You now have permission to pee in the shower.
Recently I met a woman who told me she used to be a runner. Naturally, I asked: Why don't you still run? The answer: "Because 60 hours of labor with my first child and a forceps delivery ruined my desire to run anymore."
To sum up for those who still may not infer the problem: She pees her pants when she picks up the pace.
My friends and I joke about sneeze pee, jumping jack pee, trampoline pee, and other bladder challenges. But full blown incontinence is no laughing matter. I'm a firm believer that a strong pelvic floor is the answer to incontinence (although pharmaceutical companies and surgeons often try to persuade people with other remedies). A strong pelvic floor, I've learned, not only makes the difference between wet and dry running shorts, but also keeps me running pain-free: I no longer suffer from the back and hip problems that used to plague me.
So today I bring you an interview with Katy Bowman. I have had the opportunity to interview Katy for magazine articles. Since becoming a freelance writer 13 years ago I have interviewed scores of sources. Very few I remember. Katy made an impression. She is a biomechanical scientist who applies her knowledge on the human body. Among other things, she has her own DVD program, "Aligned and Well," and is the director of the Restorative Exercise Institute. Her blog, Katy Says, is amazing (and she's as funny as she is smart). I like that combination so I asked her to chime in about the pelvic floor. I had no idea she would rock my pelvic floor world. Even if you've never peed in your running shorts even a little bit, you should still read what she has to say about pelvic floor strength.
Mama Sweat: First, a lot of women just assume it's childbirth that causes incontinence, but I've read that pregnancy itself puts a strain on the bladder (so a c-section won't necessarily save you) and that most women, as they get older--whether they've had children or not--will likely experience problems with incontinence. And even men aren't immune. All this suggests that a weak pelvic floor doesn't discriminate.
Katy Bowman: Nulliparous women (that's women who've never had a baby) and men are equally affected with PFD (pelvic floor disorder) so while child birth may accelerate PF weakening, it is not a primary cause of PFD. PFD is first caused by slack in the pelvic floor due to the fact that the sacrum is moving anterior, into the bowl of the pelvis. Because the PF muscles attach from the coccyx to the pubic bone, the closer these bony attachments get, the more slack in the PF (the PF becomes a hammock).
MS: So rather than a hammock, you'd rather your PF be more like a stretcher--more firm and able to hold up weight without buckling?
KB: I like to think of the PF like a trampoline--the material is supple, but taut...the perfect muscle length.
MS: And kegels. Everyone on my blog has heard me preach about kegels. I want to make sure all my readers are doing them right. Suggestions?
KB: A kegel attempts to strengthen the PF, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to PFD. Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the PF is beginning to weaken. Deep, regular squats (pictured in hunter-gathering mama) create the posterior pull on the sacrum. Peeing like this in the shower is a great daily practice, as is relaxing the PF muscles to make sure that you're not squeezing the bathroom muscle closers too tight. Just close them enough...An easier way to say this is: Weak glutes + too many Kegels = PFD.
MS: OK, I had to step away from my computer a moment to fully process this. First of all, you just said it's OK to pee in the shower, but what really has my head spinning--did I catch this right?--you said: Too many Kegels can cause PFD? Did everyone hear that loud screeching noise? You realize this goes against everything I've ever heard or read; that kegels are the be all end all for pelvic floor strength.
KB: I know, I feel like I'm running around saying The Sky is Falling, The Sky is Falling. The misunderstanding of pelvic floor issues is so widely spread, I'm a Team of One right now. But, I've got all of the science backing it up and it makes sense, the kegel is just such a huge part of our inherited culture information, no one bothered to fully examine it. Anyhow, your PF is underneath the weight of your organs, and the strength your PF needs is equal to this weight (you don't need SUPER STRONG PF muscles, just enough to keep everything closed). When you run, the extra G forces (2-3) actually increase the "weight" while running, but the PF should be adapting, just like all your muscles. One of the biggest misnomers is that tight muscles are "strong" and loose muscles are "weak." In actuality, the strongest muscle is one that is the perfect length - you need Pelvic Floor Goldilocks - it's juuuuuust right. The Kegel keeps making the PF tighter and tighter (and weaker and weaker). The short term benefits are masking the long term detriments. Ditch the kegels and add two to three squat sessions throughout the day (anywhere). The glutes strengthen and as a result, they pull the sacrum back, stretching the PF from a hammock to a trampoline. Viola! You can still practice opening and closing your PF in real-time situations, but you don't have to approach it like a weight-lifting session or anything. It doesn't need to be on the To Do list :)
MS: I am ALL for scratching items off my to-do list! Before we get too carried away with our newfound freedom from Kegels, I want to get back to the role of our glutes. What you’re saying--and I love this--is that there’s a much better reason, besides aesthetics, to avoid the flat butt syndrome found in most older women (further exacerbated in "mom jeans"). Having a booty--as in strong glutes--will not only do wonders for your view from the backside but prevent you from peeing just a little (or a lot) when you sneeze. This is revolutionary. I love what I'm hearing.
KB: Ok, I'm yelling this: YOU REQUIRE YOUR BUTT MUSCLES! There aren't any extraneous parts on the body! Every muscle is really a pulley that is holding your skeleton just so. When you let your glutes go, you allow the bones of the pelvis to collpase into themselves. The squat is the most effective and natural glute strengthener--using the full range of motion and your body weight. It is entirely more effective than any gym machine or contrived exercise. The hunter-gathering folks squat multiple times a day (or at least once in the morning), so they had a nice routine down over a lifetime. Doing this four to five times a day, every day of your pregnancy will improve the delivery as well!
MS: I’ve also read that squatting during pregnancy helps prevent the posterior position during delivery (when babies emerge face up, rather than face down), which causes excruciating back labor and with it more interventions, more cesarean deliveries. In America, where we tend to sit back and put our feet up rather than squat and sit forward, the posterior position is more common than in countries where squat sitting is the norm. I was a squatter during my pregnancies, but now I will continue: when I’m playing with The Boy, picking weeds in the yard, pulling laundry out of the dryer or getting a pot from the cupboard. Lots of opportunities to squat!
I know you've brought up posture as a culprit too. How does posture play a roll and how do we keep good pelvic posture?
KB: You can only have optimal PF function when the pelvis is in a particular position. The two bony points on the front of the pelvis (where you put your hands on your hips) should be vertically stacked over your pubic bone. Most women have become "tuckers" based on their mom or gram telling them to not stick their butt out. Athletes tend to be super-tight through the quads and psoas, which also keeps the pelvis tucked under. Wearing high heels requires women to reposition their joints to deal with the torque at the ankle, and many women will post-tilt the pelvis there as well. For optimal pelvic health, one needs to make sure the posterior muscles (glutes, hams, and calves) aren't pulling the pelvis under and keep the psoas and groin loose as well.
MS: So, this requires that we stretch out the muscles in front and strengthen the muscles in back?
KB: The muscles are weak because they are tight. More "strength" or tension-increasing exercises are going to make it worse. Instead, muscle lengthening exercises--especially stretching the calves, hamstrings, groin (adductors)--are the best prescription. Also, you need to learn how to hold your pelvis correctly to optimize strength!
MS: Which brings me to your DVD with the awesome title: "Down There."
KB: The DVD is designed to get the pelvis in the correct position so the PF can work optimally. Typical PF treatment is trying to strengthen the PF muscles with the pelvis itself is in the wrong position, which means the treatments don't work very well. That's why once you have surgery, the statistics say you will have to have a 2nd, 3rd, and even a 4th in your lifetime! It is not a permanent fix, so it's better to not even go down that road. The DVD will teach you to stretch and relax the muscles that are pulling the pelvis out of alignment--and let the correct muscle tone of the PF re-establish itself.
MS: Should we watch it in the bedroom with the shades drawn or is this something we can do with the kiddies around?
KB: Yes! You can keep the lights on and even the front door open. The exercises are mostly inner thigh and back-of-the-leg stretching, so if you don't tell anyone what it's for then they'd never know. And it's also a great program for kids to follow--especially if they are having problems wetting the bed--the muscle tension pattern is the same in the kids as they are in incontinent moms.
MS: OMG! If you were sitting here in front of me I'd kiss you right now! I am forever washing bedsheets. I can't wait to try it out.
Let's get back to peeing in the shower. Now that you've legitimized it for us (I don't advise this practice at the gym, however), let me ask this: Why do I feel the urge to pee a little (or, OK, I'll say it, sometimes a lot) when I hit a warm shower? Wasn't this covered in a Seinfeld episode? Seriously, what is it about the warm water that makes me want to let go?
KB: When the PF is weak, women start to use the glutes and adductors to keep the bladder closed (instead of the sphincter muscle of the bladder itself). When you hit the shower, those external muscles relax and HELLO! you realize that you don't have actual control of the deeper, internal muscles of the PF.
MS: OK. I thought my PF was strong, but I see I have more work to do. I suppose it’s like any muscle, strengthening must be an on-going practice. But for someone who is suffering from incontinence, or this friend of mine who is afraid to run, how soon should they expect to notice a difference once they start a "training program"? And at what point should a woman consider pharmaceutical or surgical options? Ever?
KB: I don't think a surgical option is ever a good idea, as the problem isn't coming from one time damage, but the accumulation of 1) bearing down a lot and 2) from squeezing the PF all the time. Working on relaxing the PF and keeping it closed "just enough," stretching the backs of the legs to free up the pelvis, doing regular, daily squats to strengthen the glutes, and ditching the heels (except in special occasions) are things you can do all the time for all-the-time improvement. Also, doing tons of crunches where you are bearing down on the PF will only make PF health worse. It's better to do transverse abdominal stabilizing exercises - like the plank - that will decrease any bearing down that sprains pelvic organ ligaments. Once you get yourself out of the weak and overcompensating PF tension cycle, you should feel like you have better bladder control within a few weeks. If you are already experiencing organ prolapse (it is way more common that people realize) you need to skip the run and switch to long, endurance walks (minimize G forces), and do your pelvic-aligning exercises every day--maybe even twice.
MS: Wow. This is revolutionary. And it makes sense. I can hardly believe I'm just. now. learning. this. I can't be the only one who's feeling a little cheated. Women (and men) need to know all this. Thank you, Katy, for answering my questions and sharing your knowledge. I know this information will change a lot of lives. And if I can stop buying nighttime pull-ups for my girls, the benefits are more far reaching than I thought!
****Due to the popularity of this post (where are all you people coming from?!) I did a follow up interview with Katy Bowman. This is especially important if you're a Kegel fan--we haven't written them off entirely. Check out Pelvic Floor Encore.