In our introductory article, 3 Reasons You Pee When You Powerlift & How To Fix It (Part 1), we identified why PUI is different from traditional Urinary Incontinence. We also identified three possible realms to address in the barbell athlete and when you should seek out a pelvic floor consultation. If you haven't read Part 1 of this series, read it here!
In the next few articles, we'll discuss each realm of Powerlifting Urinary Incontinence in depth so you can help yourself, or your athletes, address it.
First, we want to rule out the most easily modifiable factors, including belts, incorrect breathing, technical breakdown, and bloating. These fall under the realm of mechanical stress acting directly on the bladder that can cause leaking. When there is internal pressure or mechanical stress on the bladder applied quickly, it tricks the bladder into thinking that it's full and time to void. In powerlifting scenarios, this usually happens so fast that your brain doesn't have time to recognize it's happening. When this happens, you can't react quickly enough to stop the flow of urine with your pelvic floor muscles, as is the case when we decide it's an appropriate or inappropriate time to pee.
Mechanical Contributions to PRI:
Belt Use: When symptoms are only present with a belt, we need to make sure the belt is being utilized correctly, and sized appropriately for the lifter and the lift. The five most common sizing errors with belts include being too wide, thick, bulky in front, loose or tight. Below is a chart depicting various belt metrics and who and what lifts they are typically appropriate for.
These charts will help you size your belt appropriately based on your height and lift you're performing. In general, for all females, we recommend a 3 inch 10-millimeter belt as the most usable and versatile belt for all shapes and sizes. However, the charts below elaborate on when a 13mm or 10mm belt is appropriate.
If you use a belt that is too wide or thick for your body, you run into a few problems. First, the belt likely covers your hip bones and rib cage, which poses the issue of discomfort and possible bruising. More importantly, because the belt covers your hip bones and ribs and doesn't fit in between, you can't get the belt tight enough. You want the belt to be snug so that it minimally moves while executing the lift. If the belt is too wide or loose, it may move up and down and mechanically change the intra-abdominal pressure more than it already does as we move throughout the lift. This change in pressure, or physical push of the belt on the bladder, can cause the involuntary leakage urine.
Improper Breathing: If you've been resistance training or physical therapy, you've probably been told, "don't hold your breath while you lift." You've also probably heard of the Valsalva Maneuver and instructed that the proper way to use your breath and belt is to "push your belly into your belt."
Here's what you need to know:
The Valsalva Maneuver is NASA: Necessary, Automatic, Safe, and Adaptable. For details about why we need to do this when we lift heavy things and why you won't stroke out by holding your breath, check out this video by Dr. Stef Bradford, PhD, SSC, and this fantastic article by Dr. Jonathan Sullivan, MD, SSC.
Stop listening to people who tell you the Valsalva Maneuver promotes incontinence! In the absence of an actual disorder, dysfunction, or injury to the pelvic floor (see this chart to screen yourself), your pelvic floor is working correctly. The Valsalva Maneuver and the pelvic floor work symbiotically to stabilize your organs, spine, cardiovascular system, and brain while lifting heavy things. Studies have shown that the Valsalva Maneuver is associated with an increase in pelvic floor muscle activity. There is also neural pre-planning that activates your pelvic floor and abdominal muscle before you load your body. So, the Valsalva Maneuver is not bad for your pelvic floor. Still, you also don't need to actively think about "engaging" or "activate" it because it happens automatically when your body gears up to move a load. So, to reiterate, both the Valsalva Maneuver AND pelvic floor muscle contractions are automatic, safe, and necessary when you go to lift a heavy load.
Pushing your belly into your belt is hindering you, not helping you! When the Valsalva Maneuver is appropriately performed, the abdominal muscles, the pelvic floor muscles, and diaphragm contract in their neutral position. These muscles pull inward slightly before maintaining an isometric contraction to maintain a rigid, stable, core to transfer force. By pushing your belly outward, you're mimicking the "baring down" motion associated with voiding. This comes along with a descent of the pelvic floor and downward distribution of the intra-abdominal pressure that promotes voiding. So stop doing it!
Check out this Instagram post on how to appropriately utilize the Valsalva Maneuver while lifting versus what not to do!
You might also find this podcast beneficial as well!
Technical Breakdown: When symptoms of Powerlifting Urinary Incontinence are only present at higher intensities, we need to consider that one or both of two contributing factors might be at play here.
You're Not Prepared For Intensity: The external load you're working against is more than your pelvic floor muscles are prepared for so you cannot adequately maintain continence (we'll talk about this in a future lecture). OR…
Change In Position Under Moving Load: Your form breaks down as the intensity increases, thus changing your spinal position or approximation of your gut and thighs. When your torso changes position under moving load, the inner core pressure distribution changes and may increase pressure on your bladder, causing a voiding reflex to occur. Similarly, if your gut and thighs come together faster or more intensely than usual, it can cause direct pressure on your bladder to stimulate the voiding reflex quickly. In both scenarios, it happens so fast that you're unable to recognize it's happening and react quickly enough to stop the urine flow.
The Squat and Deadlift are the most symptomatic lifts when it comes to powerlifting urinary incontinence. Let's understand why it happens so we can work on addressing technical contributions to symptoms. The below mechanical mishaps change intra-abdominal pressure or the approximation of your gut and thighs. This puts direct pressure on your bladder, potentially causing reflexive emptying.
Your spine position changes to a more flexed position.
You hitched the bar.
You went too low (Ass-To-Grass).
Your spine rounded (either your upper back or lower back).
Although the above mentioned are mechanical stressors to the bladder, the most effective way to address them is through appropriate programming. We'll discuss programming in the next part of this Powerlifting Urinary Incontinence Series. Sneak peek: work at loads where you can maintain proper lifting mechanics with minimal form break down; this is usually the RPE 7-8 range. I would not recommend working off of percentages of a 1RM if you're experiencing urinary incontinence when you lift.
Bloating/Constipation: The last mechanical contribution to urinary incontinence when you lift that we'll discuss is menstrual bloating and gas and constipation. While these factors won't necessarily cause urinary incontinence, they can potentially do so either independently or collectively with other contributing factors.
Menstrual Influences: During the time leading up to your period, your uterus increases it's lining and swells in preparation for egg implantation. This small size change in the uterus can cause a bit of pressure on the bladder even when you're not training. Many women who experience urinary incontinence symptoms irregularly when training might find that symptoms increase during the days leading up to and during their periods. So, if you cannot find a reason in your programming or technique that seems to be contributing to the problem, it may be a good idea to track your symptoms relative to your cycle. If you end up establishing a correlation between your cycle and symptoms, it may make sense to adjust your program to work at lighter loads symptoms tend to be worse.
Gas & Constipation: When you think about it, our organs are in tight proximity in our pelvic cavity and only have so much give. Hard bowels or gas reduces the flexibility of your colon and becomes a hard item taking up space. As intra-abdominal pressure increases and your body position changes, hard bowels and gas may cause increased pressure on your bladder, stimulating the voiding reflex.
Just think about how uncomfortable you feel when you're constipated, have gas, or get your period. Now add a lot of weight to that and bend over...just imagine. Also, women tend to experience constipation and gas a little bit more frequently around their period. Put that all together, and you may have a situation where the pressure on your bladder is too much. It's never a bad idea to reduce the loads if your pelvic cavity contents are causing your discomfort. But remember, not everyone gets symptoms of incontinence from bloating. So don't adjust unless you need to.
If you feel you're experiencing powerlifting urinary incontinence because of one, some, or all of the factors mentioned in this article, it could be an easy fix:
Get an appropriately sized belt and wear it correctly
Fix your breathing technique
Address and reduce technical breakdown
Modify training when you're experiencing bloating
Making these changes may increase the relative intensity of the lifts, further promoting incontinence. So always make technical adjustments with an associated drop in loads, so you have time to adapt! You can also read our free guide to healthy barbell training here.
Need some help? Head over to our free Facebook community, The Secret Society of Barbell Mastery, where we do form checks every Wednesday and Friday and answer questions regularly! Or, book a free call with a PRS Clinical Coach here!
If you're interested in learning how to optimize barbell technique, maximize strength and muscular development, and reduce injury risk (and peeing) for you, your clients or patients, then join the waitlist to get insider information on all the PRS online courses when they're ready for enrollment!
Citations
Ball R, Weidman D. Analysis of USA Powerlifting Federation Data From January 1, 2012-June 11, 2016. J Strength Cond Res. 2018;32(7):1843–1851. doi:10.1519/JSC.0000000000002103
Alter-Petrizzo R, Petrizzo J, Wygand J, Otto R. Stress Urinary Incontinence in Female Powerlifting: A Survey. Medicine & Science in Sports & Exercise. 2018; doi:10.1249/01.mss.0000538444.72232.53
de Mattos Lourenco TR, Matsuoka PK, Baracat EC, Haddad JM. Urinary incontinence in female athletes: a systematic review. Int Urogynecol J. 2018;29(12):1757–1763. doi:10.1007/s00192-018-3629-z
Teixeira RV, Colla C, Sbruzzi G, Mallmann A, Paiva LL. Prevalence of urinary incontinence in female athletes: a systematic review with meta-analysis. Int Urogynecol J. 2018;29(12):1717–1725. doi:10.1007/s00192-018-3651-1
Wikander L, Cross D, Gahreman DE. Prevalence of urinary incontinence in women powerlifters: a pilot study. Int Urogynecol J. 2019;30(12):2031–2039. doi:10.1007/s00192-019-03870-8
Almousa S, Bandin Van Loon A. The prevalence of urinary incontinence in nulliparous female sportswomen: A systematic review. J Sports Sci. 2019;37(14):1663–1672. doi:10.1080/02640414.2019.1585312
DeLancy J, RIchardson A. Anatomy of genital support. In: Benson T, ed. Female Pelvic Floor Disorders. New York: Norton Medical Books; 1992.
Sapsford H, Bullock-Saxton J, Markwell S. Women’s Health: A Textbook for Physiotherapists. Philadelphia, PA: W.B. Saunders Ltd; 1998:62-66.
de Groat WC, Griffiths D, Yoshimura N. Neural control of the lower urinary tract. Compr Physiol. 2015;5(1):327–396. doi:10.1002/cphy.c130056
Sugaya K, Nishijima S, Miyazato M, Ogawa Y. Central nervous control of micturition and urine storage. J Smooth Muscle Res. 2005;41(3):117–132. doi:10.1540/jsmr.41.117