"I Coughed So Hard I Peed My Pants"

We are very lucky to have Victoria Dawes, a pelvic floor physiotherapist from Toronto and grandmother of a child with CF, write an article for us on a topic that is not very often discussed but impacts many of our lives. This is urinary incontinence as a result of hard coughing, and can be especially problematic for women. I am so grateful to Victoria for putting together this fantastic information for us, and some exercises we can use to address the problem. 

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I COUGHED SO HARD I PEED MY PANTS
by Victoria Dawes, Registered Physiotherapist

Under ordinary circumstances , with the stress and strain of daily life, one in four women will develop urinary incontinence at some point in her life because of pelvic floor muscle dysfunction.  Women with Cystic Fibrosis who have a persistent cough are at even higher risk because of the increase in abdominal pressure during coughing which displaces the pelvic floor downward.  Knowing how to effectively engage the pelvic floor muscles will not only prevent leakage of urine but will create a more powerful cough to clear airway secretions/mucous because the force of the cough will be directed upward as the strong pelvic floor muscles resist the increase in abdominal pressure. Coughing is exhausting so it is desirable to develop a strong, effective cough and at the same time prevent embarrassing urine leaks.

The pelvic floor is a deep, dark mysterious place. The biggest challenge with pelvic floor activation is that many of us do not have awareness or perception of the pelvic floor muscles. In other words, it is very difficult to train muscles that we can’t easily see, touch, or visualize. Rehabilitation of the pelvic floor is as much about rewiring the nervous system to develop communication between the brain and the perineum as it is about strengthening the muscles.

The pelvic floor has two opposite functions: it is closed to provide support for the organs and prevent escape of urine and stool, but needs to open up for urination, defecation, intercourse and childbirth. The pelvic floor plays a role in core stability, breathing, balance, posture, body centering, and facilitation of blood and lymph circulation in the pelvic basin.

The pelvic floor is a hammock of layered muscles that stretches from the pubic bone at the front and attaches to the sacrum and tailbone at the back. It forms a soft bottom to the abdomen.  We can stop the flow of urine by contracting the front of the pelvic floor, and stop the passing of gas by contracting the back of the pelvic floor.  Although the entire pelvic floor generally works as a unit we can isolate separate areas.  Visualization is a powerful tool that can be used to recruit the muscles of the pelvic floor.  By focusing on imagery we can develop awareness of the perineum and greatly improve the function. The pelvic floor muscles are programmed to work along with the respiratory diaphragm so when first learning a Kegel it is best to contract the pelvic floor muscles as you breathe OUT, and relax the muscles as you breathe IN.  A healthy muscle needs to be able to relax and have flexibility as much as it needs to have power and endurance.

LEARNING HOW TO DO KEGEL EXERCISES

1. Imagine that there is a marble just outside your anus and you are drawing it into your rectum.  Hold the contraction while you breathe out ( 5 seconds) then relax as you breathe in and rest for another breath ( 15 sec) . Repeat the contract/relax sequence 5 times.
   
2. Imagine that the sitz bones (the bones you feel in your buttocks when you are sitting) are magnets.  As you breathe out visualize the magnets being strongly drawn together.  As you breathe in relax then rest. Repeat as in #1
   
3. Imagine a ping pong ball sitting just outside the vagina.  Visualize squeezing the ball and drawing it into your vagina as you breathe out. Relax as you breathe in and relax then rest. Repeat the sequence as in #1.
   
4. Picture that you are picking up a jellybean with your labia as you breathe out. Relax as you breathe in, then rest.  Repeat the sequence 5x.
   
5. Imagine that you are drawing a raisin into your urethra or that you are lifting the urethra up behind the pubic bone. Repeat as above.
   
6.  When you have developed an awareness of the separate areas you can begin to combine the effort in various combinations ie. # 1+ 2,   # 2 + 3,  # 3 + 4,  # 4 + 5
   
7. Now put it all together: as you breathe out engage the entire pelvic floor by imagining an elevator rising, or a hammock being pulled out and lifted, or a lotus flower tightly closed. On the relaxation phase visualize the elevator being lowered to the sub-basement, the hammock lowered and slack, or the lotus flower completely opened out.
   
8. It is also important to exercise the fast-acting muscle fibres that quickly engage in response to the urge to cough, sneeze, and on impact. Contract for 1 second, then immediately relax for 1 second.  Repeat 10 x. Visualize the action like a ball bouncing, i.e. it has to hit the ground before rising up again.
9. Finally, as you begin to breathe out engage the entire pelvic floor and maintain the hold while you produce one strong cough. Relax and rest after the cough then repeat 5x.

Exercises 1 - 7 develop the muscles that provide endurance and support to the organs and sphincters.

Exercises 8 - 9 strengthen the response to prevent urine leaks during coughs and are important in sexual function.

REPEAT THE EXERCISES SEVERAL TIMES PER DAY AND AFTER SEVERAL MONTHS YOU WILL SEE AN IMPROVEMENT IN THE STRENGTH AND SUPPORT OF THE PELVIC FLOOR MUSCLES.

Be diligent and purposeful in your practice. Engaging these muscles requires concentration but with some effort your brain will learn how to use them effectively again. If you are not getting stronger, or this is too abstract to learn on your own, and it is within your means, seek treatment from a Pelvic Health Physiotherapist (Physical Therapist) who has specialized training to help you retrain the pelvic floor muscles using internal palpation.

You can search for a qualified P.T. in Canada at www.pelvichealthsolutions.ca

Or on www.physiotherapy.ca/Find-a-Physiotherapist

 or in the United States on the American Physical Therapy Website under Women’s Health. www.women’shealthapta.org/plp/

You can direct any questions to the author of this information:
Victoria Dawes
Registered Physiotherapist, Women’s Pelvic Health
v.dawes@pelvicfloorplan.com