Fitness for Your Pelvic Floor, not Just Your Abs


By Lauren Streicher, MD

Published Jul 24, 2014, EveryDay Health

For the millions of women who lose urine every time they cough, sneeze or laugh, exercise is high on the list of activities that can cause accidental leakage. But a new study suggests that not only do incontinent women avoid exercise but that vigorous exercise might increase the likelihood of incontinence; not just bladder leakage, but stool leakage as well.

Specifically, according to Colleen Fitzgerald, MD, a researcher at Loyola University in Chicago, one in three female triathletes suffer from urinary incontinence, 28 percent have inadvertent loss of stool and 5 percent have pelvic organ prolapse. What all of these conditions have in common is a weak and ineffectual pelvic floor, the group of muscles that keep your bladder, uterus, and rectum in place and in shape. The study was presented at the American Urogynecologic Society 2014 Scientific Meeting in Washington, DC.

If anyone is going to have strong muscles throughout the body, one would think it would be an elite athlete! But what this study demonstrates is that toned abs and calves do not correlate with a toned pelvic floor. While there seems to be an association between triathletes and these disorders, it’s unclear if vigorous exercise causes the problem, or if these are women are at high risk for other reasons and exercise worsened the condition.

The clear message, in any case, is that even if you exercise regularly and are really strong, you can still be one of the millions of women who have a weak pelvic floor and experience urinary or fecal incontinence.

While 80 percent of women do nothing about it, there are solutions beyond the pads and diapers that manage — not treat — incontinence!

Obesity is a known risk factor. Lose the weight and you might lose the diapers, but it needs to be in a healthy way since the Loyola study showed that 22% of athletes in the study reported eating disorders. Smoking cessation and healthy voiding habits also impact the degree and frequency of incontinence.

A Personal Trainer for Your Pelvic Floor

At the end of the day, since incontinence is a result of a weak pelvic floor and inadequate support of pelvic organs, strengthening the pelvic floor is the best first approach to treatment.

Kegel exercises are commonly recommended. And almost as commonly, they fail. Hence the multi-million dollar diapers industry! Studies show that few women do them correctly or consistently. Success is most likely in women who work with a pelvic floor physical therapist.

That’s right, a pelvic floor physical therapist. In one of my recent surveys  only 20 percent of women were even aware of the existence of this highly specialized branch of physical therapy that can help strengthen pelvic floor muscles and effectively treat all types of incontinence.

The pelvic floor therapist uses a number of modalities, including biofeedback, bladder training and pelvic floor muscle exercises. Mild electrical stimulation is also often utilized to stimulate and strengthen pelvic muscle contractions.

Pelvic floor physical therapy works, but only a small percentage of women have access to and utilize this option.

Your Home Pelvic Floor Gym

A number of over-the-counter­ vaginal weighted cones and balls can facilitate the success of do-it–yourself pelvic floor exercises. But no scientific studies show that these products work, despite enthusiastic testimonials on the product websites.

InTone  is a new FDA-listed prescription device that a patient can use at home. It not only utilizes pelvic floor stimulation, but also includes voice coaching and biofeedback to reproduce what a pelvic floor physical therapist does and in a recent clinical trial demonstrated improvement or resolution of incontinence in the majority of users.

What about surgery? Surgical procedures all have the common goal of supporting the urethra and base of the bladder. Success rates are high. But as in any surgery, there is risk of bleeding, infection, and injury to surrounding structures. While infrequent, mesh erosion may occur and require subsequent procedures. Excluding certain isolated situations, surgery should not be the first treatment option!

It’s time to talk about this taboo topic before diapers become the newest accessory in the Nike store. So yes, strengthen your calves and abs, but don’t forget to strengthen your below-the-belt muscles to be truly fit!

New Guidelines for Urinary Incontinence, But Are They Enough?

By Lauren Streicher, MD

Published Sep 15, 2014

If you are a woman who is afraid to laugh without crossing her legs, you are hardly alone. A whopping 57 percent of mid-life women and up to 75 percent of elderly women suffer from urinary incontinence. The impact of urinary incontinence on health and quality of life is dramatic.

In spite of the prevalence of the problem, most women do not report their incontinence. Sometimes this is due to embarrassment, but also can be because of the assumption that a leaky bladder is a “normal consequence of aging” without effective treatment options beyond medication or surgery. Approximately half of women who do report leakage to a healthcare provider are inadequately treated. Pads and diapers are commonly recommended, but they should be thought of as a means to manage — not treat — incontinence.

New Treatment Rules: A Good Start

With all this, it’s welcome news that the American College of Physicians (ACP) has published new treatment guidelines to address the fact that urinary incontinence is underreported, under-diagnosed, and under-treated.

The ACP stresses that the type of incontinence, “stress” or “urge,” dictates treatment. Stress incontinence means the loss of urine with cough laugh sneeze, while urge incontinence means “I’ve gotta go, and I’ve gotta go right now!

Stress? Start with Kegel exercises. Since most stress incontinence is a result of weak pelvic floor muscles with subsequent inadequate support of the bladder neck and descent of the urethra, I could not agree more that pelvic floor muscle strengthening is the first step. But Kegel exercises?

It’s true that Kegel exercises are commonly recommended. And almost as commonly, they fail. Multiple studies show that few women do them correctly or consistently. Success is most likely in the young, highly motivated patient who works with a pelvic floor physical therapist. Face it, if Kegel exercises worked, the adult diaper industry would not be advertising on prime time television and would not be a gazillion dollar a year industry. The ACP recommends Kegels for “pelvic floor muscle training.” But what the ACP does not acknowledge is that success is dramatically higher if they are done in conjunction with pelvic floor physical therapy.

Urgency? Go with bladder training. Bladder training is behavioral therapy. It involves urinating on a set schedule and gradually increasing the time between voids. This sometimes helps and is recommended for women with urgency incontinence. It will do nothing for stress incontinence.

Consider watching your weight. Obesity contributes to both urge and stress incontinence, and when women are informed that excessive weight is a factor, it can be a significant motivation for weight control. Having said that, many thin women are incontinent.

Know when to turn to medication.The ACP correctly points out that medication treats overactive and urge incontinence, not stress incontinence and should never be a first treatment.

So there you have it. The ACP recommendation is to do Kegels, which commonly fail, bladder training which may help with urgency not stress, and weight loss, which is often unrealistic and not always the problem. If all else fails, ACP recommends medication, which only helps urgency, must be taken for a lifetime, and is not without side effects.

More Options for Incontinence

Where does that leave the woman who follows these recommendations and is still peeing in her pants? Pretty much nowhere since the ACP did not include in their recommendations other effective nonsurgical treatments. These include:

  • Formal pelvic floor physical therapy
  • InTone home therapy
  • Biofeedback
  • Botulinum toxin
  • Percutaneous nerve stimulation
  • Electrical stimulation

While not a first line option, sling surgery should be offered and considered for women with stress incontinence who have failed non-surgical options. I have had dozens of patients that as a result of a 15-minute vaginal sling procedure are able to jump, skip and run without wearing diapers.

The ACP recommendations are a good start and since the internists no longer recommend an annual pelvic exam it is reassuring to know they are not completely overlooking the lower half of a woman’s body. Still, a majority of women who fail these primary interventions are left not knowing about other options when Kegels and weight loss fail. The guidelines should make it clear that women with incontinence who are not successfully treated can still be helped, and should be referred to an expert for treatment options beyond what an internist is able to offer.


Everyday Health Sept 15, 2014

Everyday Health Sept 15, 2014