Incontinence

Incontinence

Bladder control

Embarrassingly, 1 in 3 women who have had a baby wet themselves. Women who have one baby are nearly three times more likely to leak urine than women who have not had a baby.

Why does having a baby cause urine leakage?

When the baby moves down through the birth canal (the vagina), the canal is stretched. The nerves, ligaments and pelvic floor muscles that control the bladder opening (urethra), are also stretched.

This can lead to weakened muscles and less structural support around the bladder opening, resulting in less bladder control. The symptoms? Leaking urine with coughing, sneezing, lifting, exercise.

Is this leaking likely to go away by itself?

The leaking is not likely to go away unless you guard against further damage and exercise your pelvic floor muscles to help them to get their strength back. As you get older, your pelvic floor muscles will tend to get weaker.

If you do not get the muscle strength back after each baby you have, you are more likely to leak urine. Following menopause, there is a higher risk of having problems with urine leakage also.

How does my bladder work?

The bladder itself is a hollow, muscular pump. The bladder fills slowly from the kidneys. You should be able to hold on until there is about 300-400ml inside the bladder. The bladder closing muscles are called pelvic floor muscles. When you are ready, the pelvic floor muscles relax and the bladder squeezes the urine out. Then the same cycle begins over again.

What do my pelvic muscles do?

 These muscles do a number of things such as:

• Help to close off the bladder, the vagina and the back passage (the anus).
• Help to hold the bladder, the uterus and bowel in their proper place.

What happens if my pelvic floor muscles are weak after the birth?

• You might leak urine when you cough, sneeze, lift, laugh or exercise.
• You might not be able to control your wind (flatulence)
• You might feel a sense of urgency when you need to empty your bladder or your bowel.

Prolapse

When one or more of your pelvic organs sag down into your vagina, this is called pelvic organ prolapse.  Prolapse is very common and happens to about one in ten New Zealand women. If you have a feeling of ‘something coming down’, you might have a prolapse. See your doctor if you are not sure about this.

How do I exercise my pelvic floor muscles properly?

Position: Sit upright on a chair with your back supported. Relax your abdomen and thighs. Breathe normally – your abdomen should gently rise and fall as you breathe.

Pelvic Floor Muscle contraction: Imagine – ‘squeezing around the vagina entrance and lifting the vagina up inside’ or ‘squeezing around the bladder outlet and lifting the bladder up ’Feel the pelvic floor lift.

At first, the movement that you feel may be very small.

If your muscles are weak, you may feel very little at all. Make sure you keep breathing. If you draw your abdomen in strongly or hold your breath, this will hinder your ability to contract your pelvic floor muscles.  Make sure that you do not have any downward movement of your pelvic floor when you try to do a squeeze and lift.  The lower part of your tummy muscles should gently pull in as you squeeze and lift your pelvic floor muscles.  You might like to use a hand mirror to see your pelvic floor muscles working if you feel comfortable doing this. You will see an inward movement of the perineal body (the area between the vagina opening and the anal opening).

If you have difficulty isolating a pelvic floor muscle contraction, try lying on your side. In this position, it is easier to relax your abdominal muscles and therefore easier to feel your pelvic floor muscles tighten.

Pelvic Floor Muscles exercise programme

Step One: Isolation.

It is important that you are correctly contracting your muscles. (see the steps above on how to exercise your pelvic floor muscles) it does not matter if you cannot hold your muscles for long or if they feel weak. The technique is the most important first step.

Step Two: Strengthen – gentle lifts

Positions: lying down or sitting

Begin by gently lifting and squeezing. See if you can hold for 1-2 seconds then build up to 5-10 seconds. This is a gentle lift, not a ‘hard/strong lift’. Once you can hold for longer, see if you can keep breathing while lifting your pelvic floor muscles.

Step Three: Strengthen – strong lifts

Positions; lying down, sitting, standing leaning forwards, straight back and with hands on a bench or table.

Once you are able to control gentle lifts, aim to lift your muscles more strongly. Focus on a quick and strong lift. You will not be able to hold as long as a gentle lift.

Aim to hold for 2-3 seconds then build up to 5 seconds. This will take time and remember to keep your technique correct. Watch that your abdomen does not ‘suck in’ strongly, however, the more strongly you contract your pelvic floor muscles the more you will feel your abdomen tighten but it should remain flat (not suck in or bulge out).

The following is a suggested guide for exercising your pelvic floor muscles.

Lift and hold strongly: 1-5 seconds

Let go completely and rest: 2-5-seconds

Repeat: 8-12 times

Do this routine 3 times per day, daily for up to 5-6 months or until you have reached your goal which could take more or less time.

Step Four: Maintenance

To maintain the good strength and function of your pelvic floor muscles, keep exercising them often by following the above routine 3 times per week aiming for strong lifts.

Throughout the day, think of doing gentle sustained lifts when you are feeding your baby, driving your car or when exercising. Balance type exercise is good for this. For example, sitting on an exercise ball or standing on one leg. Aim to feel your pelvic floor muscles automatically tighten as you keep your balance.

It is also recognised that general exercise is good for improving pelvic floor muscle function. Walking swimming or doing low impact exercise at the gym are beneficial.

Aim to control your weight to a level that suits your height and build. Being overweight can lead to decreased control over your bladder and/or bowel and may also weaken your pelvic floor muscles.

Step Five: Functional

This means to use your pelvic floor muscles during activities of each day especially those activities which may cause urine leakage.

For example:  Lift strongly before you cough, sneeze, laugh or lift your child. This is sometimes called ‘the knack’.

Relationships

Your perception of a continence problem may affect your personal and/or intimate relationships and how you feel about yourself. Pelvic floor muscles play an important role in bladder and bowel control and also affect sexual function and sensation. If resuming sexual activity is concerning you, talk about it to someone who is knowledgeable and sensitive to this aspect e.g., your GP or midwife. Unfortunately, this issue is frequently overlooked or considered unimportant.

How can I be sure that I have good bladder habits?

It is normal to:

• Go to the toilet about 6-8 times each day. Try not to go “just in case”.

• You should pass about 300-400ml each time you go to the toilet.

• It is OK to get up once each night to pass urine. Try not to go just because you have to get up to the baby.

Try to:

• Drink at least two litres of fluid each day, which is 6-8 cups at 250mls per cup. If you are breastfeeding you may need a few more cups per day. You should have mostly water in your total daily fluid intake. Eg. 4-6 cups of water and 2-4 other drinks.
• Avoid too much caffeine or carbonated drinks, limit to 2-3 cups per day. That is coffee, tea, coke, other fizzy drinks. Try a herbal or fruit infusion tea.

You should ask for help if you notice any of the following:

• Any leaking of urine that is not improving
• Needing to go urgently to the toilet. Sometimes you may not be able to hold on and leak before you reach the toilet.
• Burning or stinging as you pass urine.
• Having to strain to start the flow of urine.
• Blood in the urine.

Can constipation cause urine leakage?

Yes! Excessive straining to pass a bowel motion can weaken and damage the pelvic floor muscles and supporting ligaments of your pelvic organs. This includes the bladder and bladder outlet. With strong straining, the bladder is also forced downwards leading to an increased risk of urine leakage problems. Constipation can also give the sensation of needing to go frequently or urgently to pass urine. In severe constipation, the bladder outlet can get obstructed causing difficulty in passing urine. The urine flow may be ‘stop/start’, ‘slow and trickly’ or ‘hard to start’.

How can I avoid constipation?

• Drink plenty of fluid (at least 2 litres per day) especially if you are breastfeeding.
• Eat high fibre bread and breakfast cereals.
• Eat fruit, three pieces each day. Include kiwifruit.
• Use a natural fibre supplement – Eg. Metamucil, Benefiber or Phloe. You can get these from the supermarket or pharmacy. Psyllium husks are much cheaper (get these from a health food shop).
• Vegetables and lentils or pulses are all high in fibre.
• Sit correctly on the toilet to pass a bowel motion. Follow the instructions below:
• When you sit on the toilet, raise your heels or put your feet on a low stool.
• Keep your back straight as you lean forward slightly.
• Relax your pelvic floor, and gently bulge your tummy. It feels like the beginning of when you bear down. You will feel the sides of your tummy bulge and the lower part of your tummy will bulge forwards slightly. (If you overstrain, you will feel your pelvis and back move backwards. That is – round your back. This is incorrect.)
• Do not rush. Work with the natural urge to pass a motion. If you try and push and strain too much, this hinders effective and complete emptying.
• When you have finished, tighten your pelvic floor muscles a few times while still sitting on the toilet.

Special notes:

• Always use this sitting position. This is not just for when you have had a baby.
• Normal frequency to pass a bowel motion is 3 times per day to once every three days and your bowel motion should be soft but formed like a sausage, not too hard and not too soft!
• If you have some swelling and/or stitches in your pelvic floor area after having your baby, you may need to support your perineum while passing a bowel motion. With some toilet paper around your hand, place it over the area between the vagina opening and back passage as you pass a bowel motion.
• If you having problems passing a bowel motion or with faecal leakage or uncontrolled wind (flatulence), let your GP or midwife know. They can advise you on what to do or refer you to a health professional.

 CHECKLIST TO KEEP YOUR PELVIC FLOOR IN CHECK

1.  Maintain good bladder and bowel habits.
2.  Learn how to exercise your pelvic floor muscles correctly and aim to strengthen them. When they are stronger, lift your pelvic floor muscles before you lift, cough, sneeze etc
3.  Start some general low-impact exercise like walking. As time and energy allow try some other types of exercise.
4.  Aim for a healthy body weight. It is normal to have put on weight after having a baby but don’t allow it to ‘hang around’ set goals of healthy eating and exercising to reach your ideal weight.
5.  Avoid heavy lifting, straining and high-impact exercise.
6.  Avoid prolonged periods standing or being upright especially in the early weeks and months post-partum.
7. Have some rest periods for yourself and for your pelvic floor.

If you have trouble with your bladder or bowel do not despair! The chances for a cure for an incontinence problem are good if you seek the right advice. Enjoy your pregnancy and your baby. Both before and after your baby is born, remember that it is important to take care of yourself.

 Need Help?

For information on managing incontinence:

• This might be your GP, your specialist or your midwife.
• Speak with the healthcare professional who is helping you after the birth of your baby
• Many local hospitals have continence advisors. Please phone the Bladder Help Line for a contact list or view at www.continence.org.nz

They can also provide you with the name of the physiotherapist nearest to you who has a special interest in helping women with pelvic floor problems.

Discuss continence with your health professional. You should ask each of your health professionals how any aspect of care during your pregnancy, delivery or post-natal period could affect your bladder or bowel control (e.g. epidural, induction, repair of episiotomy or tears). Consider this information when making any decisions regarding your pregnancy, delivery and after-care.