Frequently Asked Questions

Q: How common is losing urine in pregnancy?

A: About one in three women experience some urinary leakage just before and during pregnancy. This includes leakage with cough and sneeze (stress urinary incontinence), with urgency and frequency of urination (urge urinary incontinence) or both. Stress urinary incontinence is the most common type. However, before their first pregnancy, most women leak very rarely; fewer than one in ten of women who leak experience it every day or a few times a week.

On the other hand, among women who leak during pregnancy, half leak more than once a month and nearly one in five leak every day or a few times a week.

In other words, the frequency of urinary leakage is higher during pregnancy.

Reference:

• Daly D, Clarke M, Begley C. Urinary incontinence in nulliparous women before and during pregnancy: prevalence, incidence, type, and risk factors. Int Urogynecol J. 2018 Mar;29(3):353-362.

Q: When does urinary leakage typically start in pregnancy?

A: Urinary leakage can start at any point (and sometimes predates pregnancy) but it is more common, more frequent and more severe as pregnancy advances. Some studies show that 9% of pregnant women leak in the first trimester, 19% of pregnant women leak in the second trimester and 34% of pregnant women leak in the third trimester. Bother from urinary leakage during pregnancy is mild to moderate and women are most bothered in the third trimester.

Reference:

• Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. Prevalence, incidence and bothersomeness of urinary incontinence in pregnancy: a systematic review and meta-analysis. Int Urogynecol J. 2021 Jan 13. doi: 10.1007/s00192-020-04636-3. Epub ahead of print. PMID: 33439277

Q: Are there any activities I should avoid, during pregnancy, to reduce urinary incontinence?

A: Often during pregnancy higher impact activities such as running and jumping or lifting heavy weights can contribute to pelvic floor symptoms like leaking of urine. This is mainly because of increased pressure on the pelvic floor and could be because of weakness or impaired coordination of the pelvic floor muscles. While this can be distressing, and could possibly be a factor contributing to urinary incontinence in the early days postpartum, it may not necessarily contribute to long-term urinary incontinence. So while it may be important to modify exercises to a lower-intensity option if higher-intensity activities are causing you to leak, don't avoid exercising altogether, as moderate-intensity exercise during pregnancy helps to minimize the risk of medical complications and postpartum pelvic floor problems.

References:

• Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, Issue 12.
• Nygaard I. Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians. 1997; 90(5):718-22.
• Mottola MF et al. No367- - 2019 Canadian Guideline for Physical Activity throughout Pregnancy. JOGC. 2018; 40(11): 1528-1537

Q: Are there any pelvic floor exercises I should avoid in pregnancy? If yes, why?

A: We know that pelvic floor exercises during pregnancy decrease the risk of urinary incontinence later in pregnancy and postpartum, so they are a valuable tool and should be included in all prenatal exercise programs. There have been some claims that pelvic floor strengthening exercises or high intensity exercise can cause the pelvic floor to be "too tight", but this is not supported by research. The most important thing about doing pelvic floor exercises is that you are focusing on both the contracting (squeeze and lift) and relaxing (letting go) part of the exercise. It is also important to get your pelvic floor assessed by a pelvic health physiotherapist, if possible, so that you understand how to properly do your pelvic floor exercises, and so they are tailored specifically to your needs. And one more thing; don't do your pelvic floor exercises while sitting on the toilet! Stopping the flow of urine to "practice" your pelvic floor squeezes can interfere with the body's natural reflexes and could contribute to bladder problems.

References:

• Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2017, Issue 12.
• Mottola MF et al. No367- - 2019 Canadian Guideline for Physical Activity throughout Pregnancy. JOGC. 2018; 40(11): 1528-1537
• Bo K, Nygaard I. Is physical activity good or bad for the female pelvic floor? A narrative review. Sports Medicine. 2020; 50:471-484

Q: I’m curious what the evidence suggests about choosing vginal birth after cesarean (VBAC) or elective cesarean section (C/S). What are the pros and cons of each? What questions should a person consider?

You should discuss choosing VBAC or elective C/S with an obstetrician who can explain the benefits and risks of both approaches, including surgical risks of C/S. During this conversation, your obstetrician will carefully consider your age, your family history, your desired total number of pregnancies, the reason why you needed a prior C/S and your risk factors for pelvic floor trauma. Some of these risk factors are mentioned in our OASIS video on our website. As your pregnancy progresses, there are additional risk factors that can be considered, such as the presence of gestational diabetes or a twin pregnancy. Your plan for VBAC or C/S is not set in stone. Things can change as late as during your labour. For example, if your labour is not progressing well and your baby is not in a correct position for delivery, you may change your mind about VBAC and ask for a C/S instead. The best way to prepare is to educate yourself about different options so you can make the best choice when time comes.

Q: Will urinary incontinence go away after I have my baby?

A: Not necessarily. While most women will recover fully, some will have persistent leakage long after childbirth. If you continue experiencing bothersome leakage six months after you give birth, this is not normal and should be investigated by a gynecologist or urogynecologist. Pelvic floor muscle exercises and guidance from a pelvic floor health physiotherapist will help guide your recovery.

Q: Are there specific exercises for women who have anal incontinence?

A: Pelvic floor exercises are also used for the treatment of anal incontinence. The focus of these exercises may be directed more specifically to the anal sphincter and the sling of muscles that loop around the rectum. Working with a trained pelvic healthcare professional will help you identify how to correctly contract and relax this area and work through a training program specifically tailored for you.

References:

• Abrams,P, Cardozo, L, Wagg, A, Wein, A. (Eds) Incontinence 6th Edition (2017).
• Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A Hay-Smith EJC.
• Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews 2020, Issue 5

Q: I’ve heard that with pelvic floor exercises bladder prolapse is reversible. Is this true?

A: This can be true but it depends on how far advanced the prolapse is and how strong and functional your pelvic floor muscles can get. Typically prolapse can be reversible if it's very mild to start with. If it's advanced, it's unlikely to be cured with pelvic floor muscle strengthening alone.

Q: At what age should you start doing pelvic floor exercises?

A: Research shows the best time to learn pelvic floor muscle exercises is very early in life and on an intact pelvic floor. We should ideally introduce the concept of pelvic floor health along with sexual education for school age children. Another great time to discuss these exercises with a healthcare professional is at the time of a first screening Pap smear. After pelvic floor stretching (through childbirth, for example), many women are found to push rather than pull up on their pelvic floor, which can worsen pelvic floor symptoms instead of making them better.

Q: How do you know if you’re doing kegels correctly?

A: You should feel a lift of your pelvic organs (bladder, bowel, uterus). Another way to identify the pelvic muscles is to try to stop the flow of urine while on the toilet urinating. However, this should be done for muscle identification only. Repetitive pelvic floor muscle exercises should be performed in a comfortable position, preferably while lying down. Doing Kegel’s on the toilet can be harmful as it can stop the bladder from emptying completely.

Q: Should I use kegel weights?

A: Yes, if designed specifically for this purpose. They are a great way to show you improvement over time. If you can hold an increasingly heavier weight, that means you are exercising correctly and your pelvic floor muscles are getting stronger.

Q: Are there any reasons why you shouldn’t do kegels?

A: You should not do kegels by yourself if your pelvic floor muscles are already too tight. You should see a pelvic physiotherapist to learn to correctly tighten and relax these muscles.

Q: I have difficulty doing kegels without holding my breath. Is it better to do them without breathing or not at all?

A: It is common for people to use compensation strategies such as holding their breath when learning to do pelvic floor muscle exercises. Sometimes these compensation strategies may give people a false sense that they are contracting their pelvic floor, which may not be effective or beneficial. It is important to learn to correctly contract and relax the pelvic floor without using other muscles or breath holding. This may require guidance from a pelvic health practitioner and can take time, patience and practice. It is also recommended that a correct contraction be confirmed prior to commencing pelvic floor muscle training which should then involve progression towards integration into functional positions and activities.

Q: Is there a right time to connect with a pelvic floor health team?

A: Pelvic floor muscle exercises are recommended for both prevention of pelvic floor concerns, as well as treatment of urinary leakage. The best time to learn to do pelvic floor muscle exercises correctly is when you have an intact pelvic floor, typically before your first pregnancy. The earlier the better. Don’t wait until you have pelvic floor concerns to protect your pelvic floor. If you start exercising with a healthy pelvic floor, you can learn to do these exercises and continue on your own easily at home. However, one of three women are unable to squeeze their pelvic floor on demand and one in four actually strain rather than squeeze, which worsens their pelvic floor. This tendency to strain instead of squeeze gets worse after the pelvic floor goes through pregnancy and childbirth. So it’s important to have your doctor, maternity care provider or physiotherapist check your pelvic floor muscles before pregnancy, during pregnancy and afterwards as well. Especially after pregnancy, a pelvic health physiotherapist is best trained to recommend an exercise program that is tailored to your needs.

References:

• Robert M, Ross S. No. 186-Conservative Management of Urinary Incontinence. J Obstet Gynaecol Can. 2018 Feb;40(2):e119-e125.

Q: How do I know if my pain is caused by a problem with my pelvic floor?

A: If you wish to know if there is a pelvic floor component to your pain, please get a referral to a pelvic floor specialist or pelvic physiotherapist who can examine your pelvic floor for signs of tenseness and recommend relaxation exercises.

Q: How to stop leaking while using Uresta?

A: If you are still leaking with Uresta in place, it may be that you need a different size or that you have an incorrect diagnosis for your urinary incontinence type. If you have all 3 Uresta sizes in the original kit, try them all and see if another size fits better. Please check in with your doctor for other investigations and treatment options.

Q: Should I see a pelvic health physiotherapist if I experience slight discomfort when first having intercourse? Discomfort dissipates quickly, just first few moments.

A: The discomfort you describe could be due to a condition of your vulva or vagina, in which case you need to see your family doctor or gynecologist. However, it could also be due to tight pelvic floor muscles, in which case a pelvic physiotherapist is indeed your best choice.

Q: Is a pessary available at a pharmacy?

A: Pessaries for prolapse can be picked up at some pharmacies and medical supply stores, as well as online, but need to be fitted first. The only pessary available at a pharmacy without the need to consult a healthcare professional is Uresta, which is a pessary for stress urinary incontinence (not prolapse) designed to be self fitted. To get the correct size for all other pessaries, you need to go to a clinic with experience in pelvic floor health first. Many gynecologists and some pelvic physiotherapists can also fit pessaries.

Q: I am 83 and in pretty good health. I usually wake up twice in the night to pee. However, because of arthritis, I am slow getting moving after I get out of bed and have to consciously relax my hip and quad muscles to help me get started. It is difficult to do this and hold on to my pee at the same time and I sometimes leak on the way to the bathroom. Is there a way to keep that "gate" shut until I am ready to open it?

A: A good way to prevent these nighttime leaks is to get your pelvic floor muscles stronger. Given your arthritis and hip issues, it may be useful to work with a pelvic floor physiotherapist to strengthen these muscles and improve your mobility. Also, avoid drinking after 7 PM and hopefully your bladder won’t be too full overnight. Hope this works for you!

Q:What do you recommend for pelvic floor health in long distance runners?

A: Seeing a pelvic floor physiotherapist for an assessment of your pelvic floor is key, especially if you have been pregnant and/or birthed a child, or are nearing menopause. Impact sports such as running and jumping require a higher level of function of the pelvic floor muscles than lower impact activities. It is important to make sure that you have adequate strength, endurance, flexibility, and coordination of the pelvic floor and “core” muscles. And if you are getting pelvic floor symptoms when you run, that doesn’t necessarily mean you have to stop! A pelvic health physiotherapist can help you troubleshoot the reasons for your symptoms and teach you exercises that can help. Or sometimes they will recommend a change in the terrain, modification to your training program, or suggest a product like a pessary.

Q: Are some women "too tight," due to training in certain sports?

A: The pelvic floor muscles act similarly to muscles in other parts of the body. Just like muscles in our arms and legs get stronger and more toned the more we exercise them, so do the muscles of the pelvic floor. And, similar to muscles elsewhere in our body, not only do they need to be strong, they also need to be able to lengthen. Some sports, especially those involving impact (eg: running, jumping sports) and heavy lifting (eg: weight lifting) require more work from our pelvic floor muscles and may result in them being stronger and more toned. But this doesn’t necessarily dictate that they will be able to function well. Sometimes the pelvic floor can be strong and function really well (great!), but sometimes it can be strong and not coordinated or not flexible, neither of which is optimal. A pelvic floor that is not coordinated or flexible could contribute to pelvic floor symptoms. “Tight” isn’t necessarily the best descriptor for the pelvic floor, as this doesn’t really give a good idea of what the function is like; and the function is what is most important, not the amount of “tension” in the muscles.

Q: If estrogen plays a role in urinary incontinence, would hormone therapy or BCP help?

A: Estrogen administered orally or transdermally (by patch) does not help with incontinence. However, vaginal estrogen can help with urge-related urinary symptoms after menopause.

Q: Do jade eggs work?

A: Please do not use jade eggs as vaginal weights. There are many other marketed products which are safe to use as inserts for pelvic floor muscle exercises. The vagina is full of bacteria which are useful in the right amounts. Jade is a semi-porous material, which means bacteria can get in, multiply, upset the natural environment of the vagina and cause a vaginal infection over time. Even if you clean your jade eggs carefully, you cannot completely eliminate microscopic organisms. Also, you want to avoid products that can crack and scratch your vaginal wall, or worse that can chip off and stay in your vagina.