Stress urinary incontinence (SUI), or leaking, is one of the most common complaints I treat, affecting up to 45% of women postpartum (Koomso, 2024) and over 60% of women in the general population (Patel, 2022). Trust me, you are not alone here! But this is not normal after the early postpartum days and is not something you “just have to deal with” as a price for being a mother. Urinary incontinence can happen with stress (think coughing, sneezing, laughing), impact (jumping, running, HIIT), or even with daily activities requiring exertion such as pushing baby in a stroller, lifting up a heavy bag from the floor, or carrying your baby. Leaking is more common with vaginal births, but can absolutely happen after C-sections too due to the impact of pregnancy on our bodies. You can also have urge incontinence (false sense you have to pee) or mixed incontinence (both stress and urge), but that’s a discussion for another day.
There are many different causes for SUI, but in this article we'll dive into some of the most common reasons. Remember, there is no “one size fits all” when it comes to diagnosis and treatment. So, what may help one person may actually make symptoms worse or cause new symptoms for another. Therefore, it's important to identify what is driving YOUR symptoms so that you can follow a treatment plan that is effective and helpful, not harmful or time wasting.
So what are some of the most common reasons?
1. Pelvic floor weakness due to hypotonicity (decreased tone) or tearing
3. Not enough progressive strengthening or specificity
2. Pelvic floor weakness due to hypertonicity (increased tone/tightness)
4. Decreased connection to our pelvic floor
5. Pelvic organ prolapse
9. Hormones
8. Stress and anxiety
7. Hip dysfunction
6. Poor posture, breathing, and pressure management
Hormonal fluctuations during menstruation and menopause can often contribute to exacerbation or onset of new pelvic floor symptoms like leaking. The changes in tissue elasticity and hydration, muscle mass, joint laxity, GI symptoms, and even stress and sleep can all play a role in your symptoms during this time.
There are so many factors to examine when looking at why you may be leaking. So if you’re frustrated with persistent symptoms, just remember that chances are you haven’t explored them all. Of course, there are many other causes too, so reach out to me for a free consultation and let's discuss how I can help you become symptom free!
It's very common for our bodies to respond to stress and anxiety by holding a lot of tension. You may notice yourself falling into a shallow breathing pattern, having difficulty sleeping, or start to clench your jaw, glutes, or even pelvic floor. This, along with the disruption stress and anxiety have on our central nervous system, can contribute to leaking or exacerbation of existing symptoms. Therefore, approaching SUI from a holistic lens by addressing mental health and lifestyle is key.
Deep hip muscles such as the obturator internus are directly connected to the pelvic floor, so any dysfunction in your hips can play a big role with how your pelvic floor functions. Research even shows improvement in urinary incontinence after total hip replacements, demonstrating the importance of addressing hip dysfunction when treating incontinence.
Poor posture, breathing, and pressure management all go hand in hand, so if you have dysfunction in one of these areas it will affect the others. One potential consequence from this is too much pressure being sent down onto your pelvic floor. This can contribute to leaking if the pressure is higher than what your pelvic floor can handle. Some common examples of these dysfunctions are a shallow breathing pattern, forward head/shoulder posture, coning and doming (see article for more details) and bearing down/straining with effort.
There are often multiple factors at play when a prolapse is involved with leaking such as a hypertonic or hypotonic pelvic floor, poor intra-abdominal pressure management, and poor fascial integrity that all need to be addressed for the full resolution of symptoms. But the actual prolapse itself can shift throughout the day, with certain activities, and as it improves and returns to its original position. This shifting can contribute to the “kinking” and “unkinking” of the urethra, and result in subsequent leaking.
The lack of pelvic floor health education in general leaves women unfamiliar with their own anatomy and its many functions. Then when you add in all the changes we experience during pregnancy and postpartum, connecting to our pelvic floor can feel almost impossible. Education on our anatomy, function, it's relationship with breathing and the core, and how to relax and engage the pelvic floor to strengthen it's neuromuscular (brain-body) connection is sometimes all that is needed to stop the leaking.
If you feel like you can do isolated kegels all day long but are still leaking with jumping, running, weight training or other higher level activities, you may need a different approach. Our pelvic floor needs to show up at different levels of intensity and responsiveness based on the demand of our activities. So even if you have strong pelvic floor engagement with low level daily activities, if it's not trained for endurance, dynamic movement, increased impact, or quick firing, you may be missing a large piece of the puzzle.
Our muscles need the ability to fully lengthen and relax in order to get a complete and functional contraction. So if your pelvic floor is too tight to lengthen, it’s going to prevent it from fully engaging to stop leaking. Essentially, a tight muscle is a weak muscle so we need to figure out why it’s tight and work on bringing back length before we can effectively strengthen it.
Our pelvic floor stretches about 300% with a vaginal birth, so no wonder why there can be lingering weakness! Perineal (superficial) or even levator ani (deeper) tearing can also occur, contributing to weakness while healing and scar tissue development. Our fascia also gets stretched out, so loss of these supportive structures contributes to decreased ability to contract our pelvic floor to stop urine flow.
