the knack: your pelvic floor is for preventing urine leaks when you cough or sneeze

The Knack: my No 1 piece of physio advice for new mums

I still clearly remember  when I helped a client stop leaking in just one week by teaching her the Knack – and she was FURIOUS.

Sarah came to physio with the problem of urinary stress incontinence, leaking urine when she coughed and sneezed. It had been happening since her second son was born……….17 years before.

She had diligently practiced pelvic floor muscle exercises as everyone had told her to. When we checked them properly, with a vaginal examination, her muscles were firm, with an excellent strong contraction.  But, no one had ever explained the connection between practising strong muscle squeezes and WHEN TO USE THE SKILL IN REAL LIFE

I taught her about the Knack.  The next time she came back she was CROSS!  It worked – no leaks when she coughed – and quite rightly she was angry that no one had taught her something so easy, so simple and so effective sooner. It was humbling.  And my priority ever since to make sure I spread the word about this technique.  I don’t want today’s new mums to wait even 17 hours to figure this one out.

What is “The Knack”

The Knack is the magical art of drawing up your pelvic floor muscles just before you cough, sneeze, laugh or pick up something heavy.  Research has confirmed it works *

Your pelvic floor is like a trampette

You probably didn’t have to do this pre-contraction of the pelvic floor before you were pregnant, because a pre-pregnancy pelvic floor has a lot of the Knack: your healthy pelvic floor bounces pressure away like a new trampette natural tone and tension in it.  Like a trampette, straight out of the box from Argos, you can bounce up and down on itand your body weight barely makes a dent in the springy surface.  Pre-pregnancy, most of the down pressure when you cough or jump is deflected straight back up towards your head by the pelvic floor muscles.  Your bladder barely feels a bump.

However, you don’t need me to tell you that pregnancy and delivery have a notable affect on our soft tissues.  The abdominal wall is a clear indicator of what happens when you stretch  elastic slowly and steadily for 9 months.  Some are more lucky than others in the natural ‘spring back’ department.  Most women know that they are going to have to work the Knack: after a pregnancy the pelvic floor is stretched like a used trampetteto restore abdominal muscle tone and strength.   The pelvic floor has carried the same baby-burden and if you had a vaginal delivery (or pushed a long time before eventually needing a caesarean) there will have also been some micro tears to the muscle fibres and their connective tissue attachments.  Now, at least temporarily, the pelvic floor behaves like the well-used trampette – a sense that if you jump too hard your feet might touch the floor!

The Knack creates supportive tension

the knack: what your friends and your pelvic floor are forIf you tighten your pelvic floor muscles, in the exact moment before you cough, it is like two friends pulling your trampette tight for you just for that moment that you want to jump.  Yes, I admit its not ‘natural’, it’s not ideal, it requires thinking, you didn’t have to do it before……but it can make the difference between a bladder leak or not. 

Practice makes perfect

Practice  the Knack with a ‘pretend’ cough after you have had a wee. Your bladder is empty so you are unlikely to come unstuck. Challenge the system gently.  Hold your pelvic floor muscles firmly – cough lightly.  After a few days of practice, when that is feeling safe and secure, challenge the skill by coughing a bit harder.  Then increase your confidence by allowing an hour to pass so that your bladder is fuller when you cough (but start with the lighter coughs again!). 

With practice you will train a “learned-reflex”, a habit.  Your brain gets so used to the sequence of prepare, protect, cough that you do it on auto-pilot.

Sneezes are harder (and coughing fits, choking, vomiting….)

Sneezes are harder to resist with your pelvic floor than coughs, because you have less warning that they are coming and generally they create more downward abdominal pressure. Especially if you are one of those people who make everyone in the room jump out of their skin when you sneeze or are prone to 6 in a row?   A hacking cough with a head cold, or an allergy induced coughing fit are jolly tricky too.  Work on getting the anticipated, lighter coughs sorted first and then the rest can follow as your muscles strengthen.

Allow yourself some slack

Beware multi-tasking – I remember having a full bladder, baby in one hand, the folded Maclaren in the other, one foot on the escalator, and I sneezed – NOPE – the Knack did not work!!!  But hey, I could live with that – it seemed fair – it was a lot to ask of my pelvic floor system. 

If you can successfully use the Knack 9/10 times and only the occasional leak gets through that is excellent. 

Know when to ask for help

The Knack alone might not be enough for you.   Your pelvic floor muscles can be so weak that you need help to get them working again.  And it is possible to have muscles that have repaired too tight or are constantly overworking and becoming easily fatigued or sore.    Remember there are specialist physiotherapists attached to every UK maternity department who can give you an individual assessment, training and support.   Don’t hesitate to ask your GP to refer you to a specialist physiotherapist (full members of pogp.csp.org.uk have extensive post-graduate training).   

Does the Knack work for you? Any questions?  Please do ask, I am very happy to help.

*  Clarification and confirmation of the Knack maneuver: the effect of volitional pelvic floor muscle contraction to preempt expected stress incontinence.   Miller, J.M., Sampselle, C., Ashton-Miller, J. et al. Int Urogynecol J (2008) 19: 773. doi:10.1007/s00192-007-0525-3).

Drawings copyright of A M Savage  (Proudly using stickmen since 1991)

3 Ps of a perfect poo: are you sitting comfortably? Amanda Savage specialist physiotherapist gives sound and hilarious advice

3 Ps of a perfect poo: are you sitting comfortably?

There are 3 Ps of a perfect poo which you should keep in mind during your ablutions!  Are you doing any naturally?  How do you sit?  Do some people in your family take a LONG time in the toilet? Who reads the paper? Should you keep books in the loo? Might you be helping too much?

Do see the video below to learn more about good bowel habits and promote some healthy/unusual/hilarious family discussions!

P for Position

P for Patience

P for don’t Push – rather Pant!  

NOTE:  This last P got a bit lost in the talk (this was my first talk to a public audience and I got a bit muddled when they showed me the 2 minute warning!).  I got to fill in the gap to the audience in the awards bit (they voted it the “peoples choice” which was very encouraging).   The danger of a traditional hold-your-breath-push is that you can accidentally tighten your pelvic floor just as the stool is trying to come out.  This can cause it to be pinched off midway so you get some out but lots gets left behind in the rectum. You might not be able to feel it there but it goes on giving off gas, making  you windy, pressing on the rectum walls, making you uncomfortable, and drying out into small pebbles.   Rather open your mouth (which helps relax your pelvic floor) and let out pants or sighs, just as the midwives teach you to pant to deliver your babies head.  This allows the poo to come out as one full tube with just a nudge and light pressure from you.  Now you really know everything!  Do go share!

About to have a baby or just delivered??  Do see the post 10 tips for the first postnatal poos for more ways to help you have comfortable bowel movements.

PS  It was a great Public Speaking course – I highly recommend the team at Ginger

**  My original title was The Life Changing Magic of Sitting Comfortably.. but it now seems to be known as the 3 Ps talk……

Why do tampons go sideways? Amanda Savage, specialist physio, explains

Why do tampons go sideways?

Have you ever had the experience of an uncomfortable tampon or one that looks as though only the side half of it has absorbed anything? So annoying.  Why do tampons go sideways?

A BIT OF VAGINA ANATOMY

The vagina inside is surprisingly wide and stretchy, leaving plenty of room for things to move about.  In our heads I think we picture it as a narrow tube rather like a hosepipe but actually, though narrow at the opening, inside it is quite a decent tubular space – it has to be to let a babies head out without damage to the vagina itself. 

why do tampons go sideways?

the vagina is shaped like a squashed tube

Imagine a  tube that has been squashed. This shape means that we are narrow top to bottom (termed anterior to posterior in medical terms) but have plenty of room side to side.  This is just like the shape of a mouth.  Even open wide the mouth has a surprisingly small opening top to bottom but plenty of room side to side, in the cheeks.

Keeping with the mouth analogy, at the back of your mouth you have an epiglottis dangling down, at the back of the vagina tunnel the cervix dangles down; more like the size and shape of a nose. The cervix is pretty solid and though it pushes up out of the way during sex, it is quite easy to end up with a tampon nudging against it.

You will recognise this sensation, though you might not have realised what it was.  Have you ever put a tampon in and then barely 5 minutes later you have an overwhelming desire to pull it back out ?  It is just not right, or downright uncomfortable, almost as if your body is rejecting it?  The cervix is the only bit inside with decent nerve endings  (so if you knock it during sex it you might get a short sharp mild pain) but if a tampon is pressing on it relentlessly you get this strong urge to bear down and feel that the tampon is pushing out.  Or alternatively the tampon itself comes up against the cervix as you insert it and as you keep pushing it tilts off sideways into the ‘cheek’ area giving you inadequate protection and that ‘half used’ look when you remove it.

TIPS TO GET TAMPONS IN THE RIGHT PLACE

  • Don’t rush the process (mums!   you know you do)
  • Visualise what you are doing.  Keep contact with the back wall of the vagina (the bowel side) as you are putting the tampon in and it will end up underneath the cervix rather than on it.  Aim for your back passage.
  • Not all tampons are the same – some types expand widthways but others expand lengthways so they can effectively push themselves out as they become elongated when full. If you can’t picture what yours do, drop one  in water and see what shape it becomes.
  • Applicator tampons give you a bit more option to position the tampon before you let go – nice to use for the beginnings and ends of periods when the vagina is a bit drier and less easy to slide tampons in
  • Pop a dab of lubricant (water-based) on the end of the tampon to help it slide in more easily
  • If you feel your cervix is sitting very low since your baby try using a menstrual cup (like a MoonCup) instead of tampons – these are designed to sit closer to the opening of the vagina rather than deep inside (more like the position of a cork in a bottle).

How have you got on with returning to having periods and using tampons and sanitary pads?  Any questions?

What is the difference between water-based and oil-based lubricants? Specialist Physiotherapist Amanda Savage explains

What is the difference between water-based & oil-based lubricants?

If sex is painful, personal lubricant could be life-changing.  It is useful to understand the difference between water-based lubricants and oil-based lubricants.

If you have you have never tried a personal lubricant you might not realise what you have been missing. Those inventors should get Nobel Prizes!  Forget teen movie references to ‘lube and gloves.   And pity our poor grandmothers with probably only vaseline as an option.  Personal lubricants have come an enormously long way in their formulation, effectiveness and packaging.  I hope for the sake of these unsung heroes of our intimate lives that they get a better reputation soon.

IF SEX IS PAINFUL BOTH WATER-BASED Lubricants AND OIL-BASED PERSONAL LUBRICANTS ARE WONDERFUL!

There are some reasons why you might need to use one type over another, such as if you want to use condoms (the lubricant needs to be safe with latex), or you want to use an electricity based pelvic floor gadget (which need a water-based product).  But if you are just experimenting to improve your comfort I would recommend getting some samples of both types from several manufacturers and seeing what suits you and your partner best.

Below I have explained the key differences between water-based and oil-based and there are links to the websites of some of the brands my physiotherapy clients have liked.   

WATER-BASED LUBRICANTS

  • You will probably have come across the water-based lubricants in your ‘medical’ journey.  These are used in gynaecology clinics and smear tests.
  • If you want to use one of the pelvic floor enhancing gadgets (see Gadget Girl!) then you will need to use a water-based lubricant to create a connection between the pelvic floor and the gadget.     Think of how they smeared your belly with gel to do your ultrasounds during your pregnancy. The equipment will need the same kind of contact.
  • A water-based lubricant also works well to help insert a tampon, without interfering with its absorbency.
  • You can use water-based lubricants with condoms and sex toys
  • Many people feel that water-based lubricants feel more natural, “wet”, with a realistic texture and they have no smell or taste.  They leave skin clean and residue free.
  • You can use them for instant topical relief of a dry and itchy feeling vagina and perineal area.  I have known clients keep theirs in the fridge for extra-soothingness!
  • Water-based lubricants can be effective in reducing vaginal dryness over the longer term by rehydrating the tissues (just like a facial moisturiser would do).

THINGS TO CONSIDER?

  • The most well known is the brand KY Jelly but it contains parabens and research1 has shown that the formulation of KY can irritate the sensitive vaginal tissue It can also feel sticky due to the high glycerine content.  Most chemists offer an own-brand version.  These might be well suited to a short examination procedure, or  to use with a pelvic floor exercising gadget, however for intimacy you might find that with the lower quality products can turn a bit ‘sticky’ and you should check the list of ingredients carefully avoiding glycerine, propylene glycol and parabens. 
  • They can be a bit of a devil to get from the tube to the needed body part without dripping. Related post (?!)  “applying personal lubricants without losing your momentum/dignity/sense of humour!

OIL-BASED LUBRICANTS

  • Oil-based lubricants should be formulated with natural plant-oil
  • Products made from mineral oil which is a petroleum bi-product are not suitable for vaginal use
  • Natural plant-oil based lubricants are longer lasting and can nourish dry tissue and make sex much more comfortable
  • They can be used as all-over massage oils as well as personal lubricants so their application to yours, and your partners, important bits can feel more like a natural and enjoyable part of foreplay.
  • Like the cosmetic equivalent face oils, they can protect and feed dry, intimate tissues but they cannot be re-hydrating as they do not contain water.  They can be just as soothing as water-based products and may be more comfortable if you suffer with vulvodynia or other vulval conditions

THINGS TO CONSIDER?

  • All oil based products including Vaseline, Baby Oil and Mineral Oil can affect latex and are not safe to use with condoms
  • They are not the right product to use with pelvic floor gadgets such as stimulation and biofeedback machines (these need a water-based lubricant to conduct electricity between you and the gadget).  When you are using a ‘gadget’ for exercise rather than ‘pleasure’ you may find a cheaper chemist own-brand water-based lubricant perfectly satisfactory for the purpose depending on your personal position about ingredients.
  • Water and oil-based lubricants are suitable for use with silicone toys
  • Silicone is a synthetic product which can offer longer lasting lubrication but doesn’t feel natural and cannot easily be removed with water. Silicone lubricants cannot be used with silicone sex toys but are safe to use with condoms.  They are usually well-tolerated but some people prefer to source a completely non-synthetic product, like the ones made with plant oils.
  • When trying a new lubricant it is always wise to do a patch test on the inside of your arm or wrist.

NOT ALL LUBRICANTS ARE THE SAME

As usual you get what you pay for.   The more expensive products have given attention to the quality of the ingredients and spared a thought for the packaging.  You only need a little bit each time and your intimate relationships are invaluable.  Treat yourself to something made for the purpose, in nice packaging and never run out!   

Please do let our Supported Mums readers know your preferences below and share any advice?  If you have come across a product that you think I should include in this list please let me know your recommendations?

YES®  www.yesyesyes.org

SYLK   www.sylk.co.uk

Boots own brand lubricating jelly    www.boots.com   

References:

11D. Edwards & N. Panay (2015): Treating vulvovaginal atrophy/genitourinary syndrome of menopause: how important is vaginal lubricant and moisturizer composition? Climacteric, DOI: 10.3109/13697137.2015.1124259

2World Health Organization. Use and procurement of additional lubricants for male and female condoms: WHO/UNFPA/FHI360 advisory note 2012 [7 July 2015]. Available from: http://apps.who.int/iris/bitstream/10665/76580/1/WHO_RHR_12.33_eng.pdf

3 Great Pelvic Floor Exercise Apps

If you have a smart phone you may enjoy one of the new pelvic floor exercise apps.  These are great innovations.  This week I have  tried out a couple of  reminder apps (Squeezy & my pff), a tracking app (Elvie) and an exercise workout to watch on your phone (Pelvic Floor First)

Road-testing has had entertaining moments with  my phone  beeping and buzzing.    I have done a LOT of pelvic floor exercises this week.  Perk of the job.

TIP (obvious, to everyone else I’m sure, but I did it by accident):  When you are looking at them the first time and organising your settings you might find it easier to view the app on your iPad/tablet so all the buttons and instructions are bigger.

Sadly there is no app that actually does the exercises for you.    Though they all have similar sounding descriptions on the app stores,  I would categorise them into ‘reminder’ apps, ‘ exercise tracking’ apps (with wearable device) and ‘portable exercise workouts’ to follow on your smart device.

REMINDER APPS

Pelvic floor exercise apps - Squeezy NHS

Squeezy NHS app gives regular reminders and lovely visual prompts to follow

  Squeezy – the NHS Physiotherapy App for Pelvic Floor Muscle Exercises, Propagator Ltd £2.99.  Also offers the Apple Watch App for iphone. 

This has been designed by one of my specialist physiotherapy colleagues, Myra Robson, using all her NHS experience and hundreds of clients feedback to develop an informative, easy to use, clear and visually pleasing app.  You can change settings easily yourself to chose how many times a day you want to be reminded to do your exercises.  It sends you a (silent!) text message to remind you to do your exercises.   Then you tap on the screen to start a balloon/type bubble moving – you can’t but help start squeezing in response!  Its a great visual prompt (with optional ‘boing’ noises).  There are drills to practice fast contractions or slower ‘holding’ contractions.  You can change the settings to make the exercises a comfortable speed for your ability.  You can record your sessions, as well as how much you have been drinking.   

If you are working with a physiotherapist they can help you set up your programme to fit with their training and check up on your efforts!  

pelvic floor exercise apps - My pff

My pff by tena

My pff – an app sponsored by Lights by TENA.  Free.

This free app is a similar exercise concept, with a screen changing colour up and down to show you how long to hold and relax for, but lacks the helpful information and bespoke settings options of Squeezy.     It was very simple to chose your level (in the settings bar at the base) and then get started.   I liked the very simple interface of this app but similar to the reviewers I had problems with it crashing when trying to set the reminders.  Once I had set them (2 or 3 crashes but it restarted easily each time) it worked fine.  I like that there was a simple button to turn the reminder off (if you finally get a daytime nap you would be hideously cross if it’s an app that wakes you up)

HACK  Use your phone clock function!   Free.

Set your phone’s ordinary timer to alert you every 4 hours through the day to do your exercises

Exercise tracker device with smart phone app

Pelvic floor exercise apps - Elvie

The Elvie is a discreet vaginal device which tracks your pelvic floor exercises on your smartphone

Elvie  feedback/tracker device with free app   £150     www.elvie.com  (for a 10% discount use PHYSIO as a promotion code at the checkout)

Tracking apps  communicate with a wearable device.  You may already have a FitBit worn on your wrist to communicate with your phone?  The Elvie is, as they say, ‘the most intimate’ tracker – a small, pebble shaped unit which you put inside the vagina.  Then it communicates via blue tooth to a phone app.  When you practice your pelvic floor contractions a patented force and motion sensor system detects the strength of the muscle activity and shows up on your phone screen, giving you real time information about how well you are contracting.  There are clever ‘games’ to play by contracting your muscles – think pacman controlled by your pelvic floor? It records your exercise sessions – great for motivation.

Important note – designed for discreet home exercise, unlike a FitBit, not for going out & about!

WORK OUT APPS WITH PELVIC FLOOR FRIENDLY EXERCISES

pelvic floor first app has good workouts

The Pelvic Floor First app has great pelvic floor friendly workouts

Pelvic Floor First – by the Continence Foundation of Australia . Free.

This app is not a ‘reminder-type app’, rather a portable workout regime to copy.  If you like your pelvic floor exercises disguised amongst your other body part exercises then this app may be just right for you.  The app is based on the Continence Foundation of Australia’s Pelvic Floor First website with the workouts designed by a physiotherapist and fitness professional to be ‘pelvic floor safe’.

There are 3 levels of workouts, using light hand weights and a gymball as props.  The exercises are very clearly presented as just stills, audio or audio & video together.  It has a nice feature to count down a daily workout but you do have to keep starting each new exercise by pressing the arrow on the screen.

 Have you tried a pelvic floor exercise app?  Did you like it?  Please share your recommendations in the comments below and let me know which one I should road-test next?!