Exercises for Urinary Incontinence - Naturopathic Approaches

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The structure of the pelvic floor creates a support system for the pelvic organs. These muscles, composed by the pelvic diaphragm and elevator ani complex, form a sling around the urethra, distal vagina, and rectum. Without this structural support, women are at risk of developing pelvic-floor disorders such as pelvic-organ prolapse, overactive bladder syndrome, stress urinary incontinence, and fecal incontinence. Damage or weakening of these muscles can occur from childbirth, aging, repetitive bouncing or jumping, and previous “nonuse” or nonstrengthening of the pelvic floor muscles.

Pelvic-floor physiotherapy, yoga, and exercises like “Kegels” can provide muscle training and strengthening to reduce prolapse and the stress incontinence that women experience postchildbirth and through aging. In general, pelvic-floor disorders are most common in adult women, occurring in about 24% of women in the USA,^[1] and nearly one-third of women over the age of 40 experience some form of urinary incontinence.^[2] Anticholinergic medications are often prescribed, but due to bothersome side effects are rarely continued—or even started.

Apart from aging, other risk factors include obesity and having given birth vaginally, with a greater risk for multiple childbirths.^[1] Urinary incontinence is very common immediately postpartum, and is more likely to occur in women who had prolonged labour or a longer second stage of labour.^[1] Additionally, the use of physical interventions during labour— such as forceps, vacuum, and episiotomy—also increase the risk.^[1] One study showed that women who underwent instrument-assisted births had an eightfold increase in pelvic organ prolapse 5 to 10 years postpartum.^[1]

Urinary Incontinence

Stress urinary incontinence occurs as a result of movement or physical pressure on the bladder and leads to unintentional loss of urine. It is common in women and can even deter women from wanting to exercise, for fear of leaking. This is especially common in women runners, who feel they can’t run or jog postpartum without leaking urine. One study reported that 11% of women with urinary incontinence don’t exercise because of their symptoms, while an additional 11% said they exercised less than they normally would have, due to symptoms.^[3] Even apart from exercise, women—especially pregnant women—can experience stress incontinence simply from coughing, sneezing, and even laughing. All of these, which can cause severe bladder leakage, can lead to major negative impacts on daily living. Apart from embarrassment in public, women have also reported decreases in concentration, self-confidence, performance of physical activities at work, and the ability to complete tasks without interruption or without feeling distracted.^[3] Can you imagine being terrified and anxious over sneezing or coughing for fear you will pee your pants in public? The risk of developing urinary incontinence seems to increase with delayed childbearing. A British study found an association between women who were a maternal age of 30 or older for their first vaginal delivery, and the incidence of urinary incontinence.^[1] As well, pushing longer than an hour during the second stage of labour has been associated with denervation injuries to the pelvis. This may cause soft-tissue and neuromuscular damage, as opposed to women who have a passive second stage of labour, where the risk of this type of damage is significantly reduced.^[1] It’s recommended that pelvic-floor physiotherapy should not be attempted before two or three months postpartum.[4] A minimum of three guided sessions (but often five), one-on-one with a physiotherapist or yoga instructor, are recommended, with women continuing their exercises at home. Treatments are often continued throughout a span of 16 weeks, which correlates with the time necessary to gain muscle mass in these muscle groups.^[5]

 Yoga for Urinary Incontinence

A second option to pelvic-floor physiotherapy is yoga—specifically, oneon-one guided sessions. Yoga is often used as both a physical and mental practice to improve several areas of health and wellbeing. In cases of incontinence, its usefulness is attributed to the fact it promotes awareness and control over individual muscle groups. By practicing specific yoga poses, women can identify and strengthen the muscles of the pelvic floor, while reducing stress. For those who cannot obtain services from pelvic-floor physical therapist, this may provide a promising alternative for pelvic-floor rehabilitation. Beyond the physical aspects, yoga also provides a practice for mental and physical awareness, helping to improve breathing and mindfulness. These can contribute to reductions in anxiety and stress—both of which can make the symptoms of incontinence worse. A pilot study was conducted in San Francisco of women 40 years or older suffering from urgency or stress incontinence for at least three months. Subjects were randomized to receive six weeks of yoga therapy, either one-on-one, or on their own as part of a regular class at a local yoga studio.^[2] The programs encouraged the use of props like blankets, yoga blocks, and straps to help with stability and decrease risk of injury. The emphasis of this Hatha practice was on mindful awareness and proper postural alignment throughout each yoga pose.[2] After six weeks, the frequency of incontinence in subjects who had the one-on-one yoga therapy decreased by 66% from baseline, compared to 13% in the group given passes to practice yoga within a general class at a yoga studio. Stress incontinence frequency also decreased in the one-on-one yoga group by an average of 85%.^[2]

 Pelvic-Floor Muscle Training in Pregnancy and Postpartum

Muscle training for the pelvic floor, commonly known as “Kegels,” is designed to increase the strength, endurance, and coordination of these muscles and, ultimately, increase the structural support for the pelvic organs.[5] With individualized instruction, women can learn to contract their pelvic-floor muscles to build up muscle tone so that pelvic organs are better held in place.^[6] Additionally, practicing this technique consciously, before and during any increase in intra-abdominal pressure, can reduce symptoms such as stress incontinence or prolapse from coughing.^[7] The technique was first introduced by a gynaecologist named Arnold Kegel, who was treating women for postpartum urinary incontinence. Success rates have been documented as high as 84%, with an improvement rate of symptoms as high as 100%.^[8] By starting these exercises during pregnancy, women can improve their incontinence symptoms during the remainder of gestation, but also decrease the frequency and intensity of incontinence symptoms in late pregnancy and postpartum.^[8] One study in pregnant women at 20–30 weeks of gestation found that a six-week “Kegel” program led to significantly reduced frequency and volume of urine leakage, compared to the control (“non-Kegel”) group. Multiple studies have demonstrated similar effects.^[8]

Pelvic Organ Prolapse

The expression “prolapse of pelvic organs” describes the descent of the anterior or posterior vaginal wall, the uterus, or the vaginal vault from their normal anatomical positions.^[7] A mild prolapse often incurs symptoms of pelvic pressure or heaviness, pelvic pain, and urinary and/or bowel symptoms.^[6] Although surgical correction can be used for severe prolapse, it is not always recommended, and not in mild cases. Watchful waiting is often recommended and typically includes providing women with literature and information on the importance of maintaining a healthy weight, avoiding heavy or improper lifting, and treating constipation. It is for this reason that women need another option. Watchful waiting isn’t often good enough, as women have to deal with urinary leakage in addition to feeling like they’re going to give birth to their pelvic organs.

Pelvic-Floor Physiotherapy in Older Women

In older women, practicing pelvic-floor exercises has also been shown to help improve symptoms of urinary incontinence. One study in women 55 years and older showed significant improvements in pelvic-floor distress symptoms with pelvic-floor physiotherapy, compared to watchful waiting.[6] For cases of mild prolapse, watchful waiting is a typical practice, therefore having another treatment option for symptomatic women can be extremely beneficial. Interestingly, this study reported that women who received physiotherapy treatment seemed to gain more insight into their symptoms and condition, leading to a higher subjective appreciation of improvement.^[6]  Pelvic-floor muscle training has also been shown to reduce symptoms of prolapse, though the length of benefit isn’t conclusive. One study showed that training, which included five personalized sessions with a physiotherapist, led to a significantly greater reduction in prolapse symptoms at 12 months, as well as six months and one year posttreatment.^[5] However, another study showed improvement in symptoms for up to 12 months posttraining treatment, but not in the long-term, at 6–12 years.^[4] This could be due to aging, as the risk of pelvic-floor disorders (and muscle loss in general) increases with age, or due to a lack of continued and regular practice/use of exercises.

Although some risk factors for pelvic-floor disorders are unavoidable, such as pregnancy, aging, and previous vaginal child birth, exercises that work the pelvic floor may provide a beneficial treatment solution for the reduction of urinary and prolapse symptoms. Watchful waiting alone can be frustrating for many women and can cause unnecessary distractions and interruptions from day to day. Individualized and guided sessions with a trained professional, as opposed to written instruction, can help ensure that exercises are done properly, but having a supervised session also provides a way to properly monitor progress.