Post-partum Urinary Incontinence
International Journal of Childbirth Education, June 2009
Heather Jeffcoat, DPT
There is a typical history I encounter in my practice—“I’ve had two kids and now whenever I laugh or sneeze, I experience urine leakage”. But it’s normal, right? I always tell my clients that the problem may have arisen because of childbirth, and maybe all of their friends giggle about this unfortunate consequence of having a beautiful and perfect baby. But it is not NORMAL—there is something you can do (other than surgery or medication) to get your pelvic floor muscle function back to normal. And it’s more than doing just Kegels.
I’ve had many women tell me over the years, “I do Kegels, but they don’t work”. A study published in The American Journal of Obstetrics and Gynecology (Bump, et al 1991) looked at the performance of Kegel exercises after brief verbal instruction. The results showed that 51% of women were performing a Kegel incorrectly at this level of teaching. Worse yet, 25% of women were performing them in such a way that could actually worsen their incontinence. This study highlights the principal that if an exercise is not performed properly, it will not work and has the potential to worsen the problem.
The first item to consider is, does your client perform a Kegel properly? This is an essential first step in reducing or eliminating incontinence. Here is a helpful trick your clients can try at home: Take a mirror to visualize the perineal area. When performing a Kegel, they should only see the anus and vaginal opening lift and close. They should not see or feel the muscles in their inner thighs or gluteal area contract or their abdominal muscles bulge out. This technique acts as a form of home biofeedback to train the proper muscle contraction.
Once your client is able to isolate a Kegel, a progressive strengthening program comes next. How many should they do? What type of Kegel? This question is always followed with “There is more than one kind of Kegel??” When in doubt, start with a program that’s too easy rather than too difficult.
Sample Kegel Progression:
Week 1: Hold 1 second (“Quick Flick”). Perform 2 sets of 5, 3 times per day.
Week 2: Increase to 2 sets of 10, 2 times per day.
Week 3: Increase to 2 sets of 15, 1 time per day.
Week 4: Continue with Week 3 routine, add 3 second holds (“Long Holds”), 2 sets of 5.
Continue to increase 3 second holds per Week 2 & 3 protocol. Once, up to 2 sets of 15, increase hold times to 5 seconds and reduce repetitions to 2 sets of 5 again. Continue to gradually increase repetitions. Your client’s goal will be to perform “Long Holds” for 10 seconds, at least 2 sets of 10 daily.
There are additional exercises that assist with reducing symptoms of incontinence. These
exercises work by utilizing muscles that have a synergistic effect to the pelvic floor muscles (Carriere, 2006).
Pillow Squeeze with Pelvic Curl:
Instruct your client to lie as pictured in (A) with a pillow or ball between her knees. Have her take a deep breathe in, then exhale as she imprints her spine into the floor followed by elevating her hips as pictured in (B). Cue her to inhale to prepare then exhale as she reverses this movement back to the start position.
Sidelying Hip Abduction with Hip External Rotation:
Instruct your client to lie as pictured above, with the top hip turned out slightly (so that the toes point towards the ceiling). Note, each hip should be stacked one on top of the other, with no rotation of the spine present.
Modified Downward Dog:
Instruct your client to get into the above position. Have her perform gentle abdominal contractions, cueing her to “pull her navel to her spine”. Hold for 5-10 seconds. This exercise is especially beneficial for women that also have a prolapsed uterus.
Instruct your client to lie on her stomach as pictured above. Cue her to exhale as she lifts her thighs up off the floor, pushing her pubic bone down.
All of the above exercises should be performed at least 4 times per week. A Kegel at 30% maximal effort should be performed during each of the above exercises. Begin with 8 repetitions and gradually increase to 20 repetitions as subjective strength improves.
It should be noted that any position or movement that causes a client to hold her breathe is too strenuous. This will increase intraabdominal pressure and place undue strain upon the abdominal wall and pelvic floor muscles. If abdominal bulging is observed through a separated rectus abdominus (if present), the exercise being performed is likely too difficult and should be modified or discontinued if a modification is not possible.
If your client’s symptoms don’t show measurable improvement within the first 4-6 weeks of maintaining the above exercises and sample Kegel progression, a more individualized program designed by a Women’s Health Physical Therapist may be required. The use of conservative therapy and pelvic floor muscle biofeedback is supported in numerous studies (Hay-Smith 2006, Di Benedetto 2008). However, depending on the severity of the incontinence and any additional contributing factors (for example, prolapse or pelvic pain), the total duration of their therapy may require more than 6 weeks to completely eliminate their symptoms.
Bump, et al. Assessment of Kegel pelvic muscle exercise performance after brief verbal instruction. Am J Obstet Gynecol. 1991 Aug;165(2):322-7
Carriere, B., Feldt, C.M. 2002. The Pelvic Floor. New York: Thieme.
Di Benedetto, P., Coidessa, A., Floris, S. Rationale of pelvic floor muscles training in women with urinary incontinence. Minerva Ginecol. 2008 Dec;60(6):529-41.
Hay-Smith, E.J., Dumoulin, C. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005654.
Stephenson, R., O’Connor, L. 2000. Obstetric and Gynecologic Care in Physical Therapy. New Jersey: Slack, Inc.