By Tara Bannow • The Bulletin

Exercising the pelvic floor

For many people, overcoming incontinence is a matter of exercising the pelvic floor, a crucial, hammocklike group of muscles that sits in the bottom of the pelvic bone and holds the uterus, bladder, small intestine and rectum in place.

Ever pull your car up to your house, suddenly get the urge to pee, start walking — quickly — to the door, fumble with your keys, but still leak a little bit before you make it to the bathroom?

No need to answer out loud.

“This isn’t something you should be embarrassed about,” said Aurora Fry, a physical therapist with Alpine Physical Therapy & Spine Care in Bend.

She spoke about urinary incontinence at a shop in downtown Bend last month. The small but brave group of women gathered before her on folding chairs giggled nervously.

It’s something few people talk openly about, even to their closest friends. Women are much more likely to struggle with incontinence, especially as they age, but even they tend to wait 6½ years before seeking professional help, according to the National Association for Continence. An estimated 25 million Americans struggle with the condition, more than half of them women.

“Right now it’s kind of the mindset of, ‘Oh, it’s normal. It’s part of being a woman. It’s part of aging. It’s part of having children,’” said Joyce Steele, a physical therapist with Healing Bridge Physical Therapy who specializes in pelvic floor dysfunction, “and it shouldn’t be. It’s very common, but it’s not normal.”

For a lot of people, it’s just a matter of exercising what’s called the pelvic floor, a crucial, hammocklike group of muscles that sits in the bottom of the pelvic bone and holds the uterus, bladder, small intestine and rectum in place.

A 2014 review by the ­Cochrane Institute of 21 clinical trials involving 1,281 women concluded that pelvic floor muscle training should be the first line of treatment for women with urinary incontinence.

It’s also about retraining their bladders so that they don’t contract — triggering an urgent need to urinate — before they’re full.

Retraining the bladder

The are two types of incontinence. Urge incontinence is the sudden urge to go, and often results in leakage before reaching the bathroom. Stress incontinence is when people leak while jogging, coughing or sneezing. It’s typically caused by a lack of support beneath the urethra. Most people with incontinence have a mixture of both.

For urge incontinence, Fry helps people retrain their bladders to give them more control. The first step: Stop. Don’t run to the bathroom at the first sign you have to go.

“That’s actually the worst thing that we can do when we have urgency,” she said.

That’s because rushing to the toilet strengthens the bladder contraction, making it increasingly difficult to control. Now, there’s anxiety. Time to relax, take deep breaths and distract the brain. Fry recommends rubbing your hands together, counting backward or engaging in conversation.

People should be able to hold off using the restroom for about an hour after they feel the first sensation to do so, Fry said. Experts say adults should urinate every two to three hours, or four to six times per day and zero to one time at night. Steele, by contrast, says no one under 70 should have to get up at night to pee.

In the mean time, do ­Kegels, Fry said. A Kegel is an exercise designed to strengthen the pelvic floor muscles. Repeatedly contracting those muscles will relax the bladder and help the urge pass.

Do all of that, Fry instructs, until you don’t have an active urge to use the bathroom. Now it’s time to go.

“If the urge comes back on the way to the bathroom, stop, do it again,” she said. “This is a process we repeat. If we go to the bathroom with an active urge, there’s a really high chance that we’re going to leak.”

To perform a Kegel, Fry and others instruct people to act as though they’re stopping the flow of urine while also stopping gas from passing. Squeeze the muscles upward and inward and hold for a few seconds, then relax. While doing this, it’s important not to hold your breath and not to rely on larger muscle groups like the abdominals or the gluteals.

Fry recommends patients start Kegels on their backs, then sitting and, finally, while standing. They’re most difficult to do standing because in that position the muscles are supporting internal organs.

Dr. Marta Johnson-Mitchell, a urologist with Urology Specialists of Oregon who specializes in urinary incontinence, said most of the women she sees in her practice aren’t doing Kegels correctly; many use their abdominals or bear down as opposed to trying to lift the muscles up and in.

Some women perform the exercises but don’t need to because they store muscle tension in their pelvis, Johnson-Mitchell said. On the contrary, they’ll need to lengthen their pelvic floor muscles.

Teaching with biofeedback

Johnson-Mitchell refers patients to physical therapists who show them how to Kegel correctly and perform other exercises to relieve incontinence.

One of them is Healing Bridge’s Steele, who uses a technique called biofeedback that instantly shows patients how they’re doing on a computer screen. To do this, she places sensors over patients’ pelvic floor muscles that are attached to their skin using stickers. She then directs them to Kegel, release, Kegel again and repeat. Patients Kegel in fast twitch movements for only a few seconds and for longer, 10-second endurance holds. The sensors measure the strength of the muscle contractions and transmit them to Steele’s computer, which displays the contractions as jumps and dips on a line graph.

Steele and others emphasized it’s crucial to completely relax your pelvic floor muscles between Kegels. If Steele was helping a patient improve her jump shot in basketball, for example, she might prescribe exercises to strengthen her calves.

“But if you walked out of the clinic and you’re still standing on your tippy toes, that’s going to create issues,” she said. “So if you Kegel and Kegel and Kegel and hold and hold and hold and never release, that’s going to create problems.”

Physical therapy for pelvic floor issues involves much more than just Kegels, Steele said. She teaches patients exercises to lengthen the muscles if they’re too tight. She helps patients incorporate Kegels into everyday activities and exercises.

She helps patients with lifestyle changes, such as cutting out beverages that irritate the bladder and cause it to expel liquid. Some of those irritants include coffee and other caffeinated drinks, alcohol, citrus, vinegar, spicy foods and carbonated beverages. In the summer, Steele’s clinic typically sees an influx of people whose symptoms worsen because they drink Arnold Palmers, a mix of iced tea and lemonade.

Beyond exercise

Steele also helps patients retrain their bladders using a two-day bladder diary in which they record their fluid intake and the frequency and duration of their urination. She then helps them lengthen the time periods between trips to the bathroom. Sometimes, she finds the problem is that a patient is simply drinking too much water.

If physical therapy doesn’t work, Johnson-Mitchell has a number of other procedures and medications she can try. One such procedure for people with stress incontinence involves inserting material underneath the urethra to give it more support. Urologists can inject Botox to the organ to temporarily weaken it and preventing it from contracting.

Johnson-Mitchell also implants pacemakerlike devices into patients’ tailbones that are designed to improve communication between the bladder and brain. Another procedure involves inserting a needle near the patient’s ankle that uses a stimulator to send impulses along the leg to the nerves that control the bladder.

Johnson-Mitchell couldn’t provide cost estimates for her urologic procedures but said most insurance carriers won’t cover Botox or the pacemakerlike device unless they’ve already tried and failed two other treatment options.

Lots of women will be able to fix incontinence, especially after giving birth, using Kegels, Johnson-Mitchell said. But some people will need to try surgical options or medication.

“If you lose enough support, sometimes there isn’t always a way to gain that all back,” she said.

—Reporter: 541-383-0304,

tbannow@bendbulletin.com

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