Stress incontinence is any leakage of urine caused by coughing, sneezing or other physical exertion. In my experience women typically approach urinary incontinence in one of two ways: they are either embarrassed and don’t wish to acknowledge it, or they accept it as a normal and inevitable part of aging or childbirth. But if your goal is to stop stress incontinence, neither approach is very helpful.
Urinary incontinence is certainly nothing to be embarrassed about. It is an exceedingly common problem (affecting at least one in four women, and 50% of women over their lifetimes) and is in no way indicative of being ‘unfit’. You may be surprised to learn that it is also very common in some of the most fit individuals on the planet, including professional athletes and women who regularly exercise their ‘core’ through cross-fit, Yoga or Pilates (check out our article on athletic incontinence).
Nor should urinary incontinence simply be “accepted”, because it is also very treatable – and the sooner the better. Conservative treatments (i.e. non-surgical) for stress incontinence not only help prevent the natural progression (worsening) of symptoms, they are also highly effective at treating mild to moderate cases. Two great reasons to get started today.
Why do I have stress incontinence in the first place?
To understand how to stop stress incontinence it’s helpful to first understand a little bit about the most common causes of mild to moderate stress incontinence:
- Weakness of pelvic floor muscles resulting in inadequate closure of urethral sphincters.
- Damage of fascia or ligaments following pelvic trauma such as childbirth.
- Sub-optimal communication between the nerves and muscles responsible for managing pressure change in the pelvis and abdomen (‘neuromuscular dysfunction’).
How is stress incontinence usually treated?
Thankfully, regardless of which of the above applies to you, pelvic floor muscle training is the recommended first-line conservative treatment for mild to moderate stress incontinence. This is for good reason – it is both safe and effective.
In the article below I’ll cover both supervised and unsupervised pelvic floor muscle training. But before I do, you may be able to reduce symptom severity with a few lifestyle adjustments that you can get started with right away.
Lifestyle interventions to treat stress incontinence
Here are the best lifestyle modifications to help you reduce or stop stress incontinence:
1. Reduce aggravating factors
The onset and persistence of stress incontinence is influenced by a variety of factors including: age, number of vaginal childbirths, obesity, smoking, constipation, and presence of diabetes. Here are a few that you can do something about:
Body weight– Excess body weight is a strong and independent predictor of stress incontinence, and the more you exceed your healthy body weight, the more likely you are to suffer from it (ref 1). Therefore, if you are overweight, achieving a healthier body mass index (BMI) should help reduce or even eliminate your symptoms. Clinical research in this space is small but striking. One clinical study reported that a 5-point increase in BMI increases the risk of stress incontinence by 20-70%, whereas bariatric surgery was shown to cure 41% of cases of incontinence at the one-year mark (ref 2).
Smoking – Smoking appears to exacerbate symptoms of urinary incontinence, likely because it causes excessive coughing. Rates of incontinence appear to be highest in patients who smoke more than 20 cigarettes per day (ref 3). There are obviously many better reasons to quit smoking (such as reducing the risk of lung cancer) so if you haven’t been able to quit already, it’s not likely this added incentive will be of much help. However, vaping may be a realistically achievable and beneficial alternative. In addition to being accepted as a generally healthier option, vaping should provoke significantly less daily coughing and thereby reduce leakage.
Childbirth – Pelvic floor muscle training both during and after pregnancy has been shown to have a positive effect on reducing the incidence and severity of stress incontinence (ref 4). In many places pelvic floor muscle training has become a common educational component for expectant mothers. With growing evidence for positive preventative effects on late-term and post-partum urine leakage, pelvic floor strengthening should become a standard component of pre-natal education everywhere.
Diuretics – Caffeine and alcohol are common diuretics that increase the need to urinate. It’s probably not realistic to expect people who suffer from stress incontinence to give up caffeine and alcohol, however, there may be selective circumstances where you might consider modifying your behavior. For example, if you’re headed to a family reunion in a local park with no washrooms, you may wish to downsize your Venti Latte.
2. Turn on your pelvic floor
Consciously contracting your pelvic floor muscles prior to coughing or other activity that causes leakage can help reduce or prevent it. This isn’t surprising; pelvic floor muscle activation occurs naturally and automatically in continent women for just this reason.
You can do this by contracting the muscles that you would need to turn on in order to stop urinating mid-stream. Not sure if you’re turning them on correctly? Try it on your next trip to the bathroom (though this is not meant to be the method for actual training of these muscles – just as a quick test to find them!).
Learning how to activate your pelvic floor can be a challenge for many women with incontinence, but with some instruction and training you will be able to do it (learn more on this below). The aim of pelvic floor muscle training is to improve the body’s ability to both consciously, and automatically, contract these muscles to effectively manage pressure changes caused by physical exertion.
3. Intravaginal support devices
Intravaginal support devices may be used to help support the neck of the bladder and reduce leakage. These are typically made of silicone, such as the Uresta, but there is also a disposable over-the-counter version called the Poise Impressa.
Support devices should not be considered as treatment for incontinence, nor are they recommended as a regular preventive measure. But they can serve a valuable purpose as a temporary crutch if you are anticipating a particularly aggravating physical task.
For example, let’s say you’ve been working hard on your pelvic floor muscle training but are not yet consistently in control of your symptoms – and you’re required to attend an office team-building event at a local trampoline gym. This might be an opportune time to use an intravaginal support device, and perhaps also a good time to educate the event organizer about the issue trampolines can create for some attendees.
Pelvic floor training to treat stress incontinence
Now for the main event. Supervised pelvic floor muscle training (also known as pelvic floor physiotherapy) is the recommended first-line treatment for mild to moderate cases of stress incontinence.
A 2018 meta-analysis of clinical studies found that women who performed pelvic floor muscle training were eight times more likely to report being cured of their stress incontinence symptoms than women who did not participate in active treatment (ref 5).
Why is it so effective? Training not only increases pelvic and inner core muscle strength and endurance, it also reinforces optimal neuromuscular communication to improve the ability and timing of both conscious and subconscious muscle activation. As a result, whether your underlying cause is muscular weakness, trauma or injury to the area, or a neuromuscular activation issue, training can improve or eliminate your symptoms by:
- Improving the strength of urethral closure.
- Improving muscular support of the pelvis and reducing downward pressure on the neck of the bladder.
- Encouraging the natural and automatic coordination of pelvic floor and other core muscles to effectively manage intraabdominal pressure during physical activity.
There are two general classes of pelvic floor muscle training: supervised, and unsupervised.
Supervised pelvic floor training
I realize that this article is about self-help measures to stop stress incontinence, but understanding the differences between supervised and unsupervised pelvic floor strengthening is necessary for two reasons. First, supervised training is the widely accepted recommended approach so I would be doing a disservice not to mention it. Second, supervised training has been shown to be the more effective approach so if doing these exercises on your own (unsupervised training) fails to significantly improve your symptoms, all is not lost.
In contrast to unsupervised pelvic floor muscle training, training supervised by a pelvic health physiotherapist (or ‘physical therapist’) offers:
- A personalized treatment plan targeted to your specific condition. There is no ‘one-size-fits-all’ solution for stress incontinence. A great example is the perennially popular ‘Kegel’ contraction. ‘Kegels’ are a very commonly used pelvic floor exercise, but they are neither sufficient nor appropriate for everyone. For women with stress incontinence arising from an overactive (‘hypertonic’) pelvic floor, Kegels can actually worsen symptoms (see: Do Kegels work? Are Kegels bad for you? It depends.). Pelvic floor muscles also work synergistically with other muscles including pelvic, hip and gluteal muscles and components of your “inner core” (deep back and deep abdominal muscles and diaphragm), and so training these related muscle groups can be additionally beneficial for treating incontinence, while optimizing overall pelvic strength and support (ref 6,7,8). A pelvic floor physiotherapist can teach you the best exercises for your specific condition and instruct you on how to build strength and muscular coordination to better manage changes in intra-abdominal pressure, particularly for the activities that you find are most problematic in terms of leakage. A pelvic health physiotherapist may determine that you could also benefit from incorporating muscle relaxation techniques, breathing exercises, manual massage, or other tools in their care (such as vaginal cones or other devices described below).
- Proper instruction on how to perform pelvic floor muscle exercises. Women with urinary incontinence are less likely to be able to ‘feel’ and contract their pelvic floor muscles and are therefore more likely to perform muscle strengthening exercises such as Kegels incorrectly. In one study, over 30% of women with urinary incontinence were unable to appropriately perform a Kegel exercise without guided instruction, and instead mistakenly contracted abdominal, gluteal or hip muscles (ref 9), which can in fact be counter-productive for their incontinence.
- Better outcomes. Patients who receive targeted personalized training taught by specialized health care providers with regular follow-up, have a greater likelihood of significantly improving or curing their stress incontinence.
Whether you start out with professional advice, or get started on your own, treating stress incontinence is mostly a self-help endeavor – it’s up to you to do the work.
If you are feeling hesitant about ‘committing’ to seeing a therapist, pelvic health physiotherapy doesn’t need to be overly frequent nor time consuming. Your pelvic health physiotherapist should educate and empower you to train your pelvic floor on your own, allowing you to return as-needed for further instruction, progression of exercises, and/or hands-on care as appropriate.
Keeping the above in mind, pelvic floor muscle training is also frequently performed without supervision. Here’s how you can get started on your own:
Unsupervised pelvic floor training
As we saw above, unsupervised pelvic floor muscle training is not the recommended best approach for treating stress incontinence, but for some women it can still be very effective.
Importantly, if you do not see an improvement in your symptoms, or your symptoms worsen, I would recommend you take a break from your home exercise efforts and seek out the guidance of a pelvic health physiotherapist. If you suffer from mild to moderate stress incontinence there is still an excellent chance that appropriate cueing and strengthening can significantly reduce or eliminate your symptoms.
Here are some of pelvic floor strengthening tools pulled directly from the toolbox of pelvic floor physiotherapists that can help you stop stress incontinence:
By far the most popular pelvic floor strengthening exercise is the ‘Kegel’ contraction. The Kegel can be an easy and effective tool for reducing stress incontinence in women and men alike. Below I describe a general way to get started using them.
How to stop stress incontinence with Kegels:
- Ensure that you can properly execute a ‘Kegel’ contraction by finding and squeezing your pelvic floor muscles. Individuals with incontinence tend to have a reduced ability to ‘feel’ and contract their pelvic floor muscles, and if you’re not doing it correctly it will not be effective. The best conceptual cues are to either think about trying to stop your urine midstream or holding in a tampon. When you perform the exercise correctly you should feel a contraction and a ‘lifting up and in’ of the area spanning from the front to the back of the pelvic floor (pelvic bone to tailbone). If you feel this only around the anus, you are not engaging your full pelvic floor, and exercising only the back portion of your pelvic floor will not help prevent urine leakage. Try to not contract your abdominals or gluteal muscles (buttocks), or to hold your breath – these actions are normal compensations for a weak pelvic floor, but they can’t help you prevent incontinence (in fact, increasing abdominal pressure is likely to increase leakage). If you are not sure that you can activate your pelvic floor correctly, or cannot hold a steady contraction, you would benefit from the guidance of a pelvic floor physiotherapist. A single session may be enough to get you started on the right track.
- Perform the Kegel exercise two times per day. Do not do this while going to the bathroom.
- Get in a comfortable sitting or lying position and make sure you can ‘locate’ your pelvic floor (i.e. gently squeeze it). Depending on your position you may find that you have more or less difficulty performing a full pelvic floor contraction. Experiment to find a position that works optimally. For example, being in a ‘pelvic tucked under’ position with too much body weight into your buttocks may make it difficult for you to contract the front of your pelvic floor, while tipping the pelvis forward a bit to achieve a more ‘neutral’ spine, may help.
- Perform three sets of 10 second holds. Hold a 10 second contraction and then release for 5-10 seconds. Repeat 10 times in a row (this would be one set). Repeat for 3 sets, twice per day.
- Try using your Kegel contraction before coughing or other provocative activity in order to prevent leakage. It may take you a little practice before you can start consciously incorporating Kegels into your daily life, and with enough practice it should become automatic.
Try not to overdo it. When you start out perform only the number of contractions and sets that you feel you can execute with good form. For example, you shouldn’t be holding your breath while performing these exercises since this will increase intra-abdominal pressure, and also isn’t a good functional strategy for daily life.
In addition, there may be little or no added benefit from performing a more rigorous or frequent Kegel exercise routine, especially at first. Strenuous exercise regimens are also harder to stick with and could potentially even aggravate things. After 3-6 weeks you should be seeing a reduction in leakage. If your symptoms do not significantly improve, or at any point worsen, stop performing the exercise and see a pelvic floor physiotherapist for targeted guidance.
A wide variety of intravaginal devices exist to help strengthen pelvic floor muscles. The advantage of using a vaginally inserted device is that it can offer physical feedback to the user to help guide and encourage effective contraction. One disadvantage of these devices is that they may not encourage optimal pelvic floor muscle contraction in all women. The two basic options are weights, and squeeze devices.
Vaginal weights are inserted into the vagina like tampons. The user needs to recruit their pelvic floor muscles in order to hold the weight in, otherwise it will drop back out. These devices have been shown to be effective at improving pelvic floor muscle strength and reducing stress incontinence (ref 10). Commercial kits usually include a graduation of weights, and instructions on how to use them. Typically, the user would hold the weight in for 10 to 20 minutes at a time while performing daily activities.
When choosing vaginal weights, choose a kit that comes with a range of weights, that has an appropriate diameter (one inch should work), that is easy to clean, and that comes with good instructions for use. There are many options, so find one that works for you, but a good example that we’ve tried is the Intimate Rose Kegel Exercise System.
Vaginal contraction trainers
Vaginal contraction trainers are devices that are inserted and squeezed. These devices can measure the strength and duration of contraction and offer feedback, guidance and Kegel workout routines. A popular example of such a device is the Elvie Trainer, although I have no personal experience using it.
There is a smartphone app for everything, and pelvic floor training is no exception. It’s not clear how effective Kegel training apps are for treating stress incontinence, nor is it clear which apps are particularly good or bad, but patients are certainly interested in using them.
If you’re interested in an app, a good place to start might be to try ‘Squeezy’. The Squeezy app is apparently the most popular app of its kind in the UK, and was recommended by the UK National Health Sciences App Library.
Incontinence is not something that you have to live with, and learning how to stop stress incontinence sooner rather than later can help prevent a worsening of symptoms that in some cases could necessitate surgical intervention. The recommended and widely accepted first-line treatment for mild to moderate cases is pelvic floor muscle training supervised by a certified pelvic floor physiotherapist. Supervised pelvic floor muscle training can help you get you started on the right track, keep you motivated, and help you monitor and progress your treatment.
But if you feel more comfortable getting started on your own with Kegels, go for it! Many people have found success treating their urinary incontinence this way. Just remember that if you don’t see a significant improvement (or you experience a worsening of symptoms) don’t give up hope, get a little help from a pelvic floor specialist instead.
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