At least one in three women, and by some estimates as many as half of all people, suffer from a pelvic health disorder at some point in their lifetime. Pelvic floor disorders include common problems like stress and urge urinary incontinence, constipation, pelvic organ prolapse and pelvic pain, which are extremely common, but not normal. They cause difficulty caring for families, going out in the community, working and exercising. When left untreated, they can progress over time and lead to high distress, activity restriction, unnecessary surgeries and falls in the elderly.

Pelvic floor physical therapy (PFPT) is the gold standard for early intervention for many of these disorders; however, therapists often only get to see people once their symptoms have progressed over many years to the point of significantly impacting quality of life.

Urinary incontinence is an especially common problem in women postpartum, around menopause and later in life, but PFPT can help. The pelvic floor muscles are a group of muscles organized in layers at the base of the pelvis, suspended by ligaments and fascia and anchored to our pubic bones, sit bones and tail bone. They work as a group to lift and support pelvic organs like a hammock, and to open and close the urethra, vagina and anus. The pelvic floor muscles play an important role in maintaining continence.

It’s important to distinguish between stress and urge urinary incontinence. The former results from a sudden increased pressure on the bladder, as when laughing, coughing, sneezing or standing up quickly and lifting weight. The latter is characterized by having a “let down” response too soon during an overwhelming urge to urinate—often in response to a situational trigger like walking through the front door, hearing water running or rushing to the bathroom that causes a neurological “switch” to be “flipped too soon” without the brain being able to consciously inhibit the bladder’s release of urine. This is not always a sign of weakness. Some people accidentally train their body to be overly sensitive to the sensation of bladder filling by going “just in case” all the time, or have short, tight pelvic floor muscles that contribute to pressure on the bladder and overall hypersensitivity to stimuli in the pelvis. This often is part of a history of issues like constipation, painful intercourse and pelvic exams, and anxiety.

Through a gentle exam, a pelvic floor physical therapist can help distinguish the type of incontinence and explain the best interventions. Report any sudden onset changes in urination, gait (manner of walking) or mental status as an infection or other potential medical conditions need to be ruled out by a medical doctor.

•  Sit down if possible and put pressure on the perineum (center of the pelvic floor) by sitting in good posture with the rib cage stacked over the pelvis and weight evenly spread between sit bones. Straddling a towel roll can increase upward pressure on the pelvic floor, which cues the body to store the urine.

•  Perform five quick pelvic floor contractions—“Kegels”—with the sensation of holding in gas, sucking up a vaginal weight and stopping a stream of urine.

•  Use mental distraction like counting backwards from 100 by seven or reciting family members’ birthdays or a grocery list.

•  Keep a bowel/bladder and dietary journal to look for patterns and relationships between clusters of frequent urination and things you did, drank or ate before.

Stress urinary incontinence is usually caused by pelvic floor muscle weakness, poor endurance and incoordination of muscles during a moment of peak pressure. An example is pelvic floor muscles bulging downward and outward with a sneeze instead of squeezing and lifting the bladder upward to keep the urethra shut. This is usually helped by pelvic floor muscle training (PFMT).

•  Perform a proper pelvic floor muscle contraction. Practice squeezing and lifting the muscles around the anus, vagina and urethra with the feeling of holding in gas, lifting a weight inside the vagina and stopping a stream of urine. Relax and inhale deeply into the belly and pelvis to get ready, exhale like blowing through a straw as you move the perineum up towards the top of the head and back down smoothly like a little elevator. Pause and completely relax before trying another contraction.

•  Have an experienced pelvic floor physical therapist assess and supervise a progressive pelvic floor, hip and core strengthening program lasting at least 12 weeks when appropriate.

•  Practice timing and holding a pelvic floor contraction with moments of increased intraabdominal pressure: when getting out of a chair, coming up from a squat to lift things like laundry/kids/groceries, and coughing, laughing or sneezing.

•  Don’t practice pelvic floor contractions while peeing. While the cue “pretend to hold in gas and stop a stream of urine” is often used for a Kegel, don’t actually stop a stream of urine while on the toilet, as this could lead to urine backflow and can mess with the appropriate relaxation response of the pelvic floor while peeing.

•  Sit, don’t hover. If one doesn’t like sitting on public toilets, line the seat with toilet paper and sit down, which makes it easier to fully relax the pelvic floor and empty the bladder completely.

•  Don’t bear down to empty the bladder. Urination should be passive. Breathe deeply, relax the pelvic floor fully, and if needed, shift position and tip the pelvis forward, then relax again. Repositioning the base of the bladder may move trapped urine into the urethra.