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 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 to 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
If 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)