Here’s What You Need To Know…
1. Ladies, peeing during workouts or physical activity is not normal, and shouldn’t just be brushed off as a part of life. There’s a way to fix it.
2. Developing strong pelvic floor control and function involves more than just practicing your kegel exercises every day! This is an old school thought that needs to die, especially if you want to stop peeing during workouts!
3. Incorporating your diaphragm and breathing patterns with challenging positions such as front planks, side planks, squats and core rotation are the staples of any athlete’s urinary incontinence corrective program.
4. There’s no shame in correcting your pelvic floor function and changing the way you move, workout and live. The only shame is letting this dysfunction continue and get worse over time. Lets make the change!
Even A Little Peeing During Workouts Isn’t Acceptable!
Being a Physical Therapist somehow hardwires clam shell exercises and glute bridges into our professional DNA when it comes to women’s health and pelvic dysfunction. By all means, if you can’t do a single leg bridge, you have some strength and stability issues — but to truly work the pelvic floor, you must get functional and a bit creative! But before we move on, remember, the cure for pee pants during workouts isn’t all about the kegels as you’ve been told. It’s a little more complicated than that.
A strong pelvic floor is not only essential for women wanting to lift heavy, but for all women who want to enjoy life! While it’s awesome that the Crossfit world is bringing awareness to pelvic floor issues, simply saying it’s okay and bragging about peeing during double-unders is not a solution. It’s a crime, and it’s doing women everywhere a disservice. It’s not normal to pee yourself, EVEN JUST A LITTLE. The pelvic floor should be strong and stable like the rest of your body. Women are giving up on what they love because of their weak pelvic floors and the healthcare professionals in their lives are telling them to do more kegels. That course of treatment is outdated and ineffective, and here’s why.
The Problem With Urinary Incontinence Treatment
Western medicine is great at honing in on an area of treatment, but as we’ve learned with the knee, standard treatment protocol nowadays is to look at the foot and hip first, because it’s rarely the knee itself that’s the cause of the problem. The integration of comprehensive kinetic chain treatment for the knee took 10 years or more to hit mainstream PT. Let’s do it faster with the pelvic floor. For years, kegels were thought to be the first and ONLY line of defense for pelvic floor issues. Not only is that simply not true but it’s flat out wrong. Unfortunately, the message to women is still to do your kegels, and if you aren’t getting better then you aren’t doing enough kegels, making women feel horrible about themselves. Let’s beat a dead horse a little more because that works. Yelling at your patient for not doing enough quad sets for their knee pain just seems ridiculous. So, let’s take the time to look at the kinetic chain and be rock stars with treatment!
In order to lift heavy weights, accomplish dynamic movements, and excel in extreme sports with a strong pelvic floor, we need to be integrative. The pelvic floor is not a stand-alone muscle; it interacts with the muscles above and below it to create optimal functioning. That’s why kegels alone often do not work for people, no matter how diligently they do them: they’re only targeting one piece of a much larger puzzle. Now, just because I’m saying kegels should not be your only line of defense for pelvic floor weakness doesn’t mean you should throw out the baby with the bathwater.
What About The Kegel Exercise?
The occasional kegel exercise can be beneficial, but you need to be sure you’re doing it correctly. The common description is to stop the flow of urine, but a more accurate description is trying to draw in a tampon. Graphic, I know, but very accurate. As you lift or draw up your pelvic floor, you should also feel the lower part of your abdominal wall lifting or tightening too. These two are impossible to separate, hence why trunk alignment is so important for pelvic floor function.
The second half, and probably the most important part of doing a kegel, is relaxing or fully lengthening the pelvic floor muscles. All muscles require lengthening before they can fully contract, and when someone is weak they tend to hang on for dear life, which in the long run makes them weaker. This happens to the pelvic floor by constantly holding a low level of tone making it impossible to get a full contraction. This is why deep squatting it so awesome: it gets length to the pelvic floor without taking much effort.
But again, kegels are only part of the battle. Let’s get integrative and see what we are missing when it comes to the pelvic floor, starting with the diaphragm. Here are the three most effective methods to cure your workout pees, and exercises to strengthen your pelvic floor for good!
#1 Develop Your Diaphragm
The diaphragm is the top to your core, making it a formidable ally in your quest for stability and strength. Proper diaphragm function turns on your pelvic floor. If the diaphragm does not function correctly, the pelvic floor won’t either. They work together like a piston system.
A great diaphragm starts with a great inhale. When you lift heavy stuff, you develop strong paraspinal (back) muscles out of necessity to protect your spine. If your paraspinals become a little too hyper-vigilant, they will not relax to allow proper diaphragm expansion. Therefore, we need to shut down your paraspinals (don’t worry, they will kick back in when you pick up that heavy barbell and eventually learn to have a little more balance with the diaphragm).
A plank with relaxed hips, while focusing on breathing is a challenging exercise for the diaphragm. I love this exercise because you get increased core strength and the ability to focus on your pelvic floor, all while training your diaphragm.
The Front Plank
Front Plank Coaching Cues:
- Start on your hands and knees, and then lift your knees so you end up in a push up position with relaxed legs.
- Tuck your chin – keep your head up and in-line with your body.
- Relax your quads and hip flexors (you need strong scapula for this).
- Keep your shoulders away from your ears and your weight forward over your hands. Do not push backwards.
- Elbows pointed toward your toes.
- Tuck your butt slightly from your core, not your glutes (basically making sure your lower abs are working).
- Do not let your lower back drop down when you blow into the balloon.
- Do not let your head drop down when you blow into the balloon.
- Focus on drawing in (contracting) your pelvic floor muscles as you exhale and relaxing out on the inhale.
- If this is too hard, drop down to your hands and knees and start there.
- Don’t do this exercise if you suffer from diastasis recti
Paraspinals still tight? Try this exercise to loosen things up and get you ready for glute activation. This PRI squat really promotes diaphragm expansion and pelvic floor response. Be sure to breathe in the same way as detailed above: Inhale: pelvic floor relaxes Exhale: pelvic floor draws up
The Full PRI Squat
Full PRI Squat Coaching Cues:
- Hold onto something stable, so your arms can relax straight
- Squat down, resting into your hips as much as possible
- Balance your weight between the balls of your feet and heels
- Rest your head on your knees if you can
- Take a deep breath in, feeling the stretch across your midback
- Fully relax on the exhale
- Try to feel your pelvic floor respond to your diaphragm
- Inhale- pelvic floor relaxes down
- Exhale- pelvic floor naturally recoils up
- It may be difficult to get in air at first, this is normal, it just means you are tight. Keep going, it will get easier!
I want your pelvic floor to be automatic in response to your breathing so you never have to think about it again, but in some people the timing is off and needs work. For those people, their pelvic floor goes down when they exhale instead of up. Often, this person has resorted to bearing down pressure on an exhale or valsalva (holding your breath) when lifting to eke out every last bit of intra-abdominal pressure they could (lifting or pooping this way are both bad). Let’s consider this another form of compensation, and it’s not healthy for your pelvic floor. I’ve seen numerous patients with hemorrhoids and hernias who put tremendous pressure down on their pelvic floor without a pelvic floor counter response. But don’t worry, you can retrain this just like any other muscle memory developed in the body. If you do enough simple exercises thinking about your pelvic floor engaging up when you create intra-abdominal pressure, you can rewire the pelvic floor response to become automatic. Try this on your warm up sets with some planks and body weight squats.
Doing a few side planks is never a bad idea either! Heck, if you want to have some fun, try blowing up a balloon and timing your pelvic floor on the exhale. The balloon will create significant intra-abdominal pressure and challenge your pelvic floor to respond. I guarantee you have never done a harder side plank!
The Side Plank
Side Plank Coaching Cues:
Place your top foot in front and slightly angle your hips toward the ground.
Make sure your shoulders and hips both face down, locking your core in place so there is no twisting through your midsection
Inhale- directing air and pressure into your midback, expanding your back ribs – think bra line ladies – although all my male patients get that analogy too (pelvic floor should naturally relax down)
Exhale – from your bottom ribs (pelvic floor should naturally come up)
#2 Lengthen Your Glutes
Being told you have a tight ass is not the compliment it used to be, especially when it pertains to pelvic floor dysfunction.
Let’s bring the diaphragm and glutes together with the pelvic floor to give you a more in-depth look at the kinetic chain. A dysfunctional diaphragm, glute weakness and lack of hip rotational strength all contribute to shutting down your pelvic floor. Your pelvic floor muscles run from your coccyx to your pubic bone, providing stability for your pelvis and SI Joints, as well as holding up your internal organs. So it’s a very bad idea to let them to take a break for more reasons than just incontinence.
The glutes help to control the pelvic floor. Strong glutes = strong pelvic floor.
Two types of glute inactivity that decrease pelvic floor strength and response time:
- Too much anterior pelvic tilt (hanging forward) = slow/inadequate response pelvic floor, especially on heavy lifts. I think it’s the hanging, just makes things lazy.
- Too much posterior pelvic tilt (clenching) = decreased ability to get a full contraction of the pelvic floor = decreased strength
This doesn’t have to happen on both sides simultaneously. I’ve seen patients that think they have a strong pelvic floor, but only one side of their pelvic floor is truly contracting, while the other side is taking a mini vacation. These patients usually have accompanying hip or SI joint pain.
Hanging Into An Anterior Tilt: Post pregnancy body. I hear the flat butt complaint more than once a day, mostly from women. Pregnancy shuts down your diaphragm and flares your ribs, sending you into an anterior tilt and causing your glutes to lose their advantageous angle to work. Take away glute activation for everyday tasks and it doesn’t matter how many times you hit the squat rack at the gym; you are one step closer to flat butt syndrome.
Posterior Pelvic Tilt: There are many ways to shut down your diaphragm and kill your glutes besides being a postpartum woman. If you have you seen a guy hunch over a computer with forward head posture and rounded shoulders for hours a day then you know what I mean. That guy has no butt either; it’s literally a straight line down from his flat lumbar spine to his heels. But don’t worry, he’s getting up from his desk once every 3 hours and doing a corner stretch (like that’s going to cover it).
Clenching the glutes is a strength killer. When you clench your glutes, you keep them in a shorted position creating a tight weak butt (you may have plenty of passive length but lack eccentric controlled length). Muscles like to lengthen AND contract to get stronger, not just contract. In other words, by clenching, you are making your glutes tighter and weaker. The glutes affect the pelvic floor. Chronic clenchers generally have weak pelvic floors that do not want to activate as quickly or intensely as they should. So basically the glute clenching tells the pelvic floor it can take a break, and to throw in one more level, glute clenchers generally lose hip rotational ability as well. You can also clench on just one side. Generally my patients will describe this as their “weak hip”. Clenching, increased pronation (collapsing of the arch) and piriformis (butt) pain go hand in hand.
My favorite way to lengthen the glutes for both an anterior tilt and posterior tilt is a really deep squat. In both cases you focus on the movement coming from the glutes not the low back.
Start by holding on so you can really sit into your glutes, then progress to a front squat. As you acquire more eccentric control to your glutes you will be able to sit further and further without having to hold on.
Squat with Pelvic Floor Timing
Squat With Pelvic Floor Timing Coaching Cues:
- Try this barefoot, preferably.
- Start standing close to a bar with your feet roughly hip width apart. I don’t want them too wide or too turned out, but a little is fine. Whatever is comfortable for your hips.
- Spread your toes and engage your arch – Weight balanced – Keep your big toe down
- Tuck your chin
- Try and keep your body as upright as possible as you sit down into your glutes
- Hold a neutral spine. Do not increase or decrease your lumbar curve as you go down.
- If you lack ankle dorsiflexion, place a small book under your heels to compensate.
Not only will you get a stronger, more responsive pelvic floor, you will also develop great glutes in the process. No more flat butts! Amen.
#3 Train the Pelvic Floor for Action
The adductors and hip rotational muscles have a direct line of activation to the pelvic floor. The problem is, too many people train in the frontal plane (think front lunges) and sagittal plane (think side lunges) but not the transverse plane (think rotation). And if they do, their focus is often on the concentric (contracting or shortening) portion of the work, neglecting eccentric (lengthening) effort.
My favorite exercise for training eccentric hip rotation is a lunge with rotation.
Hip Rotation for the Pelvic Floor
Hip Rotation Coaching Cues:
- Grab the handle of the band with your outside hand, and then place your inside hand on top (recruits posterior chain of right shoulder).
- Step away to create tension.
- Tall posture. Chin tucked.
- Start down in a lunge position with your arms straight in front, like you are doing a Pilloff Press.
- As you come out of the lunge, rotate through your hips to the left.
- Your knees should stay straight ahead. This is not a pivot on your feet.
- Your trunk should stay locked in with your pelvis. No rotation is happening from the lumbar spine.
- Focus on the rotation coming from your hips.
This lunge focuses on the rotation of the femur in the socket and eccentric control as you unwind out of the lunge. Guaranteed to make your adductors and glutes sore! Plus, it will stabilize your SI Joint as well as turn on your pelvic floor.
Put An End To Pee Pants With Pelvic Floor Control
Our body is a wonderful integrated system and how one part plays off another is absolutely fascinating. In Matt Damon’s new movie, The Martian, I love it when he says “I’ve got to science the shit out of it”. That’s how we need to be looking at treatment of the pelvic floor, and frankly how we need to address every weakness in the body. Nothing is ever as simple as quad sets or kegels, so let’s stop being lazy and pretending it is.
Start asking every single client or patient, “do you feel like you need to go pee before we do box jumps or do you ever need to rush to make it to the bathroom on time?” They may think what they are experiencing is normal, but you might just discover a pelvic floor weakness that they never would have sought out help for, and can then subsequently CHANGE THEIR LIFE. Because unlike having a flat butt, you can’t “see” if their pelvic floor is working and strong. You have to get a bit personal and ask. If we all get a bit personal, it will become normal and the pelvic floor will be just like any other set of muscles in the body and readily incorporated into general PT treatment and training programs. Not only can pelvic floor training be successful, it can be but fun — and it’s a whole lot more than kegels, bridges and clams! Lets stop the peeing during workouts once and for all! Ladies, who’s with me?!
About The Author
Dr. Sarah E. Duvall, PT, DPT, CPT, CNC
Sarah Ellis Duvall, Physical Therapist and Personal Trainer, has spent the last 15 years utilizing her unique approach to create strength and cure injuries. She is passionate about women’s health and helps women in their quest to become strong and feel great. When she is not hanging off the side of a mountain or spending time with her family, Sarah enjoys writing and presenting at www.CoreExerciseSolutions.com and figuring out how her patients can continue to pursue their dreams and lead a strong, adventurous life. To learn more about her programs, including her Hip, Core and Pelvic Floor Series, visit her website.
Boyle KL, et al. The value of blowing up a balloon. N Am J Sports Phys Ther. 2010 Sep;5(3):179-88.
Hsiu-Chuan Hung. et al. An alternative intervention for urinary incontinence: Retraining diaphragmatic, deep abdominal and pelvic floor muscle coordinated function. Man Ther. 2010 Jun; 15(3):273-9.
Park H, Han D. The effect of the correlation between the contraction of the pelvic floor muscles and diaphragmatic motion during breathing. J Phys Ther Sci. 2015 Jul;27(7)
Talasz H. et al. Proof of concept: differential effects of Valsalva and straining maneuvers on the pelvic floor. Eur J Obstet Gynecol Reprod Biol. 2012 Oct;164(2):227-33.
Peeing During Workouts Summary