Incontinence is NOT “just a normal part of aging”!

Incontinence is not “just a normal part of aging”!  I don’t ever want to hear this again.  We don’t have to resign ourselves to wearing pads or Depends when our body decides to give out. All of us are constantly fighting the signs of aging, from wrinkles in our skin, to memory loss.  Some even focus on preventing muscle weakness which, as a physical therapist, is what I focus on every day when working with the aging population.  Muscle weakness affects our posture, our bone strength, our lung volume and, yes, our continence.

One of the biggest factors contributing to the decrease of our muscle strength is the gradual decline of estrogen that begins slowly after the age of 25 and then speeds up during and after menopause.   This drop in estrogen is associated with a loss of or thinning out of the connective tissues in our body and includes bone and muscle.  One of the muscular areas of our body that is always fighting against gravity and constantly having to hold up the weight of our abdomen is our pelvic floor.  So, not very surprisingly, as we lose muscular strength of our pelvic floor we begin to see signs of this weakness as incontinence and/or prolapse.

The positive message I have for you is that we can blunt these normal aging processes simply by exercising our muscles appropriately. A regular cardio program can significantly reduce our loss in lung volume as we age, resistance training of our upper and lower body can reduce our bone loss as we age, and specific pelvic floor and “abdominal basket” training can prevent and/or resolve pelvic floor weakness which can lead to incontinence. You have control over your body, it’s just a matter of exercising it appropriately!

Weighing your options and knowing your risks

When you begin to experience incontinence or prolapse symptoms, there are several treatment options to consider.  These options range from non-invasive exercise programs aimed at strengthening the pelvic floor muscles to surgical procedures that include inserting a mesh into your body to assist in appropriately supporting your abdominal organs.  A recent article in the New York Times, , highlights the risks associated with the latter. 


My personal belief is that there is a lack of information readily available to women to help them better understand both the causes of incontinence and prolapse and the various solutions available.  The below is my attempt to help educate women on the options for dealing with incontinence or prolapse (see prior blogs for discussion about the causes of incontinence and prolapse).


Option 1:  Purchase a physical therapist-guided DVD or book or attend an exercise class focused on guiding you through a pelvic floor exercise program. This option provides you with a program that you can perform in the privacy of your own home and is aimed at strengthening you pelvic floor and surrounding muscles.  The program would need to be performed three times per week, for four to six weeks to see improvement or elimination of symptoms.  To maintain symptom resolution, you would have to perform a maintenance exercise program thereafter. There are no risks associated with this option.


Option 2:  A slightly more invasive approach involves inserting weighted cones or other tampon-like weights into your vagina and receiving instruction on how to perform pelvic floor contractions.  It is also aimed at strengthening the muscles that have become weak within your pelvic floor.  Again, one should expect to see improvements in approximately four to six weeks with regular exercise.  A maintenance program should be continued thereafter.  This also can be performed in the privacy of your own home and there are no risks associated with this approach.


Option 3:  See a women’s health physical therapist in your area.  This option involves receiving an internal evaluation and then the therapist giving you both verbal and manual feedback as you work to strengthen your pelvic floor muscles.  The advantage of this approach is that you have a one-on-one coach to guide you through your exercise program, helping ensure that all your muscles are firing as they should.  With this approach, you have to take the time to make and attend regular appointments with your physical therapist but, again, there are no risks associated with this approach.


Option 4:  See your OB/GYN or family practice physician to insert a pessary device within your vaginal canal.  The pessary device is designed to help hold up or give support to your bladder or uterus, which helps relieve prolapse symptoms and may improve or resolve incontinence symptoms by giving better support to the bladder.  This approach should also be followed by an exercise program, otherwise you are simply putting a band-aid on your problem and not addressing the cause which, again, is usually muscular weakness.  There are some disadvantages and risks associated with inserting a pessary device, namely changes to your vaginal canal, infection, and bleeding.  For more information on pessary devices, go to this link:


Option 5:  Surgery to insert a mesh into your body, giving support to your bladder or uterus.  The details of this surgery should be discussed with your surgeon.  The following two sites address surgical treatments for incontinence and prolapse respectively in greater detail:



Many urologists that I have talked with have a strong opinion that an exercise-based program should always be a patient’s first course of action because of the risks associated with surgery.  They have cited the risk of infection, the lack of long-term studies to show exactly how long the mesh will last, and the unknown of how many surgeries a women should expect throughout their lifetime to correct the same problem.  As a physical therapist, I always recommend a non-invasive, exercise-based program first and a surgical procedure as a last resort due to the risks associated with any surgery.

Why expectant and new moms are wetting their pants?

I often get the question from young moms – some pregnant, some who have young babies or toddlers: “What is up with this pee thing? Why am I wetting my pants now when I cough, and when I have to run after my little one, there is no way I can hold it. What is going on with my body?”  The “pee thing” can be a bit alarming, but understanding why it’s all happening always helps.

Visualize our pelvic floor as a very thin, muscular tissue that has the responsibility of controlling the passage of solids, liquids, and air from our body, as well as holding up our bowel, bladder, and uterus.  This can help us understand how this muscle can have some difficulty doing all its supposed to do as the weight and size of our uterus increases throughout pregnancy. Incontinence reaches its peak in the third trimester, when the uterus grows most rapidly.  So this gives us insight into why we leak during pregnancy, but what about those of us who delivered months or years ago?  Why are we still leaking?  The answer is that our pelvic floor muscles were stretched beyond their limit, damaging the muscle tissue. When this occurs, there is no guarantee that our muscles will just bounce back on their own and resume normal muscle firing and coordination.  Just like after knee surgery, we have to do exercises to ensure that our quadricep muscle will fire again and resume normal strength, we should also exercise our pelvic floors after the trauma of pregnancy and delivery to get our pelvic floor to keep us continent and “supported.”  Hopefully that answers the “why” and now I want to give you some direction toward a solution.

I am a mother of three and a physical therapist who feels there are a few missing links of information when it comes to dealing with symptoms of incontinence.  First of all, women need to know that they can rehabilitate and strengthen their pelvic floor because, most often, this is a muscular issue!  And second, women need to learn howto do it.  The bottom line is, you simply have to do more than Kegel exercises to strengthen your pelvic floor.

Did you know that our pelvic floor muscles not only tighten as if to stop the flow of urine, but they also elevate to give better support to our bowel, bladder, and uterus?  It is this elevation of our pelvic floor that most women don’t get.  In order to achieve optimal pelvic floor contraction, you have to perform bothactions.  Beyond these two actions of the pelvic floor, there are also several other muscles that enclose the front, back, and sides of our abdomen, what I refer to as our “abdominal basket”.  These muscles work in a coordinated fashion with our pelvic floor muscles to enhance their contraction, so working your entire abdominal basket is the final key to regaining control of that “pee thing.”

Please note that symptoms of incontinence not only follow pregnancy but also commonly appear after menopause. We will save that discussion for next week.

Why I am here….

As we begin this blog, let me introduce myself. My name is Tasha Mulligan. I am a physical therapist, athletic trainer, triathlete, and mother of three. The topic of incontinence and prolapse isn’t one that I have always been focused on, but my own journey through pregnancy and delivery pushed me into the women’s health field of physical therapy five years ago.
My quick background – I was an avid triathlete leading up to my first pregnancy. I maintained a controlled exercise program throughout my pregnancy and was looking forward to returning to running following my delivery and my six-week follow up appointment with my OB/GYN.  But I soon found out that the stretching during the nine months of pregnancy and additional stretching and tearing of my pelvic floor muscles during delivery caused my pelvic floor to contract inefficiently and remain, overall, very weak.  Plainly put, my pelvic floor just didn’t bounce back to my pre-pregnancy days, giving me the sensation that the “bottom might fall out” when I attempted to get back to my workouts.
This is simply my story.  But then I began to realize that a lot of my female patients in the clinic would laugh and joke about wetting their pants when I asked them to perform specific exercises.  My grandmother talked about her uterine prolapse and my pregnant friends were asking a lot of questions about why they couldn’t hold their bladder.  It was then that I began to realize the widespread effect of weak pelvic floor muscles. It wasn’t just a few of us, but as I researched, I found there were millions of us, women of all ages – teenage gymnasts, new moms, older moms, women who have reached menopause and beyond – experiencing similar symptoms, often in complete silence.
So this is why I worked with a team of medical professionals to create the Hab It: Pelvic Floor DVD and why we are starting this blog.  I want women to stop laughing about it with their friends and stop accepting it as a natural process of aging or having kids and educate themselves on how one can take control. There are a lot of great resources on the internet ( is one) and hundreds of physical therapists with a specialty in women’s health nation wide.  For every woman that is willing to talk about it, there are five with symptoms who are too embarrassed to admit it.  So,  let’s talk about it, Ladies!
Let me begin with a couple of definitions to make sure everyone is clear on some important terms: Your pelvic outlet is the diamond-shaped area, bordered in front by your pubic bone, in back by your tail bone (otherwise known as your coccyx), and on the sides by your two sit bones. Your pelvic floor is the soft tissue that spans this open area. Its responsibility is to hold up your bowel, bladder, and uterus, as well as to control the passage of solids, liquids, and air from these organs through three muscular openings. That’s a lot of responsibility!
When the pelvic floor and supporting muscles become weak and can’t optimally perform these responsibilities, you may experience symptoms of incontinence, which includes the inability to control your bladder and may present as occasional leakage as you laugh, cough, sneeze, run , or jump. There are several kinds of incontinence. The most prominent are stress incontinence and urge incontinence. Stress incontinence is exactly what I have described above as involuntary urine leakage with exertion, such as when you’re running and jumping, or simply laughing, sneezing, or coughing. Urge incontinence is the inability to hold your bladder once you have the urge to go. Women with urge incontinence will often know where every bathroom is in town, “just in case”, and go frequently to avoid any big accidents.
Another term associated with weakened pelvic floor muscles is “prolapse.”  “Prolapse” is best described as your uterus, bladder or rectum pressing down into or out of your vaginal opening. You may hear women say, “it feels like the bottom is falling out”, or “there is no support down there”to describe the sensation.  Essentially, a prolapse results when the pelvic floor muscles have become weak for various reasons and no longer have the strength to hold everything up and in.
I will sign off with the message that although structures within our pelvis have been compromised, we have the ability, with the commitment to an appropriate exercise program and consistent attention to neutral spine posture, to again support our pelvic organs and feel strong from our deepest core muscles throughout our body.  I am happy to be an example of a mom who, at her worst, had a grade three prolapse, had 3 vaginal deliveries, and now 9 years later is still running, boarding, hiking, and playing without limitations with her kids.  How is it that I am now feeling stronger than ever – it is a commitment to exercise, posture, and a true understanding of my pelvic basket of muscles.  You can do it too!