The Ground Floor
The Core and Body Balance yoga class at the Cansler Family YMCA in downtown Knoxville, Tennessee, is attended by a particular mix of women: Half are new moms on hand to whip flabby abs back into shape, and the other half are retirees concerned about preventing falls and maintaining their independence.
Yoga teacher Rebecca Hicks makes the transition from the usual round of abdominal exercises to Bridge Pose, explaining with care how to engage the muscles in the pelvic bowl. "This is exactly what all you mommies and older gals need to do to get rid of those pee-pee problems," she says.
The class erupts in giggles. Everyone, it seems, can relate. Stories are swapped about little leaks that occur from climbing out of bed, coughing, sneezing, or twisting. As the women lift and release, a consensus emerges: A little leaking—or urinary stress incontinence—happens to the best of us, a natural consequence of aging or childbirth, or both. It's inevitable. Isn't it?
To say that the problem is common is an understatement. A study published in Obstetrics and Gynecology found that nearly 50 percent of all women will at some point in their lives contend with urinary incontinence, whether they ever give birth or not. Another study, published in the Journal of the American Medical Association, reported that at any given time, somewhere in the neighborhood of 25 percent of all women are coping with some form of pelvic floor disorder, including urinary incontinence.
If you're surprised by those statistics, you're hardly alone. Unless the topic happens to come up in your own yoga class, how would you know? This "don't ask, don't tell" attitude isn't lost on yoga teachers who specialize in women's health. "People still don't talk about it—they think they are the only one, and they are just so embarrassed," says Carol Krucoff, a yoga therapist at Duke Integrative Medicine in Durham, North Carolina. "You get a group of women to start talking about it, they are really shocked that it happens to practically everyone. I often bring it up in my classes just to show women that it is so common."
Prevalent as occasional incontinence is, however, it's only one aspect of pelvic floor dysfunction, the umbrella term for disorders of the pelvic floor muscles. In the case of urinary incontinence, the muscles in the area may have grown weak, or hypotonic, usually due to the kind of overstretching that can happen in childbirth. When the muscles are overly tight, or hypertonic, other conditions can result, such as urinary frequency and urgency, interstitial cystitis, irritable bowel syndrome, painful intercourse, lower-back pain, and—in men—prostate problems.
A little "pee-pee problem" probably is related to hypotonic muscles that need strengthening, says Lizanne Pastore, a physical therapist based in the San Francisco Bay Area who specializes in dealing with pelvic floor dysfunction. But it might also be caused by hypertonic muscles that have been tensed to the point of fatigue and give out at just the wrong time.
Since it's often hard to know which condition is at the root of a pelvic floor disorder, Pastore says that there isn't a one-size-fits-all exercise solution. The Kegel gospel of squeeze, squeeze, squeeze to strengthen the pelvic muscles has been presented to women for 60 years as the answer to everything. But it addresses only half of the equation. To strengthen the pelvic floor, you also need to relax the pelvic floor, Pastore says, and not everyone can do that.
If you're suffering from urinary incontinence and aren't sure whether your problem stems from muscle laxity or hypertonicity (a physical therapist or yoga therapist can make that diagnosis), it pays to find a holistic way of working with the pelvic floor that will benefit those at both ends of the spectrum. Step one is simply building awareness of the muscles in the region. "For many people, the pelvic floor is like a dead zone," Pastore notes. "They don't even know they have it."
Yogis have a bit of a leg up, in that we talk about the pelvic floor in relation to Mula Bandha (Root Lock). But even so, the complex network of muscles "down there" (with their scary, unpronounceable names, like pubococcygeus and bulbocavernosus) remains shrouded in mystery.
There are 16 muscles in the pelvic floor. But from a day-to-day functional standpoint, they're at their best when working in concert, so it's easier to think of them as a single unit. Richard Sabel and Bill Gallagher, co-owners of East West Rehab in New York City, have developed a course for working with the pelvic floor muscles, combining yoga wisdom with physical therapy. They invite students and clients to visualize the muscles of the pelvic floor as a hammock that hangs from the four corners of the pelvis. "Can you feel both of the sitting bones?" asks Sabel, an occupational therapist and Feldenkrais practitioner. "Can you feel the pubic bone in the front and tailbone in the back? Those four points define the perimeter of the pelvic floor space."
With the hammock image in mind, you can begin to work with the breath to feel that hammock move with the breeze, so to speak. "For you to breathe efficiently, the pelvic floor has to be involved," Sabel explains. "It moves in a dance with the diaphragm. When we breathe in, the diaphragm moves down, and so does the pelvic floor; when we breathe out, they both move up. If you sit quietly and observe the breath, you'll notice the natural widening outward and downward pressure on inhalation, and a natural lifting of the pelvic floor at the end of the exhalation." Once that pattern has been identified, you can begin to accentuate each end of the breath cycle, relaxing and engaging, relaxing and engaging, until the pelvic floor muscles begin to feel familiar—and, better yet, consciously available.
Learn to emphasize the lifting—working slowly and steadily, increasing effort in 5 percent increments—and you have a better, more holistic alternative to Kegels. "Working the entire pelvic floor is much more fruitful and stable than a quick, tight squeeze and release that's just working the sphincters," says Gallagher, a yoga therapist who is also a clinician in integrative rehabilitation at Mount Sinai Medical Center in Manhattan. "When you keep it connected to the breath, it's easy to find the sweet spot of engagement that's just right for any activity."
Practice makes perfect
Working both ends of the spectrum can both build strength in the pelvic floor and release the chronic tension that underlies nearly all conditions stemming from hypertonicity. A yoga mat is a perfect place to start. You can do a practice especially designed to build pelvic floor strength (see "Pelvic Floor Balancing" below) or simply slip the work into your existing routine. Sabel suggests lifting the pelvic floor on the exhalation and relaxing it on the inhalation while lying in Savasana, squatting in Malasana (Garland Pose), or performing Cat-Cow Pose. "Once you get the hang of it, it's fun to play with it in your practice," says Krucoff. "The idea is to take the body through all of its potential ways of being—sitting, standing, inverted, forward bending, backbending, twisting—and see what it takes to still find the pelvic floor."
Once you've come this far, you can practice off the mat, too. You can lift and release your pelvic floor while standing in line at the grocery story, or while driving your car. The goal, of course, is to be able to engage the muscles when you really need them in real-life scenarios—when you're playing tennis, getting up from your chair, bursting out in laughter, or engaging in any other activity that might otherwise challenge your bladder control. Sneeze coming on? Lift and hold until the ah-choo is over, then release. Picking up a toddler? Exhale deeply and lift the pelvic floor before you lift the kid.
Keep the muscles in the pelvic floor supple, strong, and responsive, and your "pee-pee problems" can be a distant memory, Hicks tells her only-too-happy-to-hear-it yoga class. She's a walking testimonial. "I used to leak like crazy after I had my second baby," she says. "But I used my yoga practice to deal with the problem, and so can you."
Pelvic Floor Balancing
Yoga can help you strengthen weak pelvic floor muscles and relax tight ones. Viniyoga, which coordinates slow movements with the breath, is particularly well suited to this kind of work. The Viniyoga sequence below, developed by physical and yoga therapist Emily Large, emphasizes both the contraction and the release of the hip adductors, pelvic floor, and transversus abdominis, which helps create pelvic stability. Practice daily until you notice an improvement.
Hook Lying with Block
Lie on your back with your knees bent, feet slightly apart. Place a yoga block (at its narrowest width) between your knees. Inhale deeply. Exhale, and sequentially begin squeezing your knees into the block with your hip adductors, lifting the pelvic floor up, and pulling the transversus abdominis toward your spine. Keep your feet and back on the floor; the lumbar curve may flatten slightly. On an inhalation, sequentially relax the transversus abdominis, and release the pelvic floor and hip adductors without dropping the block. Repeat 8 times.
Supta Prasarita Padangusthasana (Reclining Wide-Legged Hand-to-Big-Toe Pose), variation
Lie perpendicular to a wall with your legs raised and your buttocks against the wall. Inhale and open your legs wide as you relax the transversus abdominis and then the pelvic floor. As you exhale, lift the pelvic floor, contract the transversus abdominis, and bring your legs together, squeezing your knees together at the end of the breath. Repeat 8 times.