Do you know what I mean by the “Just in case wee”? That moment when you’re going out the door and you’ll just have a quick try. I used to do this all the time until I started to research into pelvic health and stress incontinence.
Removing the taboo:
It can be an issue for many women after having children but it can also be an issue for women as we get older. The changes in our hormones can often lead to less integrity around the connective tissue of the pelvic floor.
There’s a lot of different things going on in this area of our bodies. If you place one hand on your tummy and the other hand on your lower back and think about all the different systems that are involved there. There is urinary, bowel, reproductive, orthopaedic and musculoskeletal. There are also a lot of emotional issues tied up with this area.
The main nerve that supplies the motor and sensory functions in around the pelvis is the pudendal nerve. Pudendal comes from the Greek word for shame. Shame? Really? I think it’s really time that we started talking about pelvic health and thinking about it. We should feel comfortable talking about it.
When it comes to bladder fitness and pelvic health you should be able to last about 3 hours in between trips to the bathroom. That’s around 5-7 trips over a 24 hour period. You’re ideally trying to train your bladder to sleep through the night. The most important aspect of this is that you shouldn’t go to the bathroom just in case. You should wait until it’s worth your while to go.
You should never go when you feel the first urge to urinate. That’s just a little sign to let you know that your bladder is about half full. You’ve got a little bit of time and you can put it off for now. Contracting and relaxing your pelvic floor muscles a couple of times will teach your bladder to relax.
When you do go you should go for at least a slow count of eight otherwise it wasn’t worth your while going. Your bladder is elastic, it’s a storage unit and if you keep going every time you feel the first twinge you will teach your bladder to be overactive.
You should never strain to urinate it should just be a matter of you letting go so bearing down to urinate is not great. Ensuring you’re drinking enough is essential. Your urine should be pretty clear (do bear in mind that certain B vitamins and C vitamins can change the colour). If you’re getting up during the night for whatever reason, don’t go to the bathroom just in case, only go if you really have to.
Now I understand the concern of getting “caught short”. I was having a conversation with client who said they always go before their journey home from work. This is because it’s quite a long journey and they worry they won’t make it. I get that. What we’ve worked on is managing when she goes during the day. She tries to wait from 3 hours before she’s due to leave and then goes just before leaving. This means she’s not worried about the journey but she’s training her bladder to fill up and fully empty.
It’s important to understand how things affect your bladder. Try to avoid bladder irritants some people find spicy food or citrus food some people find fizzy drinks or even fizzy water can be quite irritating for the bladder. Some women find as they move through the peri-menopause they can become a little lactose intolerant. It’s again back to listening to your body. What’s it trying to tell you? What impact is the food and drink you’re consuming having on your bladder? Try using our workbook What’s My Body Trying to Tell Me? to track your symptoms.
Going to the toilet:
So let’s talk about toiletting. If we don’t have good bowel habits we can do all the great pelvic floor exercise we want but every time we have a bowel movement, we’re going to undo all that good work. So we’re going to talk a little bit about bowel habits and how we can encourage bowel health as we approach the menopause.
Firstly a quick overview of the digestive system.
Food comes into the stomach and is then moved through the digestive tract into the small intestine and then comes into the ascending colon (transverse colon) and then to the descending colon (sigmoid colon) before moving into the rectum and coming down and out. Food coming in through the mouth can take anywhere from 24 to 48 hours to come out the other end.
There’s a wide range of what’s considered normal/abnormal in terms of bowel movements. Firstly, what’s normal for you? Ideally we should be having a bowel movement everyday or every other day. Less than 3 bowel movements a week or more than 3 bowel movements a day are regarded as abnormal.
It’s quite a wide spectrum and can cause problems for women in particular. If we’re having to strain every time we have a bowel movement that puts our pelvic floor and particularly the pelvic organs (the bladder, the uterus and the rectum) under huge downward pressure. For women approaching the menopause, this comes at a time when oestrogen levels are declining. This ihas an effect on the integrity of the connective tissue.
Causes of constipation
- not eating meals regularly
- not having enough fibre (especially from vegetables)
- sedentary lifestyle
- medication (particularly pain medication)
- iron tablets (can be improved if combined with vitamin C)
- fluctuating hormones
What can you do?
- Regular routine – your bowel is a creature of habit, it doesn’t like change. It likes to eat the same food and likes to go to the toilet in the same toilet at roughly the same time everyday. Changes because of travel or life stages can often be disruptive for bowel habits
- Abusing laxatives to try to regain some control over your bowel habits can be a further cause of constipation. Like a lot of systems in our body, if systems don’t have to work (if medications are doing it for them) then they won’t work. We can end up becoming completely dependent on laxatives to have a bowel movement
- Just having a couple of extra glasses of water a day can get things moving
- Go when you need to – consistently ignoring the urge to have a bowel movement is not good for constipation.
When we think about bladder function our bladder is a storage unit we can store up to 500-600 ml in there and when we get the urge to urinate we can do some pelvic floor contracting and defer the need to urinate quite safely. The rectum is not a storage unit, it’s a transition unit and when you get the urge to go, you really should go as soon as possible. If you consistently put off that urge to have a bowel movement you can actually dampen down the reflexes between the internal and external anal sphincter. You can end up with situations not only of constipation and impaction but also situations that might end up with with anal incontinence. So when you have the urge to go listen and obey your body.
Constipation is a problem because when we sit down on the toilet, we’re having to strain to go which creates a lot of downward pressure. A small amount of downward pressure is ok but excessively straining and particularly breath holding is a really bad idea.
5 tips to becoming a super duper pooper
- Go for a walk everyday and drink more water
- Drink a shot glass of prune juice at night before you go to bed if you can get the prune juice that has the pulp in it even better
- Increase fibre especially from vegetables
- Abdominal massage – this is a great article explaining more https://www.nursingtimes.net/clinical-archive/continence/does-abdominal-massage-relieve-constipation/5027718.article
- Start the day with a warm drink (caffeine is an excellent bowel stimulant but the key here is a warm liquid so even hot water with a slice of lemon and cider vinegar can help)
Seated position on the toilet
It’s important that we use a correct toiletting position. You want to make sure that your knees are higher than your hips. You can go out and you can buy a purpose-built stool called a (Squatty Potty) but to be honest you can improvise using a toddler step your kids used to use. Even lifting your heels up a little bit just to get the knees higher than your hips, resting your elbows on your knees and leaning forwards really helps get your tailbone out of the way and opened up the exit root. You then need to find out what position you can best relax your pelvic floor. One trick if you’re struggling is to take a couple of relaxing breaths and then as you breathe out make a “grrr” or “shh” sound. Find out what works for you.
I’m sure many of you remember the programme “You are what you eat” where Gillian McKeith examined poo. Now I’m not saying you should be collecting and looking through your poo, but being aware of what’s going on can really help you identify any issues. Your poo does say a lot about your gut health and the Bristol stool scale is a great tool. You should be aiming for between a type 3 and type 4 Type 4. Ideally there should be relatively little effort to have a bowel movement.
We need to think about the different structures and functions that are going on around the pelvis. It’s important to understand the relationship between the bony structures of the pelvis and hip. We need to understand what’s going on with the pelvic floor because nothing happens in isolation in the body. We also have to be respectful of the spine, the feet and knees the diaphragm. How do we hold ourselves, our posture and how we move our bodies.
Pelvic floor muscles run like a sling from front to back from the pubic bone at the base of the symphysis pubis in the pelvic girdle right the way back to the coccyx. They support all the pelvic organs including the urinary, reproductive and digestive tract.
When we consider the pelvic floor muscles we need to also consider all the surrounding muscles such as the glutes, adductors and abductors. Nothing happens in isolation, research shows that women who have weak hip abductors or hip extensors tend to have a much higher proportion of low back pain, pelvic floor dysfunction or knee pain. We need to think about optimal strategies for not only strengthening but also stabilising all these joints in and around the pelvis.
Issues including sneezing, coughing, laughing, jumping etc. can cause challenges. Particularly when experiencing stress incontinence but by teaching yourself to tighten up your pelvic floor to brace a little bit with the breath could really prevent any leakage.
The “nack” is a useful queuing tool to help ensure your pelvic floor is working when you need it to.Sit down comfortably and have your feet on the ground. Sit forward to the edge of the chair so you’re not having to strain to go from sitting to standing. First thing you going to do is take a deep breath in and as you exhale relax. Focus on relaxing the pelvic floor. Take another breath in as you exhale close the opening in your pelvic floor lift up and continue to breathe as you stand up.
Pelvic Floor Exercises
Important: Ensure your contract all muscles in your pelvic floor – front and back – as you exhale and move– relax on your in breath
- Seated Pelvic tilt with raised arms(ideally on stability ball but if not a kitchen/dining room chair). Ensure your feet are hip width apart and you’re at right angles at your hips and knees. As you exhale roll forwards slightly on the ball tilting your pelvis and pushing through the heels of your hands to the ceiling. Roll back and lower your arms as you inhale
- Seated Pelvic tilt with marching legs. Stay in your forward position and slowly march alternate legs as you exhale
- Seated ball squeeze (again ideally on a stability ball and using a small Pilates ball but a chair and a cushion can work well too). Take your feet slightly wider than hip width apart and place the ball or cushion between your knees. As you exhale squeeze you knees together pulling up through your pelvic floor and release as you inhale.
- Seated leg stretch (again ideally on a stability ball and using a resistance band but a chair and a pair of tights can work well too). Feet are back hip width apart. As you exhale let your legs press out and if possible raise your arms overhead pushing through the heels of your hands. Release as you inhale
- Lying ball squeeze (ideally on a stability ball so the stability ball is under your head, neck and upper back and your hips are pressed up, holding your body in a straight line. Place the ball between your knees and as in the seated position your feet are slightly wider than hip width. As you exhale squeeze and release as you inhale. You can also do these lying on your back with your knees in the air or in a hip raise position
- Squat Squeezes. Ideally using your Pilates ball, as you squat squeeze the ball between your hands and exhale pulling up through your pelvic floor.
- Pick at least 2 exercises each day and perform 10 reps, 10 pulses and hold for 10 seconds. 1-5 get gradually harder so start with 1 and 2 and work your way up.
We see a huge jump in the numbers of women with prolapse in and around the menopause because our hormone levels fluctuate and as oestrogen levels are falling we see a little less integrity around the connective tissue of the pelvic floor. If we are constantly straining and bearing down pain from constipation taking part in inappropriate or poor form exercise, the risks increase.
If you are struggling with pelvic pain, any sort of leaking or pain during intercourse, it’s really important that you don’t suffer on your own. Speak with your local women’s health physio or your GP to workout your best course of action.