I tire really fast of patronising health messages. And the only thing worse than mainstream health advice with a patronising tone, is health advice that is not giving the entire story or is even entirely correct.
Stress urinary incontinence (or pee leaking when you jump or laugh) in women in their childbearing years is vaguely reported – like many stats on women’s health problems. Some studies say 4%-35%. Some say 25%-40%. Some say 45% of women have it to some degree after childbirth.
I would bet my firstborn (LOL, no I wouldn’t) that at the VERY LEAST, 50% of women who have had a baby, probably have SUI. I think that 1 in 2 seems like a safe guess – just speaking from my own field research. I have given birth. I sneeze. I work in a female-predominant workplace. I have groups of all-female friends.
Why are studies not estimating more prevalence? Probably because women have heard by now that ‘it just happens’ and there is already a gold standard at-home treatment, so they refrain from even bringing it up with their doctor or ob-gyn. Because they already know the answer. Kegels have been pounded into us as the panacea for stress incontinence since we started prenatal classes – and earlier. We all know what the solution is. Our doctors, nurses, doulas, and gynos have all made it loud and clear. So naturally, the persistent lack of control we feel is because we’re just lazy and forgetful and not doing enough Kegels.
Not a single internet info page or article will come out and say it like that. But seriously, if you don’t do your Kegels, you are one lazy mother.
I don’t like this implied message. And I am suspicious of any school of thought that believes that any condition is due to a patient’s laziness to control a problem, regardless of how it got there in the first place.
I’m not just interested in urinary stress incontinence and pelvic floor exercises because I have had a baby, either. When I was a nursing student my heart got pretty sad after seeing firsthand the disease burden of chronic incontinence in elderly people. Older women tend to be more affected, and sooner, than men. So I wrote a paper about it for one of my Public Health classes. Here it is in my portfolio.
So why do women ‘slack off’ on Kegels?
My hunch is that we know -deep down – that it’s probably not going to work – unless an extreme amount of time and dedication is spent Kegelling and it is kept up at that pace for the rest of your life. Basically super-pumping your pelvic floor. Sounds great, but is it achievable or realistic? Is this any different from other messages like ‘if you just ate this…’, ‘if you just worked out more…’?
The written wisdom on this subject is usually introduced to the reader with the same example. First, two unrealistic mommies on the park bench get talking – with about the same amount of stiffness and lack of candor as two moms in a bad example of female relationships can be (like those insurance ads where one mom realizes she picked the wrong company for her family’s health and dental, and the other one rubs that shit in). The one woman has tried everything – limiting water intake to the point of being thirsty, peeing before every activity (and several times during), not missing a bathroom opportunity, buying the dreaded “period pads”, avoiding trampolines, and leaning on one hip when she has to sneeze. Nothing helps, so the woman confides to her friend. Her friend giggles (and pees) and says, “It’s just what happens after having babies.” and they carry on with their day and put their pee problems out of their minds. Enter the Kegel expert (often a dude) to save these women from their deplorable lack of knowledge.
This is what I think of as the subtle ‘silly woman’ health message. Where a health expert writing for a health website or creating a patient handout is assuming patients with SUI are total ninnies or ‘silly women’ who skip off into the setting sun together with grocery bags of pads swinging from their arms. As if stress urinary incontinence wasn’t a huge embarrassing deal when going for a run or doing a Crossfit WOD. As if it doesn’t happen to intelligent people who know that limiting water intake is not a good idea, and they should probably do some more Kegels like the most current recommendations say. It is an embarrassing, private, ongoing struggle. It is difficult to ignore. It is uncomfortable. And women everywhere Doctor Google that problem like crazy, looking for something that could make it better. But the same thing comes up over and over – SUI is due to weak muscles and you need to Kegel that shit.
Well too bad for those assholes, I can read.
About 6 months ago an article, meant for doctors and other healthcare providers, was published called Urinary Incontinence Relevant Anatomy. And in case you were wondering about the credentials of the authors of this article, I will block quote them here for your skimming pleasure. Because science.
Well-stocked résumés aside, I will now tell you what I got out of reading this publication. Sorry in advance for the dry medical terminology in the direct quotes. All anatomical depictions belong to the aforementioned authors of this study, and are not mine.
Below is a side view of the female pelvic anatomy. See the pelvic diaphragm? It makes what is called the pelvic floor or basement.
That is the muscle you contract when being good and doing your Kegels.
Wrapped around the lower end of the urethra (not visible here), are the muscles of the voluntary external urethral sphincter (or pee-squeezer-offer).
Here is a close-up. Note there are two sphincters. One is external – voluntarily controlled during Kegels. The higher one, the internal sphincter, is “…more of a functional concept than a distinct anatomic entity”. It gets its shape from the tissue surrounding it and cannot be voluntarily controlled.
Regarding the muscles of the external urethral sphincter:
Because they are composed primarily of slow-twitch muscle fibers, these muscles serve ideally to maintain resting urethral closure. The muscles probably do maintain resting urethral closure, but they are known specifically to contribute to voluntary closure and reflex closure of the urethra during acute instances (eg, coughing, sneezing, laughing) of increased intra-abdominal pressure. The medial pubovisceral portion of the levator ani complex also is a major contributor to active bladder neck and urethral closure in similar situations.
Got it. The little sphincter around the outer portion of your urethra AND the pelvic floor muscles are in charge of squeezing shut when we laugh or cough or sneeze or run. The rest of their day is spent just hanging out and providing tone.
But if they are supposed to stop urine from leaving your bladder in the first place (because urine can’t just float in limbo once it’s in the urethra while you red-face squeeze your Kegel muscles like a fiend), why are these voluntary, consciously controllable pee-stoppers located at the end of the urethra like an emergency hatch?
Like, if I wanted to haul some dirt with a shovel, why would I place my hands at the furthest end of the handle?
Like, if I didn’t want to be catching my son while he jumps off the Ottoman fifty times, shouldn’t I move the Ottoman into our spare room instead of just standing there catching him only after he jumps fifty times?
Like, if the Titanic didn’t want to leak all over the place and sink into the Atlantic, shouldn’t it have just slowed its maiden voyage instead of hastily running into the iceberg?
You get it.
So either someone put those muscles in the wrong place. OR they are in the right place, and doing the best they can given the circumstances, considering that some kids did pass through them.
And why are we putting all the blame on this outer muscle group when something further upstream is clearly not working, either?
Your pelvic floor muscles and voluntary urethral sphincter are not the main bouncers at this club. Your pelvic floor muscles take up the basement of your pelvis but there are a lot of very crucial tenants living above it – smooth muscle (not under conscious control – like in your intestines), fascia, ligaments, and connective tissue.
The pelvic floor is the on-call back up security guard when you actually hit the softball and now have to run to first base, or you didn’t expect to find a certain joke so funny. The problem is is that mainstream health experts expect you to make those muscles like John Dalton from Roadhouse (besides, John Dalton never had to push out a baby).
So lets talk about connective tissue. Because around your urethra, vagina, and rectum there is a LOT of it, and it usually gets left out of the whole Kegel conversation.
Histologic examination of the striated urethral sphincter indicates the muscle complex largely surrounds the urethra in an incomplete fashion. Fibers have been observed to be deficient along the posterior aspect of the urethra. Thus, the shape of the muscle complex can be described as resembling a horseshoe or an omega symbol. Investigations using ultrasonographic imaging of the urethra also have confirmed a paucity of muscle bulk along the posterior urethra.
Translation: When looking just at the muscles that make up your external urethral sphincter, the front of your urethra (you know, like, the front of your body) has all the muscle bulk. The backside of your urethra has scarce to no muscle bulk. So the urethral sphincter muscles only partly surround the urethra. Like the verandah on the front of a house. Like a house that only has a front deck, but no back deck.
Sometimes, after childbirth, your urethra gets drunk and falls off the back step. This is what is called a urethrocele – when part of your urethra herniates through this weakened and damaged connective tissue into the vagina. When your urethra pulls your bladder out the door as well, it is called a cystocele. Those conditions are often corrected with surgery (but if you do not have a diagnosable herniation, any other urinary symptoms mean you should keep squeezing your Kegels, right? LOL).
The posterior wall of the urethra is embedded in and supported by the endopelvic connective tissue. This sheet of connective tissue consists of collagen, elastin, and a small amount of smooth muscle. The connective tissue envelopes the anterior vagina. This supportive tissue has been likened to a sling or a hammock around the urethra and bladder neck. Recent research has highlighted the importance of hormones and genetic factors as determinants of connective-tissue integrity in stress urinary incontinence and pelvic organ prolapse.
Note: smooth muscle is not under voluntary control. Not like striated muscle, which you use in your legs and arms to do things.
Firstly, I have heard that dainty little description of a sling or hammock, before. Kegel pushers (squeezers?) like to throw that one around a lot in describing the pelvic floor muscles. It’s a correct description – the pelvic floor also looks like a hammock, forming the undercarriage of all the pelvic organs.
But CLEARLY WE’RE FORGETTING that other nice hammock that supports our urethra a little higher up the channel. All that nice connective tissue cocooning the banks of the pee stream.
So why didn’t God spare a few more human cells and make that damn muscular sphincter go all the way around? Why all this elastic connective tissue instead?
And at the back of the urethra is also the front of the vagina. And that puppy has got to stttttrrreeeeetttttccchhhhh during childbirth. And muscles do not stretch as well as elastic connective tissue.
Which brings us to the final clincher: opposing all this connective tissue is a hard-fastened and fixed ligament: the pubourethral ligament.
See it? Right there. So while a hammock of connective tissue sits behind your urethra, and ends up quite battered and loose after childbirth, this lovely little PU ligament acts like a bellboy, holding the front wall of your urethra open when straining your abdomen. Like when a bunch of angry Black Friday shoppers break down half of a double door, and the other one still automatically opens.
The previously described endopelvic connective tissue, when intact, provides support to the urethra as a whole. With increases in intra-abdominal pressure, some believe that the urethra is compressed shut against this firm support. Stress incontinence may be associated with a deficiency in the hammocklike support of the endopelvic connective tissue coupled with relative preservation of pubourethral ligament anterior urethral support. This may partially explain the commonly observed complex rotational descending motion of the bladder neck associated with stress incontinence.
As the pubourethral ligaments limit downward motion of the anterior urethral wall, they may provide a pivot point for rotational motion around the pubic bone. Furthermore, some theorize anterior wall support may also serve to pull the anterior and posterior urethral walls apart during straining, thereby directly contributing to bladder neck incompetency and stress incontinence.
So there you have it. Stress incontinence can be functionally observed by medical imaging – as a downward slippage of the bladder neck (or base). Abdominal pressure increases + lack of support from behind the urine channel (thanks, childbirth) + and your urethra is held open by a ligament in the front. Pee escapes.
So despite factors during the birth that have very likely damaged the connective tissue around the urethra (by lots of stretching or trauma to the vagina sharing it’s posterior wall) through forceps or vacuum intervention, traumatic delivery, straining, having a large baby….
Nope, says mainstream health advice. Wasn’t the pregnancy. Wasn’t a permanent side effect of vaginal delivery. Wasn’t the forceps intervention. Wasn’t pushing the mother to push when she wasn’t ready to push. Wasn’t the actions of the healthcare team.
Let’s review some other bad advice for women after having babies that finally got archived. Not a surprise, both of these examples involve placing fault on women for having weak muscles, when connective tissue had actually been permanently altered during pregnancy and birth.
Healthcare has a sexist history. It is known for minimising the impact of natural forces beyond the patient’s control, minimising actions of medical practitioners, while magnifying the patient’s fault in acquiring their present situation.
It is easier to put 100% burden of responsibility on the woman because there is one thing she can control – Kegels – regardless of how effective they are. Patients are kept so busy trying to fix the problem at home that they are distracted from the larger problem: that her gravid belly was enormous and put strain on her bladder during pregnancy, that labour was long and difficult, mostly in a hospital, and the doctor had to pull the baby out with a vacuum. Elastic connective tissue was irreversibly stretched and altered, if not battered and torn, in the process.
Connective tissue plays a crucial role in the pelvic anatomy, and it cannot be ‘bulked’ back up like a muscle. But since when do doctors like delivering bad news. Kegels not working? Get out of my office already, lady.
Oh yeah, and your husband probably isn’t complaining about you maybe doing a few Kegels here and there. Wink wink. Motherly and wifely duties!
So bottom line, don’t do Kegels?
No. Do some Kegels. They will help. And they are good for everybody. Do them after each time you use the bathroom, for example, as apart of everyday healthy habits.
But for god’s sake don’t beat yourself up if they don’t make the pee stop coming after you’ve given birth. All things considered, they probably won’t do that.
This definition is one of the few I have read, from a reputable healthcare source (a healthcare region in Pennsylvania), that acknowledges BOTH the role that pelvic floor muscles and connective tissue damage play in SUI.
And also – try some squats!! And get to know Katy Bowman – who wants you to do them in the shower… while you pee.