Urinary incontinence is described as an involuntary urine leakage. One particular type is called urge incontinence, which presents an inability to hold back urine after feeling the urge to urinate. However, the most common type is stress urinary incontinence (SUI), when leakage occurs during activities that increase intra-abdominal pressure, such as physical exercise, sneezing, coughing, lifting, and twisting (1). SUI impacts twice as many women as men and can significantly reduce women’s self-confidence, libido, and desire to perform physical activity (2). Pelvic floor muscles (PFM) provide support for internal organs like the bladder, yet a loss of muscular control, or pelvic floor dysfunction, is implicated as a factor for developing SUI in women of all ages (3).
Exercise modalities that strengthen PFM have been explored since the invention of Kegel exercises in the 1940s. Kegels refer to the act of tightening both the anal and vaginal sphincters simultaneously and lifting the PFM upwards and inwards. Alternative exercises such as abdominal and postural training, breathing exercises, hip strengthening, and yoga poses present potential exercise avenues but lack extensive exploration in the literature (4). Yoga poses may provide strengthening to the PFM through activation of the transverse abdominus (TrA) and the focus on diaphragmatic breathing. Exercise professionals should consider modifications to basic supine exercises to improve PFM function when prescribing exercise programs for clients who may be at risk for SUI or who are demonstrating symptoms. Therefore, the purpose of this article is to bring attention to SUI, examine potential risk factors, and explore exercise interventions that can improve pelvic floor strength.
Alternative exercises such as abdominal and postural training, breathing exercises, hip strengthening, and yoga poses present potential exercise avenues but lack extensive exploration in the literature (4). Yoga poses may provide strengthening to the pelvic floor muscles (PFM) through activation of the transverse abdominus and the focus on diaphragmatic breathing.
SUI affects 25% of premenopausal women and 50% of postmenopausal women and can be a contributing factor to reductions in quality of life (QOL) and overall life satisfaction (2). Many women do not seek help for this problem and deliberately avoid physical and social activity, which increases sedentary behavior and social isolation (1). Despite the fact that SUI does not directly cause morbidity or mortality, it may lead to chronic inactivity. Many chronic diseases are linked to sedentary behavior, such as hypertension, high cholesterol, obesity, and depression (5). In addition, urinary incontinence may reduce sexual activity. Women may be fearful of leakage during intercourse or experience significant pain during intercourse due to pelvic floor dysfunction; all of which may increase frustration and sexual aversion (6).
Understanding the musculature of the pelvic floor region is important in understanding SUI. The PFM can be described as a hammock at the base of the pelvis with anterior attachments to the pubic bone and posterior attachments to the coccyx. This extends to include the endopelvic fascia, which runs from the pubic bone to the tailbone with openings for the urethra, vagina, and anus. The pelvic floor musculature can be considered to be like a three-dimensional cylinder with the key support structures found in the TrA, the diaphragm, and the posterior multifidus (3). These muscles are constantly engaged except before and after voiding the bladder but can be contracted voluntarily. According to Bø, a professor at the Norwegian School of Sport Sciences and considered the leading international expert in PFM training, the PFM are the only muscle group in the body capable of giving structural support to the pelvic organs and the vaginal, anal, and urethra openings (1). In the absence of strong PFM, the bladder, uterus and bowels will not be supported properly, which may lead to incontinence. In one study using a functional evaluation of the PFM, women with SUI had a lower active strength in the sagittal plane compared with continent women, indicating a need for exercises focusing on anteroposterior musculature within exercise programs (7).
The incidence of SUI increases with aging. Being an athlete or active as a young child may increase the chances of women having SUI later in life because abrupt changes in intra-abdominal pressure, such as occurs during sports, can damage PFM over long periods of time (8). This is especially the case in high-impact sports such as gymnastics, cross country, and track (9,10). Vertical ground reaction forces are higher in the aforementioned sports, which may increase the likelihood of incontinence (3). Female athletes who meet the Diagnostic and Statistical Manual of Mental Disorders-IV classification for an eating disorder also have significantly greater rates of SUI than do healthy athletes (11). Eating disorders may weaken the PFM (10). Bulimia, an eating disorder characterized by forceful, induced vomiting, may further damage pelvic floor musculature by rapid increases in pressure. Through ultrasound and magnetic resonance imaging studies, PFM in a more cranial, or elevated, position are stiffer in nulliparous women compared with parous women (12,13). Consequently, the number of births a woman has had is another contributor to SUI incidence because labor and delivery can stretch and damage the PFM. After labor and delivery, most primiparous and multiparous women have hypotonia of the perineal muscles (14). Finally, diabetes, obesity, smoking, stroke, depression, functional impairment, and some medications, including diuretics and angiotensin-converting enzyme inhibitors, increase the likelihood of SUI incidence in women (10).
PFM training is critical to preventing and reducing urinary incontinence, yet it often is overlooked in exercise program designs (15). This type of training has been described as “lifting the PFM in an upward and forward direction before effort.” Such action can improve the urethral pressure while concurrently supporting the bladder neck to prevent leakage. Even still, learning this technique takes practice and conscious repetition (16). Visualization and awareness of pelvic floor musculature is the first step to successfully executing exercise interventions. The pelvic floor can be thought of as being tethered between the left and right ischial tuberosity, pubic bone, and coccyx. Eventually, maximal voluntary contractions of the anal, urethral, and vaginal sphincters should occur simultaneously while lifting the PFM upwards and inwards without contracting the muscles of the buttocks, hip flexors, legs, and stomach (17).
Weakness in the hips and gluteals may further compound PFM dysfunction. A strong pelvic girdle complex includes a focus on the lateral stability of the muscles of the hips and pelvis, neighboring muscles to PFM. One study found that belly dancing improved PFM strength over a 10-week period in healthy women despite the lack of specific PFM training. A significant increase was seen because of the exercises provoking adjacent contractions of the gluteals, tensor fascia lata, abdominals, and adductors, thus illustrating the important link between strength in the gluteals and hip complex (18). In addition, women with SUI were found to have very weak hip abductors compared with healthy controls in a study by Underwood et al. (19). Hip abduction has not typically been a focus of treatment or examination in subjects with any type of urinary incontinence, but these studies suggest more research is needed to determine if this is an efficacious type of training.
Incorporating other muscles into the contractions may help with incontinence during activities of daily living (ADL). The engagement of the TrA increases PFM function in women and increases the amount of bladder neck movement in healthy women (20). The TrA also serves a purpose in respiratory function. It is the chief muscle of forced expiration and forms the deepest layer of the abdominal musculature, wrapping around the abdomen horizontally, predominantly below navel level. When used with the rectus abdominus and internal and external oblique, the TrA can keep the abdomen flat (21). Although it may seem overly simplistic to try and isolate the TrA, which functions in a highly complex working system, it may be worth exploring because women may initially find it easier to actively contract the TrA rather than PFM.
Fitness professionals can lead the way in educating women to focus on muscles supporting the pelvic floor using common supine yoga poses such as the supine crook position so that gravity is not an antagonistic factor (Figure).
In the supine crook position, fitness professionals can instruct women to place their finger on the skin between the vaginal and anal openings and feel a lifting upwards and forwards toward the bladder. In working in the crook lying position, repetitive practice of short contractions and releases, called flicks, lasting 2 to 3 seconds, can be implemented initially before working a client into longer contractions. The principles of exercise overload can be applied with gradual increases up to 8 to12 repetitions daily and contraction duration occurring up to 10 seconds (3).
The Table provides several poses that can be implemented consistently within exercise programs that can improve TrA activation, breathing patterns, and overall awareness of musculature of the pelvic region. In executing the exercises in the Table, the role of breathing should not be overlooked because poses that link movements to respiration can affect anatomical structures in the body. Observing and using the breath assists voluntary relaxation and contraction of PFM. QOL measures, leakage, and number of leaks were significantly lowered during diaphragmatic, abdominal, and PFM retraining on women with SUI (22). This suggests that synchronized retraining involves breathing awareness in addition to muscle awareness. As inhalation occurs, the diaphragm and pelvic floor move inferiorly, whereas the TrA expands outward. Conversely, during exhalation, both diaphragm and pelvic floor move superiorly, and the TrA hugs in toward the midline, so breathing is directly correlated with diaphragmatic motion, PFM contraction, and deep abdominal musculature. Inhalation and exhalation are shown to be more effective during contraction of PFM (23). Several types of yoga may be best suited for emphasizing pelvic floor awareness. Prenatal yoga focuses on lengthening and relaxing PFM with focused breathing, whereas another type, viniyoga, coordinates slow and controlled movements with deep, conscious breathing. These are very well suited for helping with SUI because of the high correlation between diaphragmatic breathing and PFM function (24).
Observing and using the breath assists voluntary relaxation and contraction of PFM. Quality of life measures, leakage, and number of leaks were lowered significantly during diaphragmatic, abdominal, and PFM retraining on women with stress urinary incontinence (21). This suggests that synchronized retraining involves breathing awareness in addition to muscle awareness.
PFM often are underprioritized in exercise programming but are critical to attenuating or preventing urinary incontinence. Simple modifications to supine exercises can provide valuable training of PFM for female clients who are at a higher risk for developing SUI. Once supine exercises are mastered, fitness professionals can progress clients to practicing activation of the PFMs in standing and dynamic postures in conjunction with stabilizing the surrounding muscles of the pelvis and hip girdle. Furthermore, once PFM have been identified, and the ability to contract them voluntarily exists, women may become more aware of consciously contracting the PFM during ADL. Tightening the PFM before any lifting, coughing, twisting, or other activities may limit urine leakage. Because there are many poses in yoga, which can include backbending, twisting, forward bending, inversions, sitting postures, and standing postures, many poses, or asanas, can eventually serve as all-encompassing, appropriate exercise avenues to prepare women for ADL and could be explored when women have successfully mastered supine exercises. Recognizing SUI concerns with female clients and incorporating exercises to improve pelvic floor activation may increase women’s self-confidence and reduce a potential barrier to participating in physical activity.
Tightening the PFM before any lifting, coughing, twisting, or other activities may limit urine leakage. Because there are many poses in yoga, which can include backbending, twisting, forward bending, inversions, sitting postures, and standing postures, many poses, or asanas, can eventually serve as all-encompassing, appropriate exercise avenues to prepare women for activities of daily living and could be explored when women have successfully mastered supine exercises.
BRIDGING THE GAP
SUI impacts twice as many women as men and may present a barrier to performing exercise in some women. PFM provide support for internal organs like the bladder, yet pelvic floor dysfunction is implicated as a factor for developing SUI in women of all ages. Exercise modalities that strengthen PFM have been explored since the invention of Kegel exercises. Alternative exercises such as abdominal and postural training, breathing exercises, and yoga poses present potential exercise avenues, which also could improve PFM strength.
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Keywords:© 2018 American College of Sports Medicine.
Stress Urinary Incontinence; Pelvic Floor Dysfunction; Premenopausal Women; Quality of Life; Yoga