Whenever I talk to mothers (and fathers) about toilet training toddlers I always start with the suggestion that learning how to go to the toilet is a REALLY big task! Sure, we now do it on autopilot (most of us at least), but let’s look at all the steps involved in being able to successfully do a wee in the toilet:
- You have to be aware of the urge to urinate
- You have to recognise that urge in enough time to allow you to make it to the toilet
- You have to find your way to the nearest bathroom
- You have to be able to remove your clothing and underwear
- You have to be able to shift your body weight onto and off of the toilet
- You have to have the neural control required to release the urine from your bladder
- You have to have the ability to sense when your bladder is fully empty
- You have to have the manual handling skills to tear the toilet paper from the roll and wipe your perineum
- You have to be able to stand up from a seated position
- You have to be able to re-dress yourself
- You have to be able to remember to flush the toilet and wash your hands.
Phew! It’s no wonder toddlers take a while to get the hang of it! Ask my three-year old – she’ll tell you!
Learning to wee? There’s more to it than you think.
So what’s my point here? Well, toileting is a really complicated task. There are several body systems and processes at play in mastering the cognitive and physical elements within it, and it also requires us to integrate those systems and processes to work together. Which is why it takes us so long to learn how to do it as toddlers – and why we tend to have so many accidents.
Frequently, I come across parents who are frustrated at how long it’s taking their child to toilet train. I find encouraging them to remember the enormity of this task – all 11 points listed above – helps shift their mindset around their child’s toilet training.
Which brings me to the topic of postnatal incontinence and pelvic floor dysfunction.
This is a common issue impacting on many postnatal women. Most recently given the less confronting title of “leakage”, postnatal incontinence has the potential to dramatically impact on a woman’s life. It can lead to issues with embarrassment, low confidence and self esteem, it can lead to women ceasing or reducing their favourite social, recreational and sporting activities, it change how they see themselves as a woman. At the extreme end, it can lead to serious mental health conditions such as depression or social anxiety. It’s difficult to feel free, spontaneous, athletic or sexy when you’re worried your pelvic floor is going to let you down. There’s such a stigma about incontinence in our society that it’s rarely spoken about out loud, and when it is, it’s almost always spoken on in diminished terms “leakage”, “light bladder leakage”, “LBL”.
Just like toilet training a toddler, dealing with adult incontinence also requires us to step back and look at a range of body systems and processes. Unfortunately the common understanding by the general public is that this issue is just related to weak pelvic floor muscles, which is not entirely true. Certainly the functional capacity of the pelvic floor musculature has a huge role in regaining and maintaining continence. But what else is there to consider?
Our overall posture: How we stand or sit throughout the day impacts on the length and function of our body’s postural muscles – many of which have connections with the pelvis and the pelvic floor muscles. Imbalanced postural muscles can impact the way our pelvic floor muscles function.
How we breathe: did you know the diaphragm (the muscle under your lungs) is designed to work in unison with the pelvic floor? To maintain good ‘intra-abdominal pressure’ they should work together – when the diaphragm contracts downwards the pelvic floor should relax downwards. When the diaphragm relaxes up, the pelvic floor should lift up. By the time we reach adulthood so many of us have developed poor breathing patterns, and we’ve lost our ability to breathe properly, or connect our breath with our pelvic floor.
What we eat and drink: A common tactic used by many women to address incontinence is to simply reduce their fluid intake. This is a huge no-no as it means the bladder becomes used to only holding small amounts of urine. Over time, it can lose it’s capacity to stretch to it’s previous size. To maintain good continence, we want the bladder musculature as functional as possible. Also, were you aware that caffeine is a stimulant for the bladder? Sometimes eliminating coffee from our diet can be a big piece of the puzzle.
Our habits: Going to the loo ‘just in case’, or because your friends are; ‘holding on’ because you want to avoid public toilets while away from the house; how about running the tap while you pee to avoid the embarrassment of someone hearing your stream on urine? We women have terrible habits when it comes to toileting – but honestly, it’s probably not our fault, it’s something we have drilled into us from an early age as young girls. The problem is, when our toilet habits become habitual or situational, it means we lose that important mind-body connection between our brain and our bladder. When we lose that connection, we lose the trust in our own bodies, and that has a huge impact on continence.
Poor toileting habits early in life can lead to continence issues down the track.
Our mental health: It’s a two way street – continence issues can increase the likelihood of mental health problems, such as depression and anxiety, but these conditions can also impact the prevalence of continence issues. When we experience depression, anxiety or social phobia, our habits and lifestyles change – which means that every one of those four areas listed above can be impacted. It changes our posture, our breathing, our nutrition and our habits. All of which can lead to pelvic floor difficulties.
Did someone say vicious cycle?
So you can see that treating pelvic floor issues is about so much more than just strengthening those pelvic floor muscles. The list above is by no means exhaustive either. But it’s enough evidence to be able to say that addressing incontinence and pelvic floor dysfunction requires a truly holistic view of the individual involved.
The good news is there’s so many wonderful health practitioners out there who can support you if you need help with this area. incontinence is not something you have to live with. It can be treated, but for best treatment, you need someone who is going to look at the whole you – not just your pelvic floor. Search around for a Women’s Health OT (like me), or a Women’s Health physiotherapist, those of us who specialise in this area know that taking an integrated approach is the best, and only, answer.
Until next time, be well.
Cheers, Sarah xx
ps. If you want to know more about how to restore your pelvic floor function after having a baby, make sure you check out my Body Mind Baby postnatal wellbeing program. This 10 week online program covers a wide range of physical and emotional challenges faced by new mothers – with information and simple, practical strategies you can implement in your everyday life to positively impact your wellbeing – you can check it out here.
So – let’s talk incontinence!!!
I came across this article yesterday on the Women’s Running Magazine facebook page and it got me fired up.
So, so, so fired up.
In case you missed it, it’s a story from a running blogger named Steph, about her little quirks that make her #uncool. Here’s what Steph wrote:
A campaign was launched last week with the title and theme of #WeAreAllUncool. The idea is to celebrate that we all have quirks, habits and differences that make us unique. Sometimes these traits lead us to feel vulnerable and embarrassed about our shortcomings. We should not have to apologize or feel ashamed.
Steph goes on to talk about the fact that she wears a sanitary pad every time she runs or works out, because she has a postnatal continence problem.
I wear granny underwear under my running shorts—even spandex—because I pee my pants on every run and workout since having my son 9 months ago. I have to wear a maxi pad to help avoid soaked pants post-run. It leads to a super-hot look when I’m rocking light-colored spandex.
Now I don’t know Steph at all. I don’t know her story of her pregnancy and labour and I don’t know what she’s been doing in terms of pelvic floor rehab. She’s clearly very fit and healthy and is an elite level runner, so I’m presuming she has great coaches and (hopefully) a top-notch physio on hand. But the reality is, she has a serious continence issue.
Now I’m not setting out to shame Steph – not at all. In fact, I think it’s remarkably brave of her to put this out there in the public arena, and opening up this conversation is always good. So many women would simply keep this to themselves and pray that no-one else finds out. So kudos to you Steph, for your bravery!
But here’s my issue, and this is what I got fired up about.
There is no context around this article. And there is no call to action for other women who may be experiencing the same problem.
I applaud Steph for bringing this issue to light. Truly I do, because it’s a serious and extremely common concern for many women, particularly those who have had children.
But I wish that Steph – or Women’s Running Magazine – would have gone a step further and talked about what she’s doing – or could do – to address this issue.
Is she doing pelvic floor rehab? She’s still only 9 months postnatal, so really she’s still in recovery phase.
Did she consider taking time off from running to get this issue resolved before she started running again?
Does she have a great women’s health physiotherapist she’s working with to get this under control?
Or did she have a severe tear which has led to significant perineal damage and the resultant incontinence?
I don’t know, but I wish there was a little more context around her frank admission, in order to give all of her readership a little more food for thought.
Instead, what we got was several other women telling their stories of incontinence, and Women’s Running facebook page replying with “Don’t worry ladies, it is so common. It feels better knowing it happens to everyone!”
I think the basis of the #WeAreAllUncool campaign is great (though I think it should be renamed #WeAreAllCool) – it’s about embracing our uniqueness, diversity and all the little foibles that make us human. That is totally cool. It’s cool to be different. In fact, it’s completely freakin’ awesome and it’s what makes this big, wide, crazy world a great place to live.
The campaign encourages us to not be ashamed or embarrassed about who we are and how we are different.
Certainly, any type of urinary incontinence has the ability to make a woman feel embarrassed, vulnerable and ashamed. Which is why I talk about it a lot. Which is why we focus on this exact topic in my postnatal wellbeing and recovery program, Body Mind Baby. Because I don’t want women to feel embarrassed or ashamed if they experience urinary incontinence. I want them to be able to address it and overcome it.
But I don’t want them to celebrate it. And that’s what this campaign is about – celebrating our uniqueness.
I know it may seem like I’m nit-picking here – but I think an issue as important as this shouldn’t be included in a campaign about celebrating our bodies – at least not without context. Because it’s actually not something that should be celebrated. It’s something that should be addressed and treated – because for the majority of women it CAN be treated.
I want women to feel comfortable to be able to talk about the fact their experiencing postnatal incontinence. But I also want them to be empowered enough to say, “I’m not going to accept that – I know there are options available and I’m going to do whatever it takes to fix this issue”.
What I’d like women to know is that “no leakage is normal”. So yes, even if you just leak a “little bit”, even it it’s only when you sneeze, jump on a trampoline or do a star-jump – that is not normal. BUT, in the vast majority of cases it CAN be resolved. So that woman can undertake all those activities again without any leakage. It is possible for the absolute majority of people.
But, recovering from postnatal incontinence takes commitment, time and effort. It also requires a great deal of respect for the body and its healing process, and an avoidance of high impact activities – such as running – until continence issues are resolved. Because if you continue to place lots of pressure on a dysfunctional pelvic floor – it is NEVER going to heal.
But so what? I hear women say. It’s just a “wee bit of wee” and it’s only when I run, and I just wear a pad, so it’s really not a problem. Right? This is what I hear from women an awful lot.
So I always encourage them to think long term. If your pelvic floor is dysfunctional in your 30’s, how’s it going to be in your 50’s? Your 60’s? Your 70’s?
Have you ever worked in an aged care facility? Have you ever seen a grown adult who simply can’t control their bladder or bowels? Did you know that incontinence is a significant factor in many aged care admissions? I’ve spent time working in aged care facilities and I know too well the pained, shamed expression of a woman (or man) who has just wet their pants. It’s tragic and I’m damned sure I’m not going to let that happen to me (at least not without a serious fight).
When I talk to so many women who say their pelvic floor is “mostly okay” as long as they don’t jump, run or do a handstand, I tell them they should be able to do these things without leaking. Most of the time they just brush it off and say it doesn’t really matter. Well I say it does. I want to be able to jump on a trampoline with my kids – and play “Pop, Bang, Go”* with them like I did when I was a kid.
But the most tragic thing, is that when I ask these women if they regularly do their pelvic floor exercises, or actively work on pelvic floor rehab (because it’s not JUST about kegels), the majority of the time they say NO.
So we have a whole bunch of women, who have just a “little problem” but aren’t doing anything about it???
That’s just not on – not in my book.
One of my favourite phrases – and I say it ALL THE TIME, in every single presentation I give, is this:
Just because something is common, it doesn’t mean it’s normal.
In case you’ve never heard me talk about this before, I wrote about it here.
So getting back to this article, (which also reminds me of this article, which I got steamed up about on my facebook page). I truly hope Steph can get her pelvic floor rehabbed. I really do. I’d love for her to be able to run leak-free. And I’d love for her to be able to have more children and to not have this issue again.
I also want for this topic to be opened up to a bigger discussion, on a more regular basis, especially amongst the postnatal community.
But what I really want, is for this issue to stop being “normalised”. What I’d love is for women to be able to feel comfortable talking about this, while at the same time taking control, respecting their bodies’ limitations and doing absolutely everything possible to address the issue. And not just accepting “leakage” as the status quo.
That’s what I want.
Until next time, Be Well.
* for those of you who don’t know, “Pop Bang Go” is a totally awesome handstand game to see who can hold their handstand the longest. I never won as a child. I still don’t win. But it’s all about how you play the game.
ps. If you’re here in Adelaide, and want some support to rehab your pelvic floor and core I’ve got a few options for you.
If you want to work one to one with me, check out my OT Core Restore program here.
Or, if you’re a new mum with a baby under 12 months old, you can join my Body Mind Baby postnatal wellbeing and recovery program. Our next program starts on February 4, 2016, and don’t forget we have a $50 early bird discounts available until January 15.
Did you know that up to 65 percent of post-natal women will experience lower back pain in the 18 months after giving birth?
Or that 45 percent of all post-natal women will experience incontinence within seven years of pregnancy?
What about the fact that 10 percent of women who experience pelvic girdle pain during pregnancy will continue to have persistent pain for two years or more following delivery?
What do these stats tell us? That post-natal injury is normal, right?
No – it just tells us that it’s common. But common does not necessarily mean normal.
What I’m talking about here is not just an issue of semantics. It’s more an issue of acceptance, attitudes and belief.
The post-natal period is an extremely vulnerable one for many women – both emotionally and physically. During this time our bodies are recovering from the enormous strain which has been placed on them over the past 40 weeks or so. I’m not just referring to the struggle to get our flat tummy back (mine was never flat to start with!). What I’m talking about is restoring our posture and alignment after several months of having a changed centre of gravity. Allowing our joints, muscles, tendons and ligaments to return to their pre-natal state after being stretched, pulled and pressurised in so many different ways to accommodate our growing baby and our changing body structure. Allowing our hormonal balance to be restored.
This all takes time (did you know it can take up to 500 days for some tissues to fully heal?), and often the body can’t do it on its own. This is when we have the potential to develop what appears to be a chronic injury.
Because it happens so often, society just accepts it as “normal”.
“Oh you’ve got back pain – yeah, that’s just normal after having a baby.”
I say don’t use the word “normal”.
My mission through my private practice and this blog is to encourage women to challenge this notion that postnatal injuries are “normal”. By giving them this label, we are subconsciously telling women that they should just expect these injuries to occur – “It happens to everyone, just get used to it and get on with life.”
Back pain is common – but that doesn’t mean you have to accept it as normal!
Last year during my post-graduate studies I completed a literature review on the incidence of soft tissue injuries among post-natal women. One of the more concerning themes that emerged in my research was the often dismissive nature regarding these injuries – both from the women themselves and also from their treating health professionals. Issues such as back pain, pelvic pain and diastasis recti (abdominal separation) were often considered to be “normal” post-pregnancy states which would eventually improve spontaneously given time – therefore they sometimes weren’t given proper consideration or treatment early in the pre-natal period. This belief is a concern to me. It tells me that health professionals need to be proactive in the physical rehabilitation of post-natal women. Not only to provide early-intervention treatment or referral to other practitioners, but also to educate women on the difference between “common” and “normal” post-natal injury and recovery.
For the vast majority of situations, these injuries can be addressed, overcome and even prevented – with the right support, treatment and advice.
So please, if you are struggling with one of these conditions and have been told – “don’t worry, it’s just normal, it’ll go away eventually”. Don’t accept that. Demand a treatment option. Seek a different practitioner. Find a qualified Women’s Health Occupational Therapist, Women’s Health Physiotherapist, or Women’s Health trained Pilates Instructor.
If you want to work with me here in Adelaide, you can undertake my one to one OT Core Restore program,
Or if you’re from anywhere else around the globe, you can join my five week online Core Floor Restore postnatal wellbeing program.
Addressing injuries early and appropriately will speed up your healing and recovery time. And that will mean you can get back to “normal” much sooner.
Until next time,
ps. Just in case you want the references:
Gustafsson, J. & Nilsson-Wikmar, L. (2007). Influence of specific muscle training on pain, activity limitation and kinesiophobia in women with back pain post-partum – A ‘Single subject research design’. Physiotherapy Research International, 13(1), 18-30. doi: 10.1002/pri.379
Lee, D.G., Lee, L.J. & McLaughlin, L. (2008). Stability, continence and breathing: the role of fascia following pregnancy and delivery. Journal of Bodywork & Movement Therapies, 12(4), 333-348.
Vermani, E., Mittal, R. & Weeks, A. (2009). Pelvic Girdle Pain and Low Back Pain in Pregnancy: A Review. Pain Practice, 10(1), 60-71.