Discover what causes those “embarrassing leaks” 

Do you leak a little whenever you cough or sneeze or laugh? Or maybe you only leak when your bladder is full and then you cough or sneeze? Perhaps you notice some leaking during sex or when you’re exercising – it may be during star jumps, jumping on the trampoline, going for a run or whenever you lift heavy weights, even lifting children or heavy shopping bags?

If you’ve answered yes to any of these questions, you likely have stress urinary incontinence (SUI). SUI is triggered by an increase in the pressure in your abdomen, such as with a cough, a sneeze, a laugh or exercise, which then puts increased pressure on your bladder and on your urethra, causing a small leak.

If you do have SUI, you are not alone. SUI affects 30-50% of women; no matter how old they are – although it is more common after pregnancy and after menopause. This means every second or third woman you know probably leaks a little too! Even though SUI is so common, it certainly is not “normal”. Interestingly, men can also develop SUI – but this is usually only if they’ve had prostate surgery. The great thing is, SUI can often be managed with pelvic floor strength and coordination exercises with your women’s health (or men’s health) physiotherapist. But there are some cases where a minimally-invasive surgery may be needed. 

Can I stop leaking with stronger pelvic floor muscles?

When we think of stress incontinence, often we immediately think that our pelvic floor muscles must be very weak. So if we have a leak we start practicing our pelvic floor muscle exercises in the hopes that the exercises should stop any incontinence. And sometimes pelvic floor strengthening work really does help. But sometimes it doesn’t. Sometimes we get frustrated because we’ve been practicing and practicing but we just keep leaking. This is why we need to understand WHY we are leaking to really address the issue and decide which treatment will be best. 

The 3 types of stress urinary incontinence

There are three main types of SUI and sometimes you can have 2 different types taking place at the same time.

Type 1 and Type 2 SUI are due to urethral hypermobility. This relates to the support of the urethra and involves the pelvic floor muscles as well as the connective tissue inside the pelvis. Imagine the connective tissue to be like tight elastic bands that hold the bladder, uterus and bowel in their places inside the pelvis. These tight elastic bands hold the organs to the top of the pelvis, to the sides of the pelvis, to the front and back of the pelvis – there’s tight elastic bands everywhere even between the organs and between the urethra and vagina.

There is a sheet of elastic tissue that goes between the pubic bone towards the vagina and completely surrounds the urethra. It is the highlighted bit in the picture above. In SUI this connective tissue is damaged and so rather than holding tight when there is a high pressure (such as a cough or sneeze) the tissue sags, which then makes the urethra drop usually taking the bladder neck with it. This extra movement of the urethra allows for a small amount of urine to escape just at the time of the increased pressure of the cough or sneeze.

In milder cases of SUI due to urethral hypermobility, pelvic floor strength and coordination exercises will help. You can coordinate your pelvic floor to squeeze and lift very strongly and tightly just before the cough and sneeze. This is called The Knack. The pelvic floor muscle supports the urethra by tensioning another sheet of connective tissue to stop any urine from escaping.

Your women’s health physiotherapist can prescribe exercises for you. Sometimes a support device called a pessary can be inserted vaginally to support the urethra – these can be fitted by your women’s health physiotherapist. In some cases, a key-hole surgery may be required to insert a mesh sling to hold the urethra in place to prevent the hypermobility – essentially replacing the role of the sagging connective tissue. This is called a TVT or a TOT. Your women’s health physiotherapist will refer you to a gynaecologist if this is required.

Type 3 SUI is due to urethral sphincter deficiency. In the picture below we can see that the urethra has an internal urethral sphincter and an external urethral sphincter, which act to keep the urethra closed. These sphincters are made of muscle, and with age and particularly after menopause there can be a loss of muscle fibres in the urethra, which can leave the urethra open. There can also be changes to the nerves or blood supply to the urethra with age.

During birth, if the delivery involved instruments such as forceps, there can be some nerve damage which can lead to urethral sphincter deficiency. Previous surgery in the area can also increase the likelihood that it is Type 3 SUI, as there can be nerve or blood supply changes. This is the type of SUI usually found in men after prostate surgery.

Type 3 SUI cannot be completely treated with physiotherapy but can certainly be diagnosed by a women’s health physiotherapist. If your physiotherapist believes you have a sphincter issue, you will be referred on to a gynaecologist. Treatment usually involves injecting bulking agents into the urethra to increase the muscle fibres or using medications that can improve the nerve supply or vaginal oestrogen to improve blood supply or nerve regeneration. In some women, a TVT operation will help.

Now that you know WHY you are leaking and HOW stress incontinence occurs you can better understand when pelvic floor exercises can help and when they are not enough. SUI is multifactorial – yes there may be some muscle involvement (which is when pelvic floor muscle exercises do help) but there can also be issues with the connective supporting tissue or with the urethra itself. If you have SUI it is important to know whether it is a urethral hypermobility issue or whether it is an intrinsic sphincter deficiency or whether you have both. Your women’s health physiotherapist can help you figure out which it is and advise you of the appropriate treatment.

Exercise ‘specificity’ at its best

https://www.youtube.com/watch?v=G_hn3UbT4zw&feature=youtu.be&utm_source=mail2&utm_medium=email&utm_campaign=BehindBallet%2395

Watching this youtube clip showing dancers in slow motion makes you realise how perfect these skilled dancers are in their movement and movement control. What is even more interesting is how precise and targeted the strengthening exercises are to exactly target that very movement and the muscles involved. This includes all muscles from the spinal stabilisers, to the joint stabilisers to the lever muscles of power.

What a perfect example of ‘training specificity’. This is the way in which exercises can be tailored to precisely strengthen the muscles you need for a particular activity. As exercise therapists (us) and those interested in exercise and staying healthy and strong (you), we should all look for better ways to make our strengthening and exercise more specific.

Your imagination is all you need.

Tabitha explores the fantastic effects of needling

Dry Needling is an exciting technique in physiotherapy (essentially Physiotherapy’s version of acupuncture). Katrina and I recently trained in this at a course in Darling Harbour. It has become another powerful tool in our tool belt when we treat our patients.

What is dry needling?

Small, ultrafine needles allow physiotherapists to target many important structures in your body affecting your movement. There are multiple applications, though each involves a needle and a few minutes with it sitting in the right position.

For example, the site where your muscle tendons join into bone can easily become thickened and irritated when overused over long periods. When a dry needle is inserted there, your body is provoked into responding to this otherwise overstimulated region. In much the same way, irregularities in your muscle tissue – both small and large – can appear when your body is adapting to excessive or abnormal tissue load. These can cause pain and other negative effects such as tightening and swelling and can be treated directly and indirectly with dry needles. Even swelling from acute injuries like ankle sprains is treatable this way.

With needling, we aim to disrupt a complex mechanism of activity involving interactions between the brain, nerves, blood vessels, hormones, chemical responses and the soft tissues of the body (ie muscles, ligaments and skin). These complex changes can cause abnormal loading/irritation of the tissues and less than ideal patterns of movement. The needles act like a combination of spotlight, alarm and jump start – the foreign stimulus causes your body to abandon its dysfunctional habits and return to a more normal state and movement.

Here’s a shot of Katrina with some needles I put in at out course in July. See, she looks nice and comfortable!

Does dry needling hurt?

Many patients are concerned about how it might feel, though in reality it is often much less painful than most treatments we perform! There is sometimes a feeling like a pinprick when we insert and remove the needles – similar to the feeling you’d get if you plucked a single hair from your head. In some people, a small drop of blood or bruise might appear. Depending on the site and the length of the treatment, you may also feel tingling (especially near nerves) or aching (near bone). Occasionally when needling the upper body you may become light headed or have an unexpected emotional response. But these will be monitored for and addressed if they do occur.

Personally, having upper body needling done in my arm makes me feel like I’ve had a lovely glass of wine, very relaxed!

Of course, we follow a strict sterilization technique and use single use, disposable needles, ensuring the slight discomfort of the technique (if any) is the only thing you have to worry about. For most patients it is surprisingly comfortable and produces very satisfying and impressive results.

Often you will have your physio combining dry needling with massage, joint mobilisations and re-alignment techniques to give you the best out of your treatment.

If you’re interested in dry needling, ask one of The Fix Program physios if it’s right for you!