Incontinence During Pregnancy and Postpartum - Q&A with a Physical Therapist

Please introduce yourself.

I’m Dr. Sneha Gazi. I’m a physical therapist and owner of Sneha Physical Therapy, a NY-based in-home and telehealth practice. I’m the founder and Executive Director of Physical Therapy International Service Foundation, a 501(c)(3) nonprofit that brings free PT to underserved communities globally. I am also the host and creator of “Fit As A Fiddle” - a health and wellness podcast featuring guest speakers from various fields and available in all major podcast platforms.

Who do you treat?

I am an orthopedic physical therapist specializing in pelvic health, which basically means I treat anyone with a pelvis. To me, being a pelvic floor physical therapist is just adding an entire truckload of toolboxes to my doctorate. I treat heads, shoulders, knees, and toes too. Everything is connected! Sometimes, foot pain can arise from alignment issues at the pelvic bones that change the way you walk or run. With a deep understanding of the pelvic floor, I treat patients for any condition by taking their entire body into consideration and not excluding this very intimate, intricate, and interconnected area. 

One of my favorite groups to treat are my pregnant and postpartum clients. For too long, people who identify as female have been told that painful sex is normal postpartum, that back pain during pregnancy is just part of the process or that leaking after your first baby is not a big deal. For too long we’ve been told a lot of things by a very patriarchal medical field. So as a pelvic floor PT, I wake up every day on a mission to dispel myths, give a voice to women, and help them navigate through a monumental shift in their physical bodies during this period.

What is urinary incontinence?

Urinary incontinence (UI) is basically when you leak urine involuntarily, without knowing it or without wanting to at that time. There are two main types. Stress urinary incontinence (SUI) is when a physical “stress” to the body (like coughing, laughing, jumping, running) causes leaking. Urge urinary incontinence (UUI), or the “key-in-the door” phenomenon, is where you suddenly have an urge to leak and can’t hold it back. Often with UUI, you link a specific place/smell/action/sight/sound to leaking, like the sound of running water. I have suffered from both types as a young girl and early adulthood. Having both is called mixed urinary incontinence.

UI can occur for both the male and female anatomy, but for somewhat different reasons. Usually I’ll find that men leak urine later in life due to prostate dysfunction while women leak earlier, during their perinatal period, and then later in their menopausal years. 

How many women suffer from urinary incontinence during pregnancy and/or postpartum? 

Studies range so vastly on the data regarding prevalence of UI, because it is a taboo subject in many cultures. Some say women can experience UI anywhere from 5-72%, but most say somewhere around 25-45%. Another factor that skews the data is the age of people studied. As our global population ages, we can see changes in these numbers too. 

UI is three times more likely to occur in females than males. Stress UI is the most common type of the three forms of UI across all age groups. Vaginal delivery increases your chances of leaking, with 35-67% of women having UI during pregnancy. Also, urinary tract infections, constipation, genetics, age, and obesity can increase the risk. 

Is it just about pee? Is it normal to leak gas as well?

Fecal incontinence (FI), similar to UI, is when you leak stool or gas involuntarily, without knowing it or without wanting to at that time. FI is even more under reported than UI. While gas and stool come out of your anal canal and urine comes out of your urethra, the muscles that surround and control both of these sphincters are your pelvic floor muscles. There are many different pelvic floor muscles and several layers of them, but they basically encompass the area that would make contact with the seat of a bicycle. 

Now everybody, listen up…. while it may be COMMON, in some statistical respects, to have UI or FI during pregnancy and/or postpartum, it is NOT NORMAL. Involuntary leakage of any solid, liquid, or gas from this area indicates dysfunction that needs to be treated. I have treated hundreds of women who have suffered in silence with incontinence for decades after giving birth. They did not seek help for many reasons, but one was because they just thought it was normal and didn’t bring it up. I have seen the immense psychosocial impact that it has on these people’s lives and I hope that through simple education and awareness, we can break this cycle. We can teach our daughters that they should not live with incontinence and that leaking is never normal. 

Why do we leak?

There are many reasons one can be incontinent. Age and genetics can play a role. With age, we naturally lose muscle mass, the very muscles that serve a huge supportive role in the pelvic floor. Sometimes I treat older patients who leak simply because they can’t get to the toilet in time due to decreased mobility or balance. UI and FI can also be caused by the things we eat or drink along with our toileting habits and toileting posture. Mental health can also affect our bowel and bladder.

Our nervous system plays a role in our bowel and bladder functioning. The parasympathetic nervous system is responsible for excretion. The muscles of the pelvic floor and bladder are controlled by very specific nerves. Dysfunction to these neural functionings can lead to incontinence.

Dysfunction to the pelvic floor muscles or the other supportive structures around the pelvis (the fascia and ligaments) can lead to UI. Generally speaking, weakness in the pelvic floor muscles is a prime factor for stress UI. The heavier we are, due to obesity or pregnancy, the more pressure we exert on our pelvic floor. This stretches the muscles and weakens their supportive function. If you are constipated, you may be straining and pushing on the toilet, which can further lengthen the tissues of the pelvic floor. However, tightness at the pelvic floor muscle can also cause UI or FI. Overly tight muscles are never strong muscles, I tell my patients. Like all muscles in the body, there must be a balance between the strength and flexibility of a muscle for it to function optimally.

If you were incontinent during pregnancy, will you be automatically incontinent postpartum? 

Not necessarily. Sometimes during pregnancy, the weight of the baby is putting extra pressure onto the pelvic floor and altering the way the muscles work to keep you continent. After childbirth, this weight is reduced and you might not experience symptoms as much... or at all. Sometimes the incontinence is caused by additional underlying factors - the way you move your body, your posture, your breathing habits, and your overall muscle strength and flexibility. In this case your symptoms may linger into your postpartum years until treated correctly.

What can you do to prevent incontinence?

Prevention prevention prevention! I am so big on this. Just like we learn to brush our teeth, I wish one day, we can all learn a few self-care strategies for our bowel, bladder, and sexual function!

The best thing you can do, before you even plan to get pregnant, is exercise and function in your everyday life with correct breathing and coordination of the pelvic floor muscles and surrounding hip/trunk muscles. I know that sounds like a lot, but a good pelvic PT can get you set up with a few key tips and a customized exercise program within just a few sessions.

It is also very important for you to practice full contraction and full relaxation of your pelvic floor muscles. It’s not just about kegels. As a general rule of thumb, you should always check with your pelvic floor physical therapist on whether you are strengthening your pelvic floor muscles correctly or not. Many times, I will have to retrain people’s pelvic floor muscles, because, while they might think they are doing a pelvic floor contraction (AKA a “kegel,”) they are actually squeezing their inner thighs or glutes. 

What are the other conditions to watch out for postpartum that affect our pelvic floor?

There are many. A few are:

• Diastasis recti: Separation of the “six-pack” abdominal muscle
• Pelvic organ prolapse: When one or more of the many organs descend/drop downward
• Back/Neck Pain: Usually happens from the new movement patterns associated with motherhood and infant care
• Mother’s Thumb: Pain on the thumb side of your wrist (often from holding/carrying baby)
• Scar issues: Pain or irritation at your C-section or episiotomy scar

Incontinence is common but not normal. Seeking help during pregnancy and postpartum is a gift of self-care that you will not regret. 

Dr. Sneha Gazi, PT, DPT is the owner of Sneha Physical Therapy, an in-home and telehealth physical therapy practice in New York. Her passion is to improve quality of life by decreasing bodily pain and dysfunction. Dr. Gazi graduated from Columbia University's Doctorate in Physical Therapy and practices therapeutic manual therapies and evidence based exercises to help hundreds of women, men, and children get back to doing all the things they love. She specializes in pelvic floor physical therapy and enjoys treating women with pregnancy-related issues such as incontinence, back pain, and pelvic pain. To give back to the community, and to the world, she began a 501(c)(3) non-profit organization, Physical Therapy International Foundation, to bring free PT services globally to underserved populations while teaching students in PT doctoral programs across the United States.