Most people chalk urinary
incontinence and excessive urgency up to age. We get old, stuff
stops working, we wake up to wet sheets. Cue jokes about adult
diapers and investing in “Depends” futures. It’s not entirely
out of line. Aging matters. There’s just more to it. Like other
aspects of “aging,” incontinence and unreasonable urgency
don’t just “happen.” Aging may hasten or accompany the
decline, but it’s by no means inevitable, unavoidable, or
There are surgical treatments available, many of which involve
the implantation of balloons and slings and rings and hammocks.
Those are beyond the scope of this post, which will focus on
exercises and other less invasive interventions and preventive
What’s the Deal With Urinary Incontinence?
The most well-known type is stress
incontinence. When you do anything intense enough to
create pressure, such as a sneeze, a particularly boisterous laugh,
a trampoline session, a power clean, or a box jump, the pressure
escapes through the weakest point of your body—your slack pelvic
floor muscles which support and enable bladder function. The result
is inadvertent leakage.
The most common type is urgency incontinence.
That’s when you can control your bladder well enough, but you
feel like you have to go more frequently than you’d like. This
can disrupt sleep and place you in uncomfortable situations.
There’s also prostate-related urinary
incontinence. If men have incontinence, it’s usually
because of prostate issues or prostate surgery altering the normal
flow and function of their urinary tract. Today’s post won’t
deal with this explicitly, although many of the exercises I’ll
discuss that help women treat incontinence can also help men treat
prostate-related incontinence. For more info on this, revisit my
post on prostate
health from a few weeks back.
Both stress incontinence and urgency incontinence
usually have the same cause: pelvic floor dysfunction. The
pelvic floor acts as a taut, supple sling of muscle and connective
tissue running between the pelvis and the sacrum that supports the
pelvic apparatus, including organs, joints, sex organs, bladders,
bowels, and various sphincters. We use it to control our urination,
our bowel movements, even our sexual functions. It’s very
What Goes Wrong?
It gets weak and tight and pulls the sacrum inward (the tail
gets pulled toward the front of the body), interfering with
urination and urinary control.
What causes pelvic floor dysfunction?
Childbirth is one potential cause, but it’s not a
foregone conclusion. Women who have vaginal deliveries are
to display more pelvic floor dysfunction than women who have
cesareans, while a more recent study found
that tool-assisted vaginal delivery and episiotomy were the
biggest risk factors for vaginal delivery-associated incontinence,
not vaginal delivery alone. Allowing passive descent in the second
stage of labor, rather than active pushing from the get-go, might
Muscular atrophy of the pelvic floor muscles.
The pelvis is where the magic happens. It’s where we generate
power, walk, run, procreate, dance, and move. To keep it happy,
healthy, and strong, we have to move. And then keep moving. Through
all the various ranges of space and time and possible permutations
of limbs and joints. That’s what all our muscles expect from the
environment. It’s what they need. When that doesn’t happen,
atrophy—just like the other muscles.
Who Develops Incontinence?
Stress incontinence is more common among women than men. And
most women with stress incontinence are older, although childbirth
can increase the incidence.
Signs of Poor Pelvic Floor Function
Besides urinary incontinence and urgency incontinence—which
are pretty tough to miss—what are some warning signs of poor
pelvic floor function?
Low-to-no glute activity when
walking. According to expert Katy Bowman, the glutes play
a crucial role in pelvic floor function and incontinence
Lack of lower back curvature. This suggests
your pelvis is being pulled inward due to poor glute activity
and/or overly tight pelvic floor musculature.
Muscle atrophy elsewhere. If the muscle’s
disappearing from your arms and legs, what do you think is
happening in other areas?
What Can You Do? Work On Your Squat
If you can’t sit in a full squat, with shins fairly vertical
and heels down on the ground, you need to work on your form.
I suggest reading this
old post by Kelly Starrett describing optimal squat form. He
focuses on performance and strength training, but the technique
applies equally to basic bodyweight squatting for pelvic floor
One thing to emphasize: go as low as you can without reaching
“butt wink” threshold. The
butt wink is when the pelvis begins rotating backward
underneath the body. If you’re butt winking all over the place,
you’re shortchanging your glutes and preventing them from
balancing out the pelvic floor situation. Stop short of the butt
Squat a Lot
You don’t have to load up the bar, although that’s a great
way to build glute strength. In fact, I’d refrain from heavy
squatting if you’re currently suffering from urinary
incontinence, as the stress placed on that region of the body
during a heavy squat can make the problem worse and cause, well,
I’m mainly talking about everyday squatting: while playing
with the kids, picking up dog poop, unloading the dishwasher,
brushing your teeth, cleaning the house, gardening. If you can
incorporate squatting while using the bathroom, perhaps with a
Squatty Potty or similar product, that’s even better. Katy
Bowman recommends women squat to pee in the shower as an integral
part of her therapy for pelvic floor disorder.
Squat To Use the Toilet (or At Least Get Your Feet Up)
I wrote an entire post almost ten years ago exploring the
squatting to poop. Not only does it improve symptoms in
hemorrhoid sufferers, reduce straining, and alleviate constipation,
but squatting to poop turns out to relieve a lot of excessive
pressure on the pelvic floor musculature.
Not everyone’s going to hoist themselves up over the toilet
standing on a stack of thick books, or go all out and build a
Southeast Asian-style squat toilet in their bathroom, or even get
the Squatty Potty. It’s probably the best way to do it—and
it’s certainly the most evolutionarily concordant way to
poop—but it’s not totally necessary. What matters most is
getting those feet up and those knees above your hips. If you can
achieve this by placing your feet on a stool (not that kind of
stool) as you sit on the toilet, it should do the trick.
Take a Walk and Feel Yourself Up
Next time you walk, rest your palms on the upper swell of your
butt cheeks. Every time you step through, you should feel your
glutes contract. If they contract, awesome. You’re unconsciously
using your glutes to propel yourself forward. If they don’t,
you’ll have to train them to contract when you walk.
Do this by going for a ten minute walk (minimum) every single
day while feeling your glutes. Consciously contract them enough and
feel yourself up enough and the resultant biofeedback will make
glute activation a passive behavior, like breathing. Eventually
you’ll start doing it without thinking. That’s the goal.
The classic therapy for pelvic floor disorder is to
train the pelvic floor muscles directly using kegels. This
is the muscle you contract to stop yourself from peeing midstream.
“Doing kegels” means contracting and releasing that muscle for
sets and reps. A common recommendation is to hold for ten seconds,
release for ten seconds, repeated throughout the day. Waiting in
line? Kegels. Eating dinner? Do some kegels. Remember that man at
the DMV last week who would randomly tense up and start sweating as
you both waited for your number? He was probably doing kegels.
Consider Katy Bowman’s take on the subject. She
thinks kegels by themselves make the problem worse by creating a
tight but ultimately weakened pelvic floor muscle that pulls the
sacrum further inward. Combine that with weak or
underactive glutes that should be balancing the anterior pull on
the sacrum but don’t and you end up with rising pelvic floor
dysfunction and incontinence. She recommends doing kegels while
in the squat position to ensure that the glutes are engaged and all
the other contributing muscles are in balance.
Do More Than Kegels
The bad news is that we don’t have controlled trials of Katy
Bowman’s protocols with deep squats and frequent daily movement
and going barefoot over varied surfaces and squat toilets. We
mostly just have basic “pelvic floor exercises,” which usually
just mean “kegels.” The good news is that even these suboptimal
exercise therapies seem to work on anyone with incontinence,
whether they’re just coming off a pregnancy, a 70th birthday, or
a prostate procedure. Young, old, middle-aged, male,
Actually, we do have one small study that suggests
kegels will work much better if you balance them out with exercises
that target the glutes and hips. In the study,
women suffering from urinary incontinence were split into two
treatment groups. One group did pelvic floor muscle exercises
(kegels). The other group did pelvic floor muscle exercises, plus
exercises to strengthen the hip adductors, the glute medius, and
glute maximus. Both groups improved symptoms, but the group that
did the combo exercises had better results.
For hip adduction, you can use that hip adduction machine where
you straddle the chair with legs spread and bring your knees
together against resistance. Another option is to use resistance
bands. Attach one end of the band to a secure structure and the
other to your ankle. Stand with legs spread, then bring the banded
leg inward toward the unbanded leg; you should feel it in your
inner thigh. Do this for both legs.
For glutes, you have many options. Glute bridges, hip thrusts,
squats, deadlifts, lunges, resistance band glute kickbacks.
If you want to get deep into this subject and really learn the
optimal exercises for pelvic floor dysfunction, I’d pick up a
copy of Katy’s Down
There For Women.
Get Strong and Stay Strong
One of the strongest predictors
of urinary incontinence is physical frailty. The more
frail—weak, fragile, prone to falling, unable to handle stairs,
unsteady on one’s feet—the man or woman, the more likely they
are to suffer from urinary incontinence. This mostly comes down to
muscle atrophy; the frail tend to have low muscle mass all over,
including the pelvic floor.
The best option is to never get frail in the first place. If
you’re younger and in shape, keep training and moving. Don’t
lose it. If you’re younger and trending frail, get training and
moving. Don’t squander the time you have. It goes quickly. If
you’re older and frail, you have to start today. Fixing this
doesn’t happen overnight. Being frail makes it harder to do the
things necessary to get strong, but that doesn’t absolve you of
The Bottom Line
None of this stuff is a guarantee against incontinence.
Guarantees don’t really exist in life. But I’d definitely argue
that anyone who employs all the tips and advice mentioned in
today’s post will have a better shot at maintaining bladder
control than their doppelganger in some parallel universe who never
tries anything—the earlier the better.
If you have any experience with urinary incontinence, let us
know in the comments down below. What worked? What didn’t? What
worked for a while, then stopped?
Thanks for reading—and sharing here. Happy Halloween,
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Kokabi R, Yazdanpanah D. Effects of delivery
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