacity if you don’t allow the bladder to fill up. It also happens when you consume high amounts of caffeine, which triggers more frequent toilet trips.

The only way is up

The bottom line, so to speak, is that strengthening exercises are essential – whether you have weak PFM now or not. To maintain PFM health, you should aim to do six to 10 squeezes in a row, each held for six to 10 seconds, twice a day. (Try it every time you’re standing in a queue). If you do have a particular problem, or to ensure you’re performing your PFM exercises correctly, it’s best to seek individual guidance from an expert.
Up to 30 per cent of women think they are strengthening their pelvic floor muscles when, in fact, they are not, says Sherin. Visit your GP for a referral or go straight to a physiotherapist who specialises in the area (contact maternity hospitals or the Continence Foundation, see Healthy habits, below).

To perform PFM exercises correctly, you should feel the anus, vagina and urethra close and lift towards the belly button. There should be no downward pressure, but an upward and lifting sensation in the vagina, says Sherin. Exercises taught by a qualified yoga teacher can assist in mastering this practice, known as mula bandha. Pilates is also helpful.

Another well-known strategy to prevent accidents and to build pelvic floor strength is ‘The Knack’. “Remember to consciously contract and hold the PFM before every cough, sneeze, nose blow, lift (whether it’s kids, shopping or washing), and to put off going to the toilet. This is called ‘The Knack’,” explains Sherin.

So go ahead and start your pelvic floor muscle exercises right now – you’ll get the knack in no time.

Healthy habits

The Physiotherapy Department at the Royal Hospital for Women, Sydney, recommends the following habits to maintain pelvic floor strength:

• Drink 1.5 to two litres of fluid a day.
• Reduce caffeine (tea, coffee, cola) to two serves per day.
• Always put off the first urge to urinate during the day (but always answer the first ‘call to stool’).
• Cease the ‘just in case’ or habit visits to the toilet (it’s actually good to hold on).
• Always sit down on the toilet seat. 
• Increase fibre to avoid straining. 
• Aim for ideal body weight.
• Treat any chronic coughs.
• Minimise heavy lifting.

For further information or advice, call the National Continence Helpline on 1800 330 066.

Raising awareness

August 5 to 11 is Continence Awareness Week. Visit www.continence.org.au.

Photography: Sam McAdam. Hair & make-up: David Novak-Piper.