Urinary Leakage or Painful Sex?

Physical Therapy Can Help That

By Jenny LaCross PT, DPT, WCS, ATC, CLT-LANA 

“You do what!? I didn’t even know that was a thing!” This is the response I commonly get from people when I tell them what I do for a living. I am a physical therapist, board certified in pelvic health physical therapy. This means that I specialize in treating women and men with pelvic health problems including, but certainly not limited to, urinary leakage, pelvic pain, sexual dysfunction, abdominal pain, and constipation. All these medical diagnoses are related, as they typically involve a group of muscles in the pelvis called the pelvic floor. Like all muscles in the body, this group of muscles has a primary function. In fact, it has four primary functions which should signify how important these muscles are. We call them the 4 S’s: sphincteric, sexual, support, and stability. When these muscles contract, they help to clamp down on the urethra and anus to prevent leakage of urine or stool. Conversely, when they relax, they allow you to go to the bathroom. Contraction of these muscles is critical for maintaining an erection (both penile and clitoral) and the ability of these muscles to contract and relax quickly is what constitutes an orgasm. These muscles help to support and stabilize all of your pelvic organs but they also help to support and stabilize your spine. Have you ever tried “core” exercises? The pelvic floor is a critical part of your core. If you hurt your knee, where do you go? Physical therapy. The rationale for attending physical therapy for urinary leakage or pelvic pain is no different. 

Has someone ever told you to do “kegels”? A kegel is a contraction of these muscles. While I can appreciate the well-meaning behind this advice, it is my biggest pet peeve because kegels are NOT appropriate for everyone and can make certain conditions worse.  Studies show when not properly assessed, 50% of women perform kegels incorrectly. This means instead of contracting the muscle you are lengthening the muscle. Being shown a video or handout with verbal directions does not constitute proper assessment. Let me paint a picture for you. You have never worked out before but you want to begin training for a marathon. Someone advises you to go to the gym. That’s great! But what should you do when you get there? Do you need to work on cardiovascular endurance, muscle strength, or flexibility? Do you know how to use the machines correctly and safely? Do you know which machines will help you to achieve your goals? Do you know what intensity level to work at and for how long? You get my point. Telling someone to do kegels is like telling someone to go to the gym. Unless your current muscle function and specific goals have been properly assessed by someone knowledgeable on the topic, it is very unhelpful and perhaps detrimental advice. This is where I come in. As a physical therapist, the musculoskeletal system is my area of expertise. People come to see me for pelvic problems because their doctor, chiropractor, or midwife believe the cause of their problem is musculoskeletal in nature. 

Urinary incontinence is defined as any amount of urine, even a few drops, leaving the body unintentionally. It affects 200 million people worldwide and roughly 25 million adults nationally, 75-80% of whom are women. That boils down to the fact that one out of every two women and roughly one out of every seven men will develop urinary leakage at some point in his or her lifetime. Women have some unique risk factors, combined with their anatomy, which place them at higher risk for urinary incontinence including pregnancy, childbirth, and menopause. Men also have a unique risk factor including surgery for prostate cancer. Risk factors affecting both sexes include obesity and diabetes. 

Just leaked a little when you sneezed? Incontinence. Standing in Walmart, got a sudden urge, and cannot quite make it all the way to the bathroom? Yep, also incontinence. There are three major types of urinary incontinence, all of which are treated differently: stress, urge, and mixed. Stress incontinence is the loss of urine with any activity that causes the pressure in your abdomen to rise, for example coughing, laughing, sneezing, jumping, and lifting. Urge incontinence is leakage associated with a sudden urge to urinate and inability to control it. For most people, there is a trigger like putting your key in the door or washing your hands. It could also be a dietary trigger like coffee, soda, or citrus. Mixed incontinence is leaking urine related to both stress and urge. When treating stress incontinence, we look not only at the function of your pelvic floor muscles (how coordinated, strong, and endurant those muscles are) but how well you regulate large changes in pressure inside your abdomen. This means your breathing strategies, posture, and abdominal muscle function are all key pieces to the puzzle. Treatment of urge incontinence usually involves several strategies. We need to identify triggers. We also provide instruction in a strategy called urge suppression which uses a specific pelvic floor muscle contraction pattern, in conjunction with deep breathing and mental distraction or visualization, to calm down bladder contractions. And we also do pelvic floor relaxation exercises. Treatment of mixed incontinence involves a combination of all the techniques mentioned. 

Pelvic pain is a broad term to indicate many things. The most common pelvic pain condition I treat in physical therapy is painful sex. One in four women will experience pain during sex in her lifetime. Cringe worthy advice I have heard given to patients by other health care providers over the years include “just drink some wine and get over it,” “you better find a patient husband,” and “it’s your duty as a woman so just relax.” Ladies, sex should never hurt. Again for the ladies in the back: sex should never hurt. While painful sex, also called dyspareunia, is complex and can be multi-factorial, two of the most common contributing factors are spasm, or the inability of the pelvic floor muscles to relax, and hypersensitivity of the nerves in the pelvis. Physical therapy is incredibly effective at addressing both problems. The Harvard Women’s Health Watch published a commentary on this in June of 2018 entitled “Pelvic Physical Therapy: Another Potential Treatment Option.” Go check it out if you want to learn more. In therapy we work to relax the muscles and calm down the nerves in the pelvis to restore or initially achieve pain-free sex. 

Do you have any of these symptoms? Do you want to get rid of them? If so, physical therapy is a great place to start. It is considered first line conservative intervention for most musculoskeletal pelvic symptoms and has no adverse side effects. We cannot say this about any drug or surgery. In the state of Oklahoma, a prescription from a doctor is needed to attend physical therapy. Pelvic Health physical therapy is covered by insurance just like regular physical therapy, because it is regular physical therapy, just in a different part of the body. Come see me at Total Health if you want someone to help you solve your pelvic health problems with an individually designed program to meet your specific goals. A healthy pelvic floor is a happy pelvic floor. 

About the Author

Jenny is currently one of only two physical therapists board certified in pelvic health physical therapy in the state of Oklahoma. She received her clinical doctorate of physical therapy from Washington University in the Saint Louis School of Medicine and her undergraduate degree from the University of Michigan-Ann Abor. She completed a pelvic health physical therapy residency at the University of Pittsburgh Medical Center and is currently getting her PhD at Texas Woman’s University with a research interest in the relationship between the hip and pelvic floor symptoms. She is a full-time staff physical therapist at Total Health. 

If you want to learn more about pelvic health, you can follow Jenny on Instagram @pelvicboxer or check out her podcast “Real Talk with the Pelvic Docs”.