The Behavioral Side of Peeing

Your bladder is a muscle — I’m sure you’ve heard that, and it’s a little true.  There is a muscle that sits on your bladder, called the detrusor. It’s job is to assist your bladder in the filling and voiding of urine.  As your bladder fills, the detrusor remains relaxed; then once filled the detrusor contracts and assists the bladder with emptying (voiding) of the urine inside.  Like most muscles, the detrusor has another muscle that “counteracts” it; we call these other muscles “antagonists”. Much like the biceps and triceps are antagonists of one another; one bending the elbow (biceps) and one extending the elbow (triceps); the detrusor is in an antagonistic relationship with another set of muscles – the pelvic floor.

The pelvic floor muscles are responsible for communicating with the detrusor muscle whether or not it’s an appropriate time for you to urinate (void).  Once the bladder reaches a certain level of fullness, the detrusor contracts, signaling to your brain that it needs to empty. Your pelvic floor has one of two options:  Relax – and allow for the detrusor to empty the contents of the bladder, or Contract – and communicate to the detrusor (and your bladder) that it’s not a good time to void, and it needs to wait (relax).

What is responsible for the upset of this relationship?  

A lot of things can be the cause for the disruption in the relationship between the detrusor and the pelvic floor musculature, we’ll just cover one of them in this article:  Behavioral Voiding

Behavioral Voiding means urinating when your brain has not received the signal that you need to go (the urge).  This would include going to the bathroom because: you’re leaving the house, or you’re about to leave work, or you’ve just gotten to a store and don’t want to be interrupted.  If you are going to the bathroom simply because you “think you should” and not because you “feel the urge” on a physiological level – you are participating in Behavioral Voiding.

But why is it bad?  

Behavioral Voiding teaches your bladder that it needs to empty prior to it being necessary to empty, and may actually cause urinary retention.  What this may eventually do is create the “urge” to go when you’re bladder is not adequately filled, resulting in increased trips to the bathroom, confusing your pelvic floor muscles and bladder, possible leakage, and increased dependence on the toilet.

What can you do?  

Timing your trips to the bathroom can be helpful.  As a rule we should be urinating 6-8x/day; and should not be urinating any more frequently than every two hours.  

If you are urinating more frequently than that, you may want to speak with your doctor and see a physical therapist who specializes in incontinence and pelvic floor dysfunction for help.

Exercising During Pregnancy

Whether you are appropriate for an exercise routine during your pregnancy is a discussion you should have with your OBGYN during the first few weeks of your pregnancy.  There are some conditions in which special considerations should be made in regards to exercise, we will cover some of them below.

Contraindications to Exercise:

Women with certain conditions or complications during pregnancy, should not exercise during pregnancy, some of these conditions may include, but are not limited to:

• Severe anemia, or low levels of blood or red blood cells, typically related to iron levels
• Multiples; being pregnant with twins, or more, may have a higher risk for preterm labor
• Preterm labor, or ruptured membranes during the pregnancy
• Preeclampsia; pregnancy induced high blood pressure, often presenting with other physical conditions with the possibility of organ damage
• Placenta previa after 26 weeks; a condition in which part or all of the uterine opening is covered by the placenta which is set low
• Cervical insufficiency; the inability of the cervix to maintain/retain a pregnancy during the second trimester
• Certain types of heart and/or lung disease

Considerations of your body’s changes, and how that can affect exercise:

Weight Changes:  With increasing weight gain, specifically located at your abdomen, this can alter your body’s sense of position during exercise.  Due to this your center of mass, and ultimately your balance will change and be challenged. It is important to avoid activities in which if you were to lose your balance, you would be in danger of hurting yourself, or your child.

Hormonal Changes:  As your body prepares for the birth of your child, it secretes a hormone which is known to cause ligamentous laxity.  Due to this hormone, it makes it much easier for you to sustain and injury of your joints while exercising. Therefore it is beneficial to avoid quick, bouncing, or high impact exercise, which could increase your risk of injury.

Precautions to take while exercising:

• Avoid overheating.  Avoid exercising outside when it is hot or humid.
• Hydration.  Ensure you are drinking adequate water before, during and after you exercise.
• Overexertion.  Recommended heart rate during exercise while pregnant is 140 bpm or less.  
• Proper support.  Wearing adequate support for your breasts and growing belly can be beneficial for your comfort during exercise.  Proper sports bras, and pregnancy belts can help with extra support.
• Avoid standing still or laying on your back.  Standing still can cause blood to pool in your lower extremities, which can cause a decrease in your blood pressure for a short period of time.  Laying on your back, especially during second and third trimesters, causes the uterus to press on the large vein that returns the blood in your lower body to your heart.  This pressure can also cause increased swelling of the legs as well as temporary low blood pressure.

Exercise!

  The Center for Disease Control and Prevention recommends pregnant women exercise for at least 150 minutes of moderate intensity aerobic activity, weekly.  Moderate intensity would be described as an activity in which you begin to sweat, but could still carry on a conversation.

Safe Exercises:

• Walking, swimming, water aerobics, stationary cycling, prenatal yoga, prenatal pilates.
• If you are an avid runner/jogger, you may be able to continue those activities into your pregnancy, but need to discuss them with your OBGYN.

Exercises to Avoid:

• Contact sports, activities that could result in a fall (ie. skiing, surfing, off-road biking, gymnastics, horseback riding, etc.), Hot yoga/pilates, Scuba diving

When to stop exercising:

The following symptoms would be indicative of exercise cessation, and immediate medical attention:

• Vaginal bleeding or fluid leaking
• Premature vaginal contractions
• Decreased fetal movement
• Dizziness or feelings of faintness
• Excessive shortness of breath
• Chest pain
• Headache
• Muscle weakness
• Calf pain or swelling
• Increased heart rate (over 140 bpm)

If you have had a regular exercise routine prior to your pregnancy, you should be able to continue that throughout your pregnancy.  Exercise does not increase the risk of miscarriage during a normal low risk pregnancy. Ultimately, it is important to discuss pregnancy exercise guidelines with your OBGYN and physical therapist to ensure a healthy and safe routine during pregnancy.

Why it’s okay to talk about it…

Dyspareunia is the medical term for painful intercourse. It is most commonly found in women, although it can occur with men as well.  For the purposes of this particular blog post, we will focus our discussion on how it affects women who engage in penetrative vaginal intercourse.

It’s difficult to know with certainty just how common this is, because of how often it goes unreported.  To the best of our ability, we believe women who have experienced prolonged pain with intercourse is around 10%:  in women 20-29 years of age it’s around 13%, and for women 50-60 years of age it’s around 6.5%.

There are many potential risk factors for women to develop dyspareunia at any point in their lifespan.  There may be correlating factors such as anxiety and depression, increased number of pregnancies, frequent sexual intercourse, sexual inexperience, being peri- or post-menopausal, as well as cultural influences regarding sexual intercourse.

There are two main kinds of dyspareunia, superficial and deep:

• Superficial Dyspareunia:  May be felt at the vaginal opening during initial vaginal penetration
• Deep Dyspareunia:  Felt with deeper penetration during vaginal intercourse

These are not mutually exclusive, and may present together.

How Can Physical Therapy Help?

Following a screening provided by your GYN, a Physical Therapist trained in Pelvic Floor Rehabilitation will conduct their own examination, both externally and internally.  A general history is first collected to best determine the kind, location, duration, and timing of the pain. Following that, a general orthopedic screen of the low back, hip and pelvic/abdominal region will be performed.  Then, with your permission, an external/internal evaluation of the pelvic floor (genital region) would be performed. From this evaluation, the therapist can determine areas of muscle tightness and/or weakness that may be contributing to your pain.  They may also offer suggestions to assist with self-management, and can even educate your partners on how they can assist with your recovery.

This condition often takes a considerable amount of time to overcome; likely due to the number of potential risk factors associated.  It’s important to be kind to yourself and allow the body to heal in its own time; but know there are things that can be done to assist with that healing process.  Please remember, you cannot get the help you need, if you don’t speak up about it!

Although c-sections are becoming fairly common in the United States, approximately 30%, that does not mean they should be considered a “small surgery”.  Cesarean births are incredibly involved; both during and following the procedure. There is cutting that occurs of skin, fat, and organ tissue, a manual separation of the abdominal wall, and the shifting of pelvic floor organs to remove the baby from the womb.  This is no small procedure! So when you are ready to return to your prior level of activity, and exercise routine, it should be a major consideration to consult not only the surgeon who performed the procedure, but a physical therapist who is comfortable treating, and trained to assist you.

Prior to beginning any exercise routine always consult your physician/surgeon.

The first 6 weeks following the cesarean should be used to rest and recover from the procedure.  It may be okay for you to begin gentle pelvic floor and breathing exercises, and be trained how to perform scar tissue mobilization by a physical therapist; but always get the “okay” from the surgeon first.

Your first appointment with the physical therapist would likely include an evaluation of the scar; ensuring proper healing and introducing you to techniques to begin to “mobilize” the tissue in that area.  It is important to assist the body in its healing so there is not an “overgrowth” of scar tissue which can lead to restriction of movement and pain in later stages of recovery.  

At this first appointment we would also likely introduce some gentle breathing and pelvic floor exercises.  It is likely, following the cesarean, we would focus on the activation and re-training of the pelvic floor through the use of kegal exercises.  

We would also assist you in safe rolling and transfers to ensure protection of the abdominal wall, and breathing techniques to assist in bracing during these functional tasks.

All of this would be tailored to your individual needs considering your muscle weaknesses/imbalances, and restrictions.

Once we get the “all clear” from your physician/surgeon we can begin gentle core exercises to re-train the abdominals and pelvic region.  We need to begin here because the abdominals are the foundation for your body; your arm and leg strength, and stability all depend on this foundational support.  So before you can begin more strenuous or vigorous exercise, we need to ensure your core has adequate strength and stability for the task.

Exercises to avoid without proper training or core stability would include the following:

• Running/Jumping/Plyometric training
• Traditional planks, crunches, or sit-ups
• Leg raises
• Heavy weighted exercises
  • Overhead press & squats with bar across the back (these can cause increased pressure on the pelvic floor)

Exercises to initiate core retraining would include the following, but should always be cleared by the physician and instructed by a trained physical therapist:

• Bridges
• Clams
• Reverse clams
• Pelvic tilting
  • With introduction of hip movements/strengthening
• Abdominal bracing
• Side planks

When returning to a more strenuous exercise program, you will want to consider the following:

• It’s going to take time:  It took 9 months for your body to change and adapt to the growing life within you – it’s going to take time for your body to recover from that change and the added stress of the birthing process.
• Start small:  We all hate set-backs, so it is so important to start small and build up to what you were previously doing.  We need to begin with training the core/abdominal region to give you the “foundational strength” and then increase exercise time/duration, and frequency as appropriate.
• Start light:  By introducing too much, too soon, you can easily overstress your body which could lead to increased pain and healing times.
• Avoid pain:  Re-introducing exercises should not be painful, this is not a situation in which you “push through” – you need to listen to your body and modify accordingly.  That is why it can be so beneficial to work with a physical therapist who understands the procedure you’ve just had, your specific musculoskeletal needs, and your ultimate exercise goals.