Monday, May 17, 2010

Pelvic Floor Party: Kegels are NOT invited.

You now have permission to pee in the shower.

Recently I met a woman who told me she used to be a runner. Naturally, I asked: Why don't you still run? The answer: "Because 60 hours of labor with my first child and a forceps delivery ruined my desire to run anymore."

To sum up for those who still may not infer the problem: She pees her pants when she picks up the pace.

My friends and I joke about sneeze pee, jumping jack pee, trampoline pee, and other bladder challenges. But full blown incontinence is no laughing matter. I'm a firm believer that a strong pelvic floor is the answer to incontinence (although pharmaceutical companies and surgeons often try to persuade people with other remedies). A strong pelvic floor, I've learned, not only makes the difference between wet and dry running shorts, but also keeps me running pain-free: I no longer suffer from the back and hip problems that used to plague me.

So today I bring you an interview with Katy Bowman. I have had the opportunity to interview Katy for magazine articles. Since becoming a freelance writer 13 years ago I have interviewed scores of sources. Very few I remember. Katy made an impression. She is a biomechanical scientist who applies her knowledge on the human body. Among other things, she has her own DVD program, "Aligned and Well," and is the director of the Restorative Exercise Institute. Her blog, Katy Says, is amazing (and she's as funny as she is smart). I like that combination so I asked her to chime in about the pelvic floor. I had no idea she would rock my pelvic floor world. Even if you've never peed in your running shorts even a little bit, you should still read what she has to say about pelvic floor strength.

Mama Sweat: First, a lot of women just assume it's childbirth that causes incontinence, but I've read that pregnancy itself puts a strain on the bladder (so a c-section won't necessarily save you) and that most women, as they get older--whether they've had children or not--will likely experience problems with incontinence. And even men aren't immune. All this suggests that a weak pelvic floor doesn't discriminate.

Katy Bowman: Nulliparous women (that's women who've never had a baby) and men are equally affected with PFD (pelvic floor disorder) so while child birth may accelerate PF weakening, it is not a primary cause of PFD. PFD is first caused by slack in the pelvic floor due to the fact that the sacrum is moving anterior, into the bowl of the pelvis. Because the PF muscles attach from the coccyx to the pubic bone, the closer these bony attachments get, the more slack in the PF (the PF becomes a hammock).

MS: So rather than a hammock, you'd rather your PF be more like a stretcher--more firm and able to hold up weight without buckling?

KB: I like to think of the PF like a trampoline--the material is supple, but taut...the perfect muscle length.

MS: And kegels. Everyone on my blog has heard me preach about kegels. I want to make sure all my readers are doing them right. Suggestions?

KB: A kegel attempts to strengthen the PF, but it really only continues to pull the sacrum inward promoting even more weakness, and more PF gripping. The muscles that balance out the anterior pull on the sacrum are the glutes. A lack of glutes (having no butt) is what makes this group so much more susceptible to PFD. Zero lumbar curvature (missing the little curve at the small of the back) is the most telling sign that the PF is beginning to weaken. Deep, regular squats (pictured in hunter-gathering mama) create the posterior pull on the sacrum. Peeing like this in the shower is a great daily practice, as is relaxing the PF muscles to make sure that you're not squeezing the bathroom muscle closers too tight. Just close them enough...An easier way to say this is: Weak glutes + too many Kegels = PFD.

MS: OK, I had to step away from my computer a moment to fully process this. First of all, you just said it's OK to pee in the shower, but what really has my head spinning--did I catch this right?--you said: Too many Kegels can cause PFD? Did everyone hear that loud screeching noise? You realize this goes against everything I've ever heard or read; that kegels are the be all end all for pelvic floor strength.

KB: I know, I feel like I'm running around saying The Sky is Falling, The Sky is Falling. The misunderstanding of pelvic floor issues is so widely spread, I'm a Team of One right now. But, I've got all of the science backing it up and it makes sense, the kegel is just such a huge part of our inherited culture information, no one bothered to fully examine it. Anyhow, your PF is underneath the weight of your organs, and the strength your PF needs is equal to this weight (you don't need SUPER STRONG PF muscles, just enough to keep everything closed). When you run, the extra G forces (2-3) actually increase the "weight" while running, but the PF should be adapting, just like all your muscles. One of the biggest misnomers is that tight muscles are "strong" and loose muscles are "weak." In actuality, the strongest muscle is one that is the perfect length - you need Pelvic Floor Goldilocks - it's juuuuuust right. The Kegel keeps making the PF tighter and tighter (and weaker and weaker). The short term benefits are masking the long term detriments. Ditch the kegels and add two to three squat sessions throughout the day (anywhere). The glutes strengthen and as a result, they pull the sacrum back, stretching the PF from a hammock to a trampoline. Viola! You can still practice opening and closing your PF in real-time situations, but you don't have to approach it like a weight-lifting session or anything. It doesn't need to be on the To Do list :)

MS: I am ALL for scratching items off my to-do list! Before we get too carried away with our newfound freedom from Kegels, I want to get back to the role of our glutes. What you’re saying--and I love this--is that there’s a much better reason, besides aesthetics, to avoid the flat butt syndrome found in most older women (further exacerbated in "mom jeans"). Having a booty--as in strong glutes--will not only do wonders for your view from the backside but prevent you from peeing just a little (or a lot) when you sneeze. This is revolutionary. I love what I'm hearing.

KB: Ok, I'm yelling this: YOU REQUIRE YOUR BUTT MUSCLES! There aren't any extraneous parts on the body! Every muscle is really a pulley that is holding your skeleton just so. When you let your glutes go, you allow the bones of the pelvis to collpase into themselves. The squat is the most effective and natural glute strengthener--using the full range of motion and your body weight. It is entirely more effective than any gym machine or contrived exercise. The hunter-gathering folks squat multiple times a day (or at least once in the morning), so they had a nice routine down over a lifetime. Doing this four to five times a day, every day of your pregnancy will improve the delivery as well!

MS: I’ve also read that squatting during pregnancy helps prevent the posterior position during delivery (when babies emerge face up, rather than face down), which causes excruciating back labor and with it more interventions, more cesarean deliveries. In America, where we tend to sit back and put our feet up rather than squat and sit forward, the posterior position is more common than in countries where squat sitting is the norm. I was a squatter during my pregnancies, but now I will continue: when I’m playing with The Boy, picking weeds in the yard, pulling laundry out of the dryer or getting a pot from the cupboard. Lots of opportunities to squat!

I know you've brought up posture as a culprit too. How does posture play a roll and how do we keep good pelvic posture?

KB: You can only have optimal PF function when the pelvis is in a particular position. The two bony points on the front of the pelvis (where you put your hands on your hips) should be vertically stacked over your pubic bone. Most women have become "tuckers" based on their mom or gram telling them to not stick their butt out. Athletes tend to be super-tight through the quads and psoas, which also keeps the pelvis tucked under. Wearing high heels requires women to reposition their joints to deal with the torque at the ankle, and many women will post-tilt the pelvis there as well. For optimal pelvic health, one needs to make sure the posterior muscles (glutes, hams, and calves) aren't pulling the pelvis under and keep the psoas and groin loose as well.

MS: So, this requires that we stretch out the muscles in front and strengthen the muscles in back?

KB: The muscles are weak because they are tight. More "strength" or tension-increasing exercises are going to make it worse. Instead, muscle lengthening exercises--especially stretching the calves, hamstrings, groin (adductors)--are the best prescription. Also, you need to learn how to hold your pelvis correctly to optimize strength!

KB: The DVD is designed to get the pelvis in the correct position so the PF can work optimally. Typical PF treatment is trying to strengthen the PF muscles with the pelvis itself is in the wrong position, which means the treatments don't work very well. That's why once you have surgery, the statistics say you will have to have a 2nd, 3rd, and even a 4th in your lifetime! It is not a permanent fix, so it's better to not even go down that road. The DVD will teach you to stretch and relax the muscles that are pulling the pelvis out of alignment--and let the correct muscle tone of the PF re-establish itself.

MS: Should we watch it in the bedroom with the shades drawn or is this something we can do with the kiddies around?

KB: Yes! You can keep the lights on and even the front door open. The exercises are mostly inner thigh and back-of-the-leg stretching, so if you don't tell anyone what it's for then they'd never know. And it's also a great program for kids to follow--especially if they are having problems wetting the bed--the muscle tension pattern is the same in the kids as they are in incontinent moms.

MS: OMG! If you were sitting here in front of me I'd kiss you right now! I am forever washing bedsheets. I can't wait to try it out.

Let's get back to peeing in the shower. Now that you've legitimized it for us (I don't advise this practice at the gym, however), let me ask this: Why do I feel the urge to pee a little (or, OK, I'll say it, sometimes a lot) when I hit a warm shower? Wasn't this covered in a Seinfeld episode? Seriously, what is it about the warm water that makes me want to let go?

KB: When the PF is weak, women start to use the glutes and adductors to keep the bladder closed (instead of the sphincter muscle of the bladder itself). When you hit the shower, those external muscles relax and HELLO! you realize that you don't have actual control of the deeper, internal muscles of the PF.

MS: OK. I thought my PF was strong, but I see I have more work to do. I suppose it’s like any muscle, strengthening must be an on-going practice. But for someone who is suffering from incontinence, or this friend of mine who is afraid to run, how soon should they expect to notice a difference once they start a "training program"? And at what point should a woman consider pharmaceutical or surgical options? Ever?

KB: I don't think a surgical option is ever a good idea, as the problem isn't coming from one time damage, but the accumulation of 1) bearing down a lot and 2) from squeezing the PF all the time. Working on relaxing the PF and keeping it closed "just enough," stretching the backs of the legs to free up the pelvis, doing regular, daily squats to strengthen the glutes, and ditching the heels (except in special occasions) are things you can do all the time for all-the-time improvement. Also, doing tons of crunches where you are bearing down on the PF will only make PF health worse. It's better to do transverse abdominal stabilizing exercises - like the plank - that will decrease any bearing down that sprains pelvic organ ligaments. Once you get yourself out of the weak and overcompensating PF tension cycle, you should feel like you have better bladder control within a few weeks. If you are already experiencing organ prolapse (it is way more common that people realize) you need to skip the run and switch to long, endurance walks (minimize G forces), and do your pelvic-aligning exercises every day--maybe even twice.

MS: Wow. This is revolutionary. And it makes sense. I can hardly believe I'm just. now. learning. this. I can't be the only one who's feeling a little cheated. Women (and men) need to know all this. Thank you, Katy, for answering my questions and sharing your knowledge. I know this information will change a lot of lives. And if I can stop buying nighttime pull-ups for my girls, the benefits are more far reaching than I thought!

****Due to the popularity of this post (where are all you people coming from?!) I did a follow up interview with Katy Bowman. This is especially important if you're a Kegel fan--we haven't written them off entirely. Check out Pelvic Floor Encore.

145 comments:

Amanda
said...

This was a fascinating read. I'd heard once in France women who had given birth got physical therapy to help the muscles recover and strengthen, but I couldn't figure out what they could be doing other than kegels. This was a fascinating interview, thanks!

This is an amazing article--thank you Kara and Katy! This theory goes a bit against my experience: I have a significant lordotic curve and, as a martial artist, glutes of steel. (Much more uncomfortable than you might imagine.) But perhaps I am observing tightness (of granite proportions) vs. actual strength. At any rate--I am intrigued enough to want to get in the running for the DVD so I can explore further.

Lynne! You are exactly right - super buff can many times equal super tight. A simple test would be looking at the ranges of motion of the hip, glutes, and piriformis! I am also linking to the pictures of the ultimate pelvic-strengthening squat: http://www.katysays.com/2010/03/30/the-hunting-and-gathering-mama/

Another bit of info - Lumbar curvature is often times mistaken for lumbar shear - where the chest is so tight, people will over arch their thoracic spine (just above the lumbar), which gives the appearance of a big curve, when actually there is none. Alignment is so subtle!

That was a really great article...I felt that the biggets take aways for me was the lumbar curvature. I tend to have a fairly nice curve in my lumbar spine, but interesting to note how it could play into weakness in my PF. I also found how PFD is very similar in children who bed wet. I don't have children yet and used to do this a lot when I was little even when I wasn't in bed. My mom actually told me the opposite, not for me to stop sticking my butt out but to stop sticking my belly out, so I was always trying to stick it back in and can see how it could cause a posterior tilt in my pelvis as well. Truly fascinating!

OK all, Katy just posted more on the PF at her blog: www.katysays.com. She has some terrific diagrams that help explain her anti-Kegel position!

Amber, I want to know about that too. Initially it was Pilates that helped me go from wet running shorts to dry running shorts after my twins were born. Maybe the difference is that Pilates makes an effort to get you in that "neutral spine" position? I always thought of Pilates as 101 ways to Kegel, but maybe that's it too--better positioning/posture. Katy?

Thank you Katy and Kara, for sharing! Katy is 100% correct, and I am living proof. When I first came to see her, I was suffering from PFD, and was on my way back to the doctor for some "corrective" surgery. Instead, Katy showed me in a mirror just how far my sacrum was pulled into my body. That explained why I kept ending up in the same prediciment after each baby, each surgery, and why things were not getting better. Her simple exercises changed everything for me, and now that you can get this information for $14.99, I hope everyone will give it a try. In fact, I think doctors should give this DVD to their patients after childbirth, instead of waiting for them to show up in a few years needing another procedure! Thank you Katy, for telling it like it is :)

Checking in with the PF muscles - a la a Pilates video, helps keep the neurological connection of the motor unit (communication between the brain and the PF muscles) healthy. There is a big difference between a gentle contraction (even holding that gentle contraction for a few seconds...just to see if you can) and gripping the PF all day long. Take away info: When the Pilates teacher says find and contract your pelvic floor, go for it. If you are instructed to keep your pelvic floor strong by holding it tight all day long, get the heck outta there.

Sheesh! No one yet will admit it? I don't SOMETIMES pee in the shower, I ALWAYS pee in the shower (at home that is). I figure it saves a flush of the toilet here in water-parched California. Though I've never tried squatting to pee in the shower, I do it all the time when I pee on my back yard(CA, remember?). This is one of the most important survival sklls my 6 year old daughter has already mastered.

This is very good information. I have to wear a thick pad every time I run. I assumed that it had to do with delivering two 10 lb babies. My doctor recently told me I was a good candidate for the sling surgery (a healthy weight, no urge incontinence etc.), but has referred me to a physical therapist first. I was a little freaked by this, but now feel like it might help more than I thought. I might even print out some of this info and take it with me.

This issue is very personal to me. After my 2nd son I had WAY more than sneeze-pee. I had to wear pads all the time due to constant leakage. I would leak walking from the bed to the bathroom. After consulting with a urologist, he referred me back to my ob/gyn because I had both a rectocele and a cystocele (basically hernias of the rectal and vaginal walls) that needed to be repaired in his opinion.

The surgery was not simple. I had the repairs done as well as a TVT procedure (trans vaginal taping) where they use a mesh material like a sling under the urethra for support. If TVT is all you need, this is a relatively new procedure and much less invasive than the "sling" procedures many of our moms and grandmothers had.

I do have to say that for me the procedure was absolutely life changing. I couldn't play with my kids at the park, lift anything, forget running or even go on a brisk walk. Now I'm a spin instructor and training for my 2nd triathlon. A not insignificant side benefit is that things "in the bedroom" feel much more like they did pre-kids.

I am interested in the information in the interview because obviously I want to keep my parts in good working order now that they're fixed up. I just think that everyone's medical situation is a bit different and some cases are definitely more severe than others.

I do enjoy telling people that I call my wee wah Jamie Sommers now. They have rebuilt her.

Fabulous...the information I need! My "leakage" occurs during dancing. I am looking forward to the benefits of having a booty to be proud of, too! Isn't it known that peeing on your feet resolves athlete's foot, too? More multi-tasking...Thanks Katy and Kara!

Jamie Sommers! You have the right idea. If the pelvic floor is failing beyond your control (it's keeping you from doing EVERYTHING!) then surgery might be your best option. BUT (a big butt...) you are exactly right in making sure you still put your pelvic and sacrum where they need to keep everything improving! Glad to hear things are so much better!

That was so interesting, because I'm definitely a Kegel believer, but have started running within the last few months seriously, and have had more issues with having to go RIGHT NOW. I would love this video! Thanks for such an great interview!

Ok I'm a PT and feel pretty bad that I just accepted what was taught in school without ever really thinking much about it! This makes perfect sense and I am completely intrigued and will definitely be forwarding this information on some of my colleagues and former professors. Wow wow wow. That'll teach me why God gave me a brain - too bad I haven't used it! Thanks Katy!!!!!

Oh, I'll admit it. I so pee in the shower... before I wash not after because that's just gross. :) Seriously I see nothing wrong with peeing in the shower, or in the woods, or on the side of the overpass during a 15 mile run and I really had to go, or in my kids potty chair (which lead to me getting locked in my car... funny story). What I don't care for is peeing myself in a race or track workout. Thank goodness for black. ;)

Really a great eye opener and something I will now discuss with my PT. It would be nice to not weezee and sneezzee, if you know what I mean. I guess twins, and two singleton births in four years will do that to your PF, who knew?

Thanks for the info and if I don't win the DVD (remember I have four kids and must feed them don't feel pressure to help me out any with a free DVD) I'll have to get my own copy.

alKeith--when reading your comment I thought you were me. I am famous among my friends for outdoor squatting, but I, too, hate peeing off the bike (because my stash of food and waterbottle always get wet) or the run (pee soaked shoes inevitably cause blisters). Then when I read the part about twins and 2 singletons I thought for sure it was me. But all in four years... no that's where our paths diverged!

I've had so much feedback and visitors to Mama Sweat from this post (ahem, the most EVER) that I wish I could give a DVD away to everyone! There will only be one lucky winner, but check out the link and remember the cost is only $14.95--minimal investment to stop, as alKeith says, weezee when you sneezee.

And here's another question for Katy on the Kegels. I don't think you're saying we write Kegels completely out of the books, are you? Would Kegels be useful, say during pregnancy and, especially immediately after childbirth when the PF has been directly traumatized? But the difference is we should not go overboard and we still have to build up the other muscles surrounding the PF. Post birth we can go from the Kegel being something we do as an exercise (a few times throughout the day versus 200 times like people have been saying) to something we do in "real time" situations (to hold back urine when we sneeze/laugh/cough/etc.)

Thanks for sharing this info -- fascinating! I've had slight leakage problems for years, and now that I'm a mom and a runner I really want to find a solution. My pelvis is extremely rotated so have have an overly pronounced lumbar curve. It never occurred to me that this might be part of the issue. I'm definitely going to explore this more.

Hi there, I am a women's health PT and found it hard to read this and not comment. I agree with Katy that there has been an over-simplification of pelvic floor exercise with everyone being directed to squeeze 80-100x/per day, but you also can't disreguard the importance of training your pelvic floor and supporting musculature. I coach patients to complete 8 kegel sequences per day including longer holds and quick flicks to work all the fibers of our pelvic floor muscles. Keep in mind that our pelvic fllor is primarily an endurance and postural muscle. It is one of our three deepest stabilizers along with our multifidi of our lumbar spine (under our glutes), and our transversus abdominus. These muscles normally fire a fraction ahead of every lift, every reach, every cough, etc. When we lose this normal firing pattern, we have to re-train it...all while holding neutral spine. There is a posture copmponent, a muscle component, and a firing pattern component. If you hit them all, you will be a success story. - Tasha Mulligan

I'm a former avid runner with two kids (and haven't found a pad yet that will contain the pee when I run, no matter how much I pee beforehand or restrict fluids). And yes, pads for regular daily living are essential for me now. This post gives me great hope--except that part at the end about giving up running if you have prolapse. Can you talk more about that? I'm pretty sure I have it. Are there options? Can anything help prolapse?

Hi guys, I can't help but post again because I want to highlight the difference in opinion between a lot of healthcare professionals on these issues. Katy, as a therapist has given her opinion, but certainly there are others, so I just want to encourage all of you to gather more information and test it all on your own body!

Simple differences are that the desire to pee when you hit the warm shower is not a relaxation of your glutes...it is a parasympathetic response that stimulates the nerves to our bladder causing this smooth muscle to contract. It is involuntary, but we maintain the voluntary muscular control to stop it....if we so choose.

Second, big difference, on the comments on prolapse. I encourage you all two review two great sites (prolapsehealth.com and hab-it.com) for more information on women who are very familiar with and have experienced prolapse issues. The advice to stop running is not true for every individual and I don't want anyone to give up on an activity that they love because of one therapists opinion. Knowledge is empowering ladies - gather as much of it as you can and be your own filter!

Hi guys, I can't help but post again because I want to highlight the difference in opinion between a lot of healthcare professionals on these issues. Katy, as a therapist has given her opinion, but certainly there are others, so I just want to encourage all of you to gather more information and test it all on your own body!

Simple differences are that the desire to pee when you hit the warm shower is not a relaxation of your glutes...it is a parasympathetic response that stimulates the nerves to our bladder causing this smooth muscle to contract. It is involuntary, but we maintain the voluntary muscular control to stop it....if we so choose.

Second, big difference, on the comments on prolapse. I encourage you all two review two great sites (prolapsehealth.com and hab-it.com) for more information on women who are very familiar with and have experienced prolapse issues. The advice to stop running is not true for every individual and I don't want anyone to give up on an activity that they love because of one therapists opinion. Knowledge is empowering ladies - gather as much of it as you can and be your own filter!

Hi all, catching up with the comments! First to you Wendy and anonymous when Katy said to skip the run for the walk if you have organ prolapse she wasn't saying to QUIT running. Sometimes we have to put certain things on the back burner due to time constraints, injury, or other "life issues." If you're experiencing prolapse then you definitely need to make pelvic floor strength a priority BEFORE you return to running, and once your parts are secured THEN it's time to run again. I would never recommend giving up on an activity you love either, but we should all use common sense when it comes to physical activity and there are certain times in our life when we need to choose different activity to better meet our fitness goals/needs. And let me add that I know this is a hard concept for people--especially runners--who just want to run, but the main goal is to run (or whatever else you love) for the rest of your life and sometimes that requires us to modify or alternate an activity for a short period of time. This is simply pushing the "pause" button. I've had to push pause on my running several times and once my body is ready to run again, I always come back--STRONGER.

Anonymous, I agree--everyone knows their own body better than anybody. What's important is to have all the information you can so you can take it on a test drive.

I think what's important about Katy's information is that most women haven't heard it so we are all excited to be given one more option to check out. And that is GOOD, especially since so many women aren't finding success through the standard recommendations (and kudos to my OBGYN here, because at my six week appt after the twins were born when I complained about peeing while running she didn't suggest Kegels she suggested Pilates!)

And fascinating add on the need-to-pee-in-warm-shower phenomenon. I can see where BOTH the sympathetic response and weak glutes can be at play. Your sympathetic response starts, but you can only choose to stop it IF your pelvic floor muscles (including your glutes) are strong enough to counter it.

Speaking for myself, the recommendations aren't either/or. what Katy has said offers a new layer of explanation and suggestions to what we already know. These are nuances (ie the importance of releasing/relaxing the pelvic floor--See Pelvic Floor encore post), and the importance of squats and stretching the hams and calves. There's no reason and certainly no harm in trying these things out. I love that we have the conversation going. The more we talk, the more we learn.

Hi Anonymous. I appreciate your passion for this issue, that’s exactly what we need right now!My enjoyment of my academic field (biomechanics), is really due to the fact that the study of classical mechanics (physics) applied to biological tissues gives me freedom from opinion. The fact of the matter is, the bladder and the uterus double to triple their weight when running. This is not a “depends on how you feel about it” thing, but a real, factual, physical law, true for everyone. If an organ is currently prolapsing, the fact that the pelvic floor structures are failing is also a real thing. The advice for treatment, however, should not be affected by the doctor or therapist’s preference for activity, but from a real, whole-body and long term evaluation point. When I say You shouldn’t run or do crunches with a prolapsing organ it is not “my opinion” that these activities will increase intra-abdominal and pelvic pressure and that pressure will further press these organs out. It’s just physics again.

Really, Anonymous, our end goal is the same. We both want women to have optimal health of the pelvic floor. To explain it in slightly more clinical terms (sorry if you all can’t follow along at home), the current therapy model is strength based on concentric contraction (muscle shortening). But all muscle science and research will say that eccentric contractions (where the muscle emits force while lengthening) gives a stronger contraction. The only point I have (and I have one, really I do!) is that the PHYSICS of the UNIVERSE dictates that continuous, concentric contraction of the PF will move the sacrum into the bowl of the pelvis, putting slack in the PF. PF contraction needs to happen while the gluteal muscles pull back on the sacrum, preventing the PF contraction from moving the sacrum and INCREASING FORCE GENERATION based on the Force/Length Diagram. I am saying that MOST women are hypertonic through their PF (too tight) as a result of low gluteal EMG. This is what is making the PF weak. Again, not my opinion, but the basic properties of muscle.

(cont. from above) Another fact of the matter is, the prevalence of PFD is increasing annually. The treatment for PFD has been the same for over fifty years and the situation is getting worse. “Advances” on the Kegel exercise have meant different ways of teaching and measuring it, but it is now time to increase our understanding of the physics of anatomy.Repairing prolapsed organs and eliminating regular incontinence is possible, it just takes a lot of work, strengthening the correct muscles, changing habits, and adjusting gait patterns (e.g. Your thigh bones actually attach right to the PF tissues. If you have asymmetrical gait, the you are going to have asymmetrical PF strength (one-sided hip pain anyone?). And if you turn your feet out when you walk, then optimal PF strength can’t be attained. You have to fix that first!)

I kind of trip out when I hear people say the PF muscles are really just stabilizers and postural muscles. HEY ALL YOU PEOPLE OUT THERE WITH ORGANS! The PF muscle is the only bottom to your container. The PF muscle group is HOLDING YOUR GUTS IN. There is an open pathway between your organs and the ground. The PF is a constantly working muscle that has the JOB OF A LIFETIME. As cute as these blogs seem, malfunctions of the PF should not be taken lightly. Your whole-body health for the rest of your life depends on it! (Oh, and if any Dudes are reading this, you don’t have a vagina that lets you know when your organs have fallen down, BUT, when your PF muscles fail, the weight of the organs (pelvic AND abdominal) end up resting on your prostate. Ponder that...)

As we see from these posts (and the ones on Twitter and the ones on FaceBook!), this is a red, RED hot issue. It is an emotional one. It is a frightening one. I offer you the Physics of the Pelvis to aid you all in any decision you would like to make regarding your body. To put things in greater perspective, I have one medical textbook printed in the last 10 years, that says that the Iliococcygeus muscle (PF muscle closest to the tailbone) “has no purpose” except to show the surgeon where to make his incision. Nice. Time for the paradigm to change, big time!

Katy,Thanks for the reply. I'm sure you and I could sit down over a cup of coffee and challenge each other on several different points. I agree, that this type of dialogue is exactly what women's health needs right now. Getting the word out about what physical therapy has to offer to the treatment of pelvic floor dysfunction BEFORE medication or surgery options are exercised is my goal.

To continue with our respectful dialogue. I also have my background in biomechanics, starting from the ground up (casting for orthotics) and a strong background in orthopedic sports medicine before my journey into women's health.

I am with you in strengthening glutes in my rehabiliation of the pelvic floor as well as the deep hip rotators and inner thighs, but focus heavily on the deeper muscles under the glutes that hold the posture we need to put our pelvic floor at the perfect length/tension relationship. Learning how to activate your multifidi muscles to hold your tail bone in its extended position is the first step and then coordinating the transversus abdominus contraction along with pelvic floor elevation is the second step. Rehabilitatin of the pelvic floor is a complex combination of posture, strengthening, and muscle firing pattern. Over simplifying it leads to frustration on the part of women attempting to resolve their dysfunction.

To close, I will go back to the forces of physics on our pelvic organs during running. I will agree that the forces on our pelvic floor organs are greater with any impact activity. The great thing about our bodies is that they adapt to the forces placed upon them. This phenomenon helps to explain why long term studies of runners has shown that non-runner undergo more knee surgeries than regular runners. The knees of runners, our bodies, and our pelvic floors, will adapt to the stresses we place upon them as long as we are also working on our posture, our muscle strength, and our firing pattern along the way.

Bottom line, there is nothing simple about rehabbing a muscle that is responsible for cradling our bowel, bladder, and uterus as well as controlling the passage of solids, liquids, and air from our bodies all day, every day.

Once again, I will stress that every situation is different, every body is unique, so read on ladies, gather lots and lots of information. There are alot of great physical therapy sites on the internet. Read from the experts in the field, including Katy.

wow. i would love the dvd, my pelvis is so out of line and it causes me pain in my lower back. arg, being a momma can be painful at times. going to the bathroom was a must after having my baby. making it there on time, was not always the case. i felt like an old woman at the ripe old age of 26! almost two years later I still haven't got complete control over things. this article opened up my eyes to what I really need to be doing. And although I loath squats, if the doctor says I have to, who am i do say no? thank you for this blog post!~

Wow, wow, wow! Thanks for this. I hate Kegels, never feel like I'm doing them right or that I get anything stronger by doing them. OTOH, I squat a lot, so maybe I don't need to worry! [so far, no incontinence problems even after 2 kids *knocks on wood*]

Awesome information! Since I started a regular yoga practice, I can tell my pelvic floor is in much better condition. I'm linking to this. Along with Fertility Awareness, natural childbirth and how to breastfeed, this is essential information to women's well-being!

Okay...I cant lie...I too pee in the shower sometimes! Thank you so much for sharing this. Now I wont feel so guilty for not doing a million kegels ever day!! Squats it is! I really want the DVD!! I wonder if the extra curvature I have at the bottom of my spine means I will have less chances of incontinence problems in the future???

I have to admit that I pee in the shower, my 2 year old dd called me out on it a few weeks ago. Seriously though - I am currently pregnant and due very soon with my 5th child and I would love to own this DVD. I have mommy butt after being formerly very fit and have two older (6 & 10 years old) children with bedwetting problems. I'd like to try this for myself and see if it help us all!

Hello all you newcomers! I'm afraid you're late to the Pelvic Floor Party! We gave away the free DVD last week. But check out the link in the post where you can go buy it--I think it's $12.99--nothing that will break the bank! Thanks for stopping by. I see many of you are midwife/doulas so you'll have to check out some of my fit pregnancy/childbirth posts!

makes so much sense to me that it's all about the glutes- if you think about it when you have to pee but you don't have the time or the moment to do it, you end up squeezing your glutes and your PF at the same time to get yourself to NOT pee so you can get where you need to be before you let go.

Could I ask for alternatives to squats for those of us with really bad knees?

I have hypermobile patellas, they've dislocated in the past, the tendons don't "fit" right, I've done biofeedback therapy to strengthen certain muscles to help hold them in place. My aunt (the condition runs in the family) was so bad, her kneecaps actually started disintegrating due to friction and she had surgery to actually remove them!

When I bend/squat, my knees scream in pain, audibly creak and grind and groan (as do I heh), and sometimes though they don't pop out of joint, they still "pop" and I'm left in terrible pain even after standing back up.

As young as age 30, I would occasionally have to use a cane to support a really painful knee. Fortunately it's only that bad once in a rare while (less than once/year), but it does happen.

Starting a routine of squats to address my 'sneeze-pee' would just be trading one problem for another, arguably worse one...

I was thinking along the lines of Mother... I have knees that aren't so good. I sit here today reading with a knee injury (I had x-rays today), pain, and wearing an ace bandage... what else can I do, or how can I do this safely/effectively without hurting my knees? Mother of 6 - sneeze pee! yuck!

Absolutely facinating! I've had 8 children (just had my 8th on june 2!) and have been lucky enough to not experience stress incontinence. I thought kegals would help me prevent it, but I always forget. Squatting, that I can do!!! Sounds like yoga's downward dog would help to. Thanks for giving me more to think about!

now I know why my PF muscles were well toned when I birthed my baby at home at 46 - 8 1/2pds..no blood..no tear!Although I was peeing regularly at night in the last 6 weeks I always squatted over a bucket in my bedroom! And boy were my bottom muscles and thigh muscles well tomed also!!!

Hello! Wow! Well, here's a link to the squat blog: http://www.katysays.com/2010/06/02/you-dont-know-squat/which will walk you through a squat. You don't have to be weight bearing on the knees to start working on pelvic alignment, so get going on a few basics. Also, the "Down There DVD" doesn't even have the advanced squat - so anyone can do it...there's no using your knees at all! http://www.alignedandwell.com/videos.html#106

I'd like to get this DVD. Uterine prolapse big time runs in my family and I've had Kegels preached at me since I was a little girl. I have a mild prolapsed uterus that, oddly enough, seems to be improving 2 years after it happened. I don't know why but I'd like to do what I can to strengthen my pelvic floor and avoid the agony I've seen my mom go through with complete pelvic prolapse and multiple surgeries.

Perfect and timely article. I nealry pissed myself on a 5K this past weekend and was seriously distrubed. I thought incontinence was something that only old women experienced. Need to speak to my Dr ASAP!!!

What an awesome article! I feel enlightened but not enough to pee in the shower. But this isn't the first positive argument I have heard for squats. Does she mean Asian style (wider stance with heels to the ground) squats or exercise style squats?

Hmmmm... I'm a little concerned here. I agree with most of the information Katy shared, but feel like we might be "throwing the baby out with the bathwater." Squats are awesome, the stretches she's talking about are great... Posture is key... But kegels shouldn't be completely ditched. No, you don't need to build up a pelvic floor of steel and you certainly shouldn't be clenching your PFM all day long, but practice makes perfect when it comes to knowing HOW to strongly contract the PFM when functionally necessary (i.e. when you're about to cough or sneeze, or when you're lifting something heavy). Regular practice of kegels helps you complete a PFM contraction quickly and easily when needed. ALSO --- you should not be peeing in the shower on a regular basis. As a women's health physical therapist I'm often advising women to urinate BEFORE stepping into the shower. When you pee in the shower on a regular basis a conditioned response can be developed such that every time you're near running water or feel warm water(for example, when you're washing dishes)you may feel a sudden, STRONG urge to pee. Not good for women who have a weak pelvic floor/core. In summary, I think moderation is key. Don't do kegels all day long, but don't completely stop. Don't pee in the shower every day; once in a while is fine. Let's all just get along, here. (Don't be a kegel-hater!)

Hi all--Yes, for all those ready to write off kegels--not so fast--make sure you read the second encore post! The problem with kegels, as Katy points out, isn't the kegel, it's how we do them and our tendency as a "clenched society" to forget to release. Also, what I think everyone is so excited about is having something else in our arsenal to work with. Thanks for all the wonderful dialogue and interest. And yes, that squat isn't an "exercise" squat but a "toddler" squat (you know the way we learned to sit before we were taught otherwise:-) Funny thing...

I LOVE this article!I am a Franklin Method® instructor which teaches this! (re: the pelvis) I teach people the bone rhythms of the pelvis & how lower limb flexion, in standing, causes the sacrum to dip forward at the top so the tail bone moves back at the bottom. With the addition of the sitz bones widening at the same time, the entire PF eccentrically contracts. If you can let go of tension & allow this to happen, it is great PF training to bend & stretch (or as she described it~ do squats). The PF muscles need to be dynamic so they are available for both eccentric as well as concentric contractions, both of which are needed all the time.

Wonderful, simply wonderful! The pee thing started shortly after I had my first baby and I've spent $$$ on sessions with a pelvic floor specialist who gave me kegels and more kegels to do! I'm done! Can't wait to get the dvd!

This explains why my incontinence problem has been getting better over the last year. I noticed I wasn't having to wear a pad anymore when I run, but didn't know why it was happening. It's the squats and stretching I do on a regular basis,of all things!Yeah!!!

This is great! I had some postpartum pee issues, but my problem is a little different. When I stretch (like during yoga), air goes into my vagina and then comes out - noisily. I can't do yoga in public! Would squats help this??

I'm a runner. And yes, sometimes I have wet shorts after my runs which is embarassing and gross. But I've noticed that it's a problem in the middle of my cycle, but not at other times of the month. So if I'm running in the middle of my cycle, I wear a pad to catch the dribbles. I always assumed it had something to do with my estrogen level and it's affect on my bladder sphincter. Is this not true?

Thanks for all your continued comments. I really can't address the dirty details, but I know Katy is working on a webinar to help answer all these questions. Keep checking katysays.com ! Oh and Anne, we have all been there--truly horrifying isn't it? And Kayris, what an interesting observation!

I just got my DVD "down there" for women. I like it, but felt the information was limited because it does not show you how to squat properly, I thought it was going to be on this DVD--that is why I bought it, I wanted guidance in doing a squat. It shows 5 exercises, but no squat. :(

Anonymous, Here is a step by step guide to squatting: http://www.katysays.com/2010/06/02/you-dont-know-squat/

The DVD addresses the standing and sitting contributions to PFD (learning to untuck the tailbone and strengthen the inner thighs, low belly, and outside hip). These things should be mastered before squatting! The squatting link above has pictures and easy-to-follow instructions! - Katy

I really like the video and the exercises are great and easy to follow. I have been sitting in a squatting position for years, but never paid attention to my back not rounding, so I just want to do it right. I have SI joint pain due to a deformed SI joint and tilted hip on the right side, plus flantar faciitis that tightens up the muscles even more. Thanks Katy for the link and love the video and am excited about doing this everyday to see what happens! I had 5 children and a little prolapse. No incontinence, the slight problem I did have went away 15 years ago when I started belly dancing!

This was very informative. Thank you Kara and Katy! Do you have any information / articles on a related topic of 'relaxed uterus'? As a runner who had my last kid 3 years ago...I still struggle with incontinence and my OBGYN recently informed me that I have a 'relaxed uterus'....not exactly something I was happy to here. Look forward to reading more. Thanks KD

Hey Thanks! Great Interview - I am an expert on the core muscle the Psoas ( www.coreawareness.com) and have been calling out to all to Please Stop Tucking The Sacrum - it is a sure way to have a dysfunctional Psoas! I have a great article with photos on how to squat to maximize your pelvic function under my articles section. So healthy PF also means a healthy Psoas = full body orgasms...

This couldn't have come at a better time. I'm 36, my kids are 10 and 12, and I am so tired of peeing every time I sneeze, laugh, cough... You get the idea. I was going to make an appt to see a urologist or gyno about the Monarch bladder sling, but I'm going to try the squats instead. I'd rather fix the real problem than opt for a surgical fix for the symptoms.

I'm pretty skeptical and am a bit disturbed to see kegeling completely dismissed as unnecessary on the basis of one article.

I have always had very tight gluts. That's my best and stronges asset. I can't say I could crack a walnut between my cheeks like Madonna, but my butt is high and tight. Squats have always been a big part of my fitness routine. And yet I was having problems with pelvic floor weakness until I began focused, regular kegeling.

As a woman's health professional, I've done quite a bit of research on pelvic floor health and talked to several physical therapists. I do think kegels have a place in a total fitness program. I agree that if the rest of you is saggy then probably kegeling alone will not help, but as part of a total exercise program I think they are still important.

I find the information fascinating and I will look further into this, but I must disagree with one point, that the kegel exercise has no practical application. Huh? I think my husband might disagree ;)

And these muscles are the key to orgasm. There is no doubt in my mind that my orgasms have become stronger and longer since I've been kegeling. I also can achieve orgasm quicker.

Despite being overall in pretty good shape, I had leakage. After making kegeling an important part of my daily exercise routine I now have absolute bladder control.

Ooooh. One other thing. I don't have the research available to me right this second, but surgery is not the panacea for many, many woman. The statistics of women who end up with sexual pain after bladder surgery is very high. I do believe that most women would commit themselves strongly to seeking a non-surgical solution first if at all possible.

Chloe my dear, I hope you have since read ALL the subsequent conversations and comments we've had about pelvic floor. We beat the Kegel up, for sure, but mostly--as you'll find in later posts--because women don't do it correctly (we squeeze to please but fail to exhale) and our PF expert, Katy Bowman, is absolutely not a fan of surgery. I'll personally avoid it at all costs for any reason! Was that last comment meant for a different blog? So I encourage you to keep reading!

Kara, I have been reading it as I can (been very busy at work). I have some concerns with what she's saying, but I'm not through the entire article yet. I do know that kegels are not "folklore". There is tons of research out there on the efficacy of kegeling.

Noooooo ladies - don't forget your Kegels!!! If they are done properly they are hugely effective! Just keep a healthy body around them and use them properly during the day. Well maintained muscles all around and good posture + good pelvic floor habits eg no straining. Kegels have such variety of benefits including incrased circulation, a good gripping vagina, slowing down the effects of menopause, help with menstruational cramps, prep for the birth canel and the list goes on!Ladies with prolapse and bad knees need an alternative to squatting.

Anonymous, never fear! Kegels are here! Just because they didn't get invited to *this* party, doesn't mean they're banished for good. Make sure to read the follow up post, Pelvic Floor Encore and some really good info and background on Pelvic Floor Strength, Kegels, and Squatting at www.katysays.com.

Holy Cow!! I'm stunned, and somehow hopeful at the same time. I've already had a hysterectomy for prolapsed uterus and bladder repositioning as well. I still have trouble though, and was concerned w/it getting worse over time. I'm anxious to get the video and see what kind of results I can experience. THANK YOU for reposting this article.

I think I need to send this to every girlfriend I have, and my mama's group and my mom....I was starting to wonder if there was something wrong with me after having my baby 17 months ago when I jump or get excited I sometimes pee just a bit. I had the sneaking suspicion that the kegels weren't working so I gave them up and now I know why and what to do about it. Thank you so much.

The doctor told me to do Kegels to help with incontinence, so the more Kegels I did, the more I wet my pants and then I started squatting over public toilets instead of sitting on them (we go out a lot and I pee every where we go) and am almost incontinence free. I could not figure what has changed and then I read this article. Thank you so much for writing this.

I had no idea! Occasionally I remember to do some Kegel exercises...because I feel guilty for NOT doing them. After all, as a mother we've all been told to "do our Kegel's"! Thank you for sharing & opening my eyes! I guess all the squatting helping little kids w/ shoes, clothes etc. really IS good for something! Planning to share w/ my girl friends!

This article is great (have been recommending it for a while), but it's missing one crucial thing - which is a *link* to the correct squat. Can you please fix the article to include it? As it is, I'm still not at all sure when I'm supposed to be doing. Thanks!

Facinating and informative! Having just had a baby in February, this is timely for me, to say the least. Thank you for putting this out there for us to learn as well. I for one am looking forward to seeing this video.

No one is talking about the description of the pelvic posture observed by the author. I am a physical therapist and the VAST MAJORITY of women I see are not tuckers but in fact are forward tilting their pelvis because of lack of core muscles (pelvic floor and deep abdominals)and still standing like they are pregnant. My mentors have been treating women for 25 years and also observe most women to forward tilt their pelvis and let their tummy hang forward (ESPECIALLY MOMS!). This is my major problem with this article and someone needs to address this fact since the rest of the article is based on this. Moms: check yourself.... Do you stand with your tail tucked between your legs or do you stand with your tummy hanging forward, knees locked straight? My friend asked me to respond to this article with my professional opinion and experience on her blog and here is the link: http://www.doulatrainingsinternational.com/to-kegal-or-not-to-kegal

Great post. My friend Joanna just sent it to me. As a former personal trainer & pialtes instructor, 15 years ago a new client came to me with a request to help her strengthen her pelvic floor otherwise she was destined for surgery. After roughly 3 months of working with her (we focused on basic strength training and flexibility as well as educating her on how to locate the PF muscles and not squeeze the 'life' out of them - on a scale of 1- 10, ten being maximum contraction, focus on a 3 or 4). The most rewarding feedback was when she told me that her surgery had been cancelled. She was elated beyond belief!

At 40 years, I've had two pregnancies and can with all certainty share that I am peri-menopausal. In fact it began about 5 years ago. My doctors had a difficult time accepting it and instead of focusing on what I was telling them looked for other causes for my list of conditions. Long story short, with the help of an MD who consults in Homeopathy, I am now applying bio-identical progesterone. I am very detail oriented and have kept a chart prior to starting the progesterone, analyzing months of symptoms to now charting months with the progesterone. I won't bore you with all the details, (I'll have to write my own post for that), but in short, when I would skip, run/jog, sneeze, laugh, well - you know...After the progesterone, nothing. From my own experience I see a relationship with the drop of progesterone and increase in estrogen at certain points in my cycle which affects the PF from doing its job. Without a doubt a functional pelvic floor is essential as it is for our entire body to be muscularly balanced. I love Katy's explanations: not too tight just right.

I've been a runner since I was 13. I love to run, it's really, truly ME time. But after my first child (he was 9 lbs 2 oz) I not only discovered I had a congenital abdominal hernia I also learned I was incontinent. I did kegels, I did physical therapy. The incontinence went away when I was pregnant with my second child, came right back after delivery. Peed myself horribly one day. Wore pads ALL the time. Sex drive down. Work confidence down. Spontaneous play with kids down. Running.....gone. Got pregnant with my third, and got a glimpse again at the "continent life." That's when I decided to fix it once and for all. I got a sling in December 2010. In April 2011, I ran a 10-miler with my best friends, leak free. In May 2011, I ran the Pittsburgh 1/2 Marathon with my husband, leak free. I lost 20 lbs! I ran my fastest 10K in YEARS this past weekend. I cannot tell you how much resolving this "minor" or "cosmetic" issue has changed my life. Everyone has to make their own choice, truly. No single solution works for everyone. But this solution worked for me!!!

Interesting interview and information. Thanks for posting.I have questions for Katy re adapting exercises for obese people and/or people with knee problems.Is there a protocol for adapting to this populations needs?Of course doing it in the shower would not be safe for people.Perhaps in a warm therapy pool...of course releasing flow before entering the pool That seems the safest place.What suggestions/adaptions would she have?Thanks!!

I teach clients to do kegels the traditional way and to also learn to push out and expand the pelvic floor (like a reverse kegel). This article helps me fully understand why both are necessary. Fabulous!

Individuality is key, not any one technique or theory. I have very well toned glutes, yet have bladder problems after my first pregnancy. My problem is purely very weak pelvic floor and poor control of these, and nothing to do with my glutes. if anything, the fact that they fire so quickly is one of the problems. I would say that the solution is different for every individual, and no one way is the ultimate right way. Anyone who says they have the one right answer for every woman - is someone that comes off my referral list for my own clients in clinic. I encourage practitioners who individualise treatment and exersice to each individual, something which i think is key to sucess.

Wow. Fascinating perspective! It makes a whole lot of sense to me. I have a bit of an anterior tilt in my pelvis, and I wonder if that has helped me avoid incontinence after having kids. Here's something I don't understand. Katy talks about tight quads and psoas pulling on the sacrum, reducing the lumbar curve. But my understanding is a tight psoas and quads in fact increase an anterior tilt of the pelvis and create a deeper lumbar curve. Can you help me understand this?

Tami- you are right in that there is a general (mis) understanding that the psoas and the quads make a lumbar curve. This is not correct. Only on of the quads even attaches to the pelvis at a point too low to cause great rotation and the psoas doesn't even attach to the pelvis at all. Mane people also mistake spinal shear for extension - but shear is not pelvic tilt either. Alignment is so specific and geometrical, but once you get the hang of it, it really makes sense! You can read a lot more on my blog (there are tons of pelvis/lumbar spine/pelvic floor posts there!)

Read more at www.lifeasafitmom.com

Mama Sweat is a blog I wrote between 2008 and 2015, during the pregnancy of my fourth child and the transition of my toddlers into tweens. Mama Sweat wasn't about weight loss or acquiring the perfect body, it was about finding fitness in the chaos of motherhood, being a good fitness role model and raising a fit family. I've kept a few posts here (including the popular pelvic floor series) but you can now find me and my writing at www.lifeasafitmom.com.

Hot (Sweaty) Mamas on Facebook

Subscribe To Mama Sweat

About This Mama

I'm mom to 12-year-old twin girls, another daughter who is 10 and a 6-year-old son. I'm also co-author of the book, "Hot (Sweaty) Mamas: Five Secrets to Life as a Fit Mom," (www.hotsweatymamas.com) and the children's book series for the Go! Go! Sports Girls (www.gogosportsgirls.com). I enjoy being active, especially (but not limited to) running, biking, swimming, and yoga. More about me at www.lifeasafitmom.com.