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Do Your Clients (Or You) Pee During Workouts?
By: Anthony Lo B.App.Sc.(Physio); Nataliya Zlotnikov, HBSc, MSc

I Pee During Workouts 

This blog post is aimed not only at clinicians but also at trainers and athletes (especially CrossFitters). 


The blog, originally written by Antony Lo and focusing on the female pelvic floor, is inspired by the video below that CrossFit HQ put out, presumably with good intentions, due to an “event” during the deadlift-box jump event at the Central East Regionals.

Pelvic floor dysfunction is real and I would never make anyone feel bad if it happens, but it is not okay or normal to pee during workouts – it is a sign of pelvic floor dysfunction.

 

Today's Blog Discusses: 

Today's blog contains a lot of interesting content, however, as it is aimed at clinicians, athletes and patients, not all categories may be of interest to you. We invite you to scroll to any section that you fancy:

  1. Visualizing the Pelvic Floor
  2. Roles of the Pelvic Floor
  3. What Is a Normal Pelvic Floor
  4. What Is Pelvic Floor Dysfunction (PFD)
  5. The Weak (Hypotonic) Pelvic Floor
  6. The Overactive (Hypertonic) Pelvic Floor
  7. Ineffective Strategies for Combating Urinary Incontinence During Exercise 
  8. 6 Things You Can Do to Minimize Risk of Leaking
  9. Additional Resources

I. Visualizing The Pelvic Floor

Before discussing pelvic floor dysfunction (PFD), let's first take a quick look at the pelvic floor itself.

We talk about the pelvic floor so often, but visualizing it can frame our discussion and make further conversation easier to understand. 

The following short, 3D video of the female pelvic floor can serve as an excellent reminder for clinicians and a useful education tool for our clients. 


II. Roles of The Pelvic Floor

What are the roles of the pelvic floor? After watching the video above we have a pretty good idea of what the roles of the pelvic floor are based on its location. Here are these roles: 

  • Provide support for your pelvic organs
  • Help control intraabdominal pressure
  • Control urine and bowel movements
  • Help provide pleasure during sexual intercourse

 

III. What Is a Normal Pelvic Floor?

A normal pelvic floor is simply one that can do all its functions – maintain continence, support the pelvic contents and contribute towards optimal movement during functional tasks.

For the average person, that means you only need to go to the toilet about 6 times during the day and you should be able to get through the night without a toilet trip – of course, this varies based on the amount of fluid you consume, the food you eat and the amount of exercise you have done.

You should be able to squeeze your vagina without “bearing down” – you can test this on your own by using clean hands and inserting 1-2 fingers (yours or your partner’s) into your vagina. When you squeeze, you should be able to generate pressure on the tampon or fingers without squeezing them out of your vagina.

You will be able to cough, laugh, sneeze and jump without fear of leaking. You will be able to feel the urge to go to the toilet but not be overly concerned about dropping everything to go to the toilet immediately.

You won’t feel heaviness in your vagina or feel anything protruding where it should not be.

During heavy lifting, you will feel comfortable and will be able to withstand the pressures on your pelvic floor.


IV. What Is Pelvic Floor Dysfunction (PFD)?

So what is pelvic floor dysfunction? It is simply where your pelvic floor is not doing its job properly.

Most PFDs are a result of the pelvic floor being too weak (hypotonic) or too tight (hypertonic).

Damaged Pelvic Floor Disclaimer: Your pelvic floor might have been through a lot. Childbirth, cancer and radiotherapy, and other conditions can contribute to tearing, scarring and damage to the pelvic floor muscles. The nerves to the area can be damaged, the muscles themselves can become detached from the pubic bone, scarring from surgery and childbirth can cause asymmetrical contractions.

If this is the case, then you really need an internal examination to determine the extent of the damage and to see what your options are. The damaged pelvic floor is beyond the scope of this blog. Please see a pelvic floor physical therapist for assessment and an appropriate treatment plan which may include a surgical consult with a specialist.

 

10 Signs and Symptoms of Pelvic Floor Dysfunction

Below are some signs and symptoms of PFD. You do not have to present with all of these signs to have PFD:  

  1. Leakage: Accidentally leaking urine or stool when you exercise, laugh, cough or sneeze
  2. Urgency: Needing to get to the toilet in a hurry or not making it there in time
  3. Frequency: Constant or frequent need to go to the toilet
  4. Difficult to start or empty: Have difficulty starting to urinate or emptying the bladder completely
  5. Loss of control: Accidentally losing control of your bladder or bowel 
  6. Constipation
  7. Flatulence: Have difficulty controlling gas
  8. Pain: Feel pain in your pelvic area or pain while urinating 
  9. Prolapse: In women, this may be felt as a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging, or dropping, (in men, this may be felt as a bulge in the rectum or a feeling of needing to use their bowels but not actually needing to go)
  10. Painful intercourse

V. The Weak (Hypotonic) Pelvic Floor

Pelvic floor muscles can become weak due to the following 8 factors: 

8 Factors That Can Weaken Pelvic Floor Muscles  

  1. Pregnancy and childbirth
  2. Not keeping pelvic floor muscles active 
  3. High impact exercise 
  4. Persistent heavy lifting
  5. Long-term, persistent coughing (such as smoker's cough, bronchitis or asthma)
  6. Constipation  
  7. Being overweight 
  8. Ageing

(Continence Foundation of Australia, 2021)

If you have a weak pelvic floor, then exercises can help in almost all cases!

Normal pelvic floor versus weakened pelvic floor
Image source: Madhav University 

Unfortunately, my experience has been that people are given pelvic floor contractions without being progressed into advanced exercises that many high-level athletes such as CrossFitters are used to.

But that doesn’t mean that you can’t, you just have to work with the right therapists to get you back to what you love doing the most! 

Anthony Lo specializes in working with CrossFitters, if you would like to learn more about training CrossFit athletes, or are a CrossFit athlete yourself and would like to get back to what you love most, hard WODs (workouts of the day, in CrossFit-speak), follow the yellow button below!


Click Here to Learn More with Anthony Lo



VI. The Overactive (Hypertonic) Pelvic Floor

There is no defining cause of a hypertonic pelvic floor, however, there are numerous activities that can lead to the pelvic floor becoming tight. 

 

5 Activities That Can Result in Tight Pelvic Floor Muscles  

  1. Holding onto core muscles excessively without allowing them to relax and let go
  2. Holding onto bladder and/or bowels for prolonged periods of time 
  3. High levels of stress, fear or anxiety
  4. Chronic pain and inflammation caused by abdominal health conditions such as endometriosis, irritable bowel syndrome, interstitial cystitis, pudendal neuralgia and vulvodynia.
  5. Birth trauma and scar tissue, with a higher risk for women who experience perineal or vaginal tearing

Although typically, a tight pelvic floor results in pain, there are also a wide variety of clinical presentations including:

Signs and Symptoms of a Tight Pelvic Floor

  • Constipation
  • Incomplete emptying of the bowels
  • Straining when emptying the bowels
  • Pelvic pain
  • Low back pain
  • Hip pain
  • Coccyx pain
  • Painful sex
  • Vaginismus
  • Urinary incontinence
  • Incomplete emptying of the bladder
  • Slow flow of urine
  • Hesitancy or delayed start of urine stream
  • Urinary urgency
  • Urinary frequency, and
  • Painful urination

(Continence Foundation of Australia, 2021)


If You Have an Overactive Pelvic Floor, Then Why Would You Leak?

It seems counter-intuitive doesn’t it? The muscles are working hard, why wouldn’t they prevent leaking?

Well, just because a pelvic floor is overactive doesn’t mean it is strong!

In this category, an overactive pelvic floor can either be genuinely strong (or at least strong enough) or genuinely weak.

If you have a “strong” pelvic floor AND you exercise a lot AND you still leak, then chances are that you also have a very strong glottis and can make your thorax and abdomen very strong and rigid.

I know this because you leak under load.

Wait, glottis? The opening between the vocal folds in the larynx that is generally thought of as the primary valve between the lungs and the mouth? Yes, that same one.

Anatomy of the Larynx

Image source: NCBI

Basically, if you can build up a lot of intraabdominal pressure, that pressure has to be contained. Some people “lose” it and you hear them grunt or scream when lifting heavy weights – that is their glottis letting go – either to breathe or it wasn’t strong enough.

Some people get an abdominal or inguinal hernia – they actually tear in their abdomen from the pressure. Still, others might get a “slipped” or “herniated” or “bulging” disc. That is because the pressure has gone through the weakest part of their system – the low back. But in you, because you leak, I know that the pressure has overcome your pelvic floor.

 

Click Here to Learn More with Anthony Lo



VII. Ineffective Strategies for Combating Urinary Incontinence During Exercise 

In everyday life, you probably don’t leak. You can laugh without issue, you can sneeze without worry but, when you work out and get tired or if you are lifting heavy weights, then trouble can strike.

You probably know how much you can lift without a problem and how much is enough to tip you over the edge.

You do everything you think you can to minimize the risk of leaking.


Here are a few bad ideas that people often try to avoid leaking during exercise: 

  • Going to the toilet just before starting your workout (preventative peeing)
  • Not drinking water for 1-2 hours before your workout
  • Not drinking water during a long workout

These are all BAD strategies to combat stress urinary incontinence.
Dehydration's effect on the bladder

 

VIII. 6 Things You Can Do to Minimize Risk of Leaking

Now that we know what NOT to do, let's take a look at a few helpful strategies for combating stress urinary incontinence.


1. Learn to Make Your Pelvic Floor Work as Part of a Whole Team

That team is your body!

My friend Julie Wiebe has a nice video on this:


The Core Machine With Julie Wiebe

You can also take a look at some of Julie's online healthcare courses available on Embodia.


Learning how to coordinate the proper cycles of breathing, activation and relaxation is simply like learning how to snatch – when you first begin, you don’t think it is possible to do everything you need to, but then you keep practicing and it slowly comes together, pelvic floor retraining is the same!

Learn how to coordinate your body into positions of dynamic stability – what that means is that you need to learn how to move and coordinate control of your whole body which includes the pelvic floor.

Remember! Bracing while lifting weights is appropriate while bracing while standing or sitting is inappropriate. 

 

2. Contact a Physical Therapist

Contact a physical therapist that understands the pelvic floor, preferably one that can do internal examinations or has a special interest in women’s health. I have a special interest in it and I work with other therapists who do the internal work while I do the whole body assessment and programming back into full function.

3. When Training, Use Weakest Link as Limiting Factor 

I would prefer that my athletes train using their weakest link as their limiting factor.

That means if your back strains under heavy squats, then you need to keep that weight at a level that your back can cope with until it is strong enough to progress, even though you have the legs for 30 kg more. I see a lot of injuries because athletes do not follow this simple rule. 

If you leak, let your limiting factor be your pelvic floor. For example, how many double-unders or box jumps can you do before you feel a bit of a leak? I would recommend that you find that out, and then treat it like a strength set. 5 sets at max perfect reps with 2-3 mins between sets. If you leak, you end the set there, preferably just before you leak.

Keep a journal of your exercises and do them at least 3 times per week. Because the pelvic floor muscles are relatively small, you will fatigue them a lot quicker than your legs – that’s ok!

Your pelvic floor just needs to catch up to how awesome the rest of your body is!

4. Learn to Train Raw

In an ideal world, Anthony prefers that his athletes train raw. No belts, braces, wraps or supports - not even tape.  

I accept that my patients will use these things and I understand the place and importance that they have in sport.

One of the biggest offenders in contributing to CrossFit-related pelvic floor dysfunction is the weight belt.

It is designed to go around your belly and back and is worn by many athletes as a way of supporting their back.

The way that you are taught to use them is to push out against the belt and use it to help support your back and tummy. But when you do that, you generate massive amounts of intraabdominal pressure which does help your spinal stiffness but at the expense of your pelvic floor. Because it is made of unyielding leather or synthetic materials, the pressure won’t be going through the belt – it will be leaving via your pelvic floor or diaphragm.

Pressure on a system will always leave through the weakest point


The diaphragm is a very strong muscle and rarely does it fail – if it does, you will find it pretty hard to breathe!

The back and the abdomen are supported by the belt which only leaves the pelvic floor – the smallest of the muscles – to hold the massive load of pressure placed upon it.

5. Check Your Ego at the Door

Ego is another thing that does not help.

The effort put is more important than the final outcome
Image source: CrossFit GroundWorks

If we ignore the fact that you leak during a WOD, then yes, you are an amazing athlete. But the fact is that you have a technique flaw that is making your weakest link fail.

“Work on your weaknesses” is something that we all know and do. If you have trouble in the squat, you work on it – you hit the roller and ball to get more mobility, you practice your squat technique, you turn that weakness into a strength!

But why don’t we do that for the pelvic floor? If you actually limited your WODs to the amount of “perfect reps” completed -and by perfect reps, I mean the number of reps you can do without leaking- then you would perform better in the long run. 

6. Be Patient

Just like it took you ages to get 1 strict pull-up (if you can’t do 1 but you do kipping pull-ups, you are asking for trouble!), so it will take you a while to get your pelvic floor to catch up to the rest of your body, but it can. Do the work and be patient.

 

Click Here to Learn More with Anthony Lo

 


IX. Additional Resources 

For healthcare professionals who are interested in learning more, here are some helpful online healthcare courses:

Not a clinician but would like to learn more? Take a look at these courses:

 

Click Here to Learn More with Anthony Lo

 


The unedited version of the original blog can be found on Anthony Lo's site

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Last update: 22 Dec 2021

Antony Lo (he/his)
B.App.Sc.(Physio)(USyd)., Master in Manual Therapy (UWA)

Antony Lo is a physiotherapist from Australia and runs The Physio Detective service. He earned his degree from the University of Sydney and has been in practice since 1997.

He completed his post-graduate masters in Manual Therapy (Musculoskeletal Physiotherapy) from the University of Western Australia and commenced his Specialisation training in Musculoskeletal Physiotherapy.

He has been involved with treating CrossFit athletes since 2011 and has helped some of the world’s best CrossFitters at the highest levels through to beginners of all ages. He loves and participates in CrossFit and is a strong advocate for the sport. Through participation and through his work as a Physiotherapist at all levels of CrossFit, he has developed a model of treatment that utilises the best from Sports Science, Musculoskeletal/Sports Physiotherapy, Pain Science, and Women’s Health research to provide a realistic holistic model of care balancing the biopsychosocial model of healthcare.

He is NOT an employee of CrossFit, he does not represent or work for them in any way and his views and opinions are entirely his own. He holds a CrossFit level 1 – Trainer Certificate and is a CrossFit Football Coach/Consultant (now CrossFit Sports Specific Application). Antony has a wife and 3 beautiful children in the best city in the world – Sydney, Australia!

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