Tag Archives: Anatomy

Is Running Bad for a Woman’s Pelvic Floor?

As some of you may know, I recently completed my second half-marathon. To make it even better, I completed it with my amazing and wonderful husband Andrew:

4 miles in to our first half marathon!

4 miles in, and feeling great!

This was my second half marathon in 1 year, and my third *big* athletic event—the other two being the Disney Princess Half Marathon and the Ramblin’ Rose Sprint Triathlon. I started out 2013 with the goal of being healthier and developing strategies for life-long fitness, and I really am proud to say that as I approach the end of 2014, I am well on my way to better fitness.

Disney princess half

Disney Princess Half Marathon with my awesome sister, Tara and wonderful colleague, Jenna

After completing my last half-marathon, I received the following question from a previous patient of mine,

“Ok, I have to ask, after seeing your race pictures,

isn’t running bad for a woman’s internal organs??”

My initial thought was to respond quickly with a, “Not always, but sometimes…” type of response. But then it got me thinking, and inspired me to really delve into the issue with a little more science to back my thought—although honestly, the gist will stay the same.

So… Is running bad for the pelvic floor? Let’s take a look.

When someone initially looks at the issue, there may be the temptation to respond with a resounding, “YES!” We initially think of running and think of “pounding the pavement,” identifying large increases in intra-abdominal pressure and assuming that this pressure must make a woman more likely to experience urinary incontinence and/or pelvic organ prolapse.

But, what does the research really show?

1. Urinary incontinence during exercise is common and unfortunate.

  • Jacome 2011 identified that in a group of 106 female athletes, 41% experienced urinary incontinence. However, they also found that UI in those athletes seemed to correlate with low body mass index.

2. High impact athletes often may require more pelvic floor strength than non-athletes.

  • Borin 2013 found that female volleyball and basketball players had decreased perineal pressure when activating their pelvic floor muscles compared to nonathletes which they concluded placed these women at an increased risk for pelvic floor disorders and especially UI.

3. Over time, physically active people are not more likely to have urinary incontinence or pelvic organ prolapse that non-active individuals.

  • Bo 2010 found that former elite athletes did not have an increased risk for UI later in life compared to non-athletes (although she did find that women who experienced UI when they were younger were more likely to experience UI later on in life).
  • In another study, Bo (2007) found that elite athletes were no more likely to experience pelvic girdle pain, low back pain or pelvic floor problems during pregnancy or in the postpartum period compared to non-athletes.
  • An additional study by Braekken et. al. 2009 also did not find a link between physical activity level and pelvic organ prolapse. However, they did find that Body mass index, socioeconomic status, heavy occupational work, anal sphincter lacerations and PFM function were independently associated with POP.

Is your head spinning yet?? Let’s make some sense of this research…

First, it does seem like UI is a common problem in athletes—the cross-fit video that had all of my colleagues up in arms identified this problem really well—and honestly, runners are no exception to this. Every week, I work with women who experience urinary leakage when they run or may have even stopped running due to leakage, and I can assure you this causes a huge impact to these women’s lives. I also can assure you that there are many women out there dealing with leakage during running or other exercises who suffer in silence, too embarrassed to get help or somehow under the impression that leakage with exercise is normal.

With that being said, I am not ready to throw away running or really any other form of exercise all together (other than sit-ups…let’s never do those again). Running has amazing benefits—weight control, cardiovascular improvements, psychological improvements/stress reduction—and these should not be cast aside due to a fear that running could cause a pelvic floor problem.

As a pelvic floor physical therapist working in a predominantly orthopedic setting, I see many men and women enter our clinics with aches and pains—and injuries—that began while starting or progressing a running program. Often times, our amazing PTs identify running gait abnormalities, areas of weakness, or biomechanical abnormalities which can be contributing to hip/knee/foot/etc. pain with running. Improving those movement patterns and improving those individual’s dynamic stability seems to make a huge difference in allowing the client to participate in running again without difficulty.

To be honest with you, I see pelvic floor problems in runners the exact same way. When a woman comes into my office complaining of urinary leakage during running, I look to identify running gait abnormalities, areas of weakness or biomechanical abnormalities which are impacting her body’s ability to manage intra-abdominal pressure during running. I also make sure I am managing other things—identifying pelvic organ prolapse when it may be occurring and helping the woman with utilizing a supportive device (tampon, pessary—with collaboration with her physician, or supportive garment), managing co-existing bowel dysfunction or sexual dysfunction, and making sure the patient has seen her physician recently to ensure she is not having hormonal difficulties or medication side effects which could worsen her problems.

We know that intra-abdominal pressure is higher when running. A poster presentation at the International Continence Society in 2012 identified that running does in fact increase intra-abdominal pressure compared to walking—but not as much as jumping, coughing or straining (Valsalva). And not as much as sit-ups…which I hate.

Kruger et. al. ICS Poster Presentation, "Intra-abdominal pressure increase in women during exercise: A preliminary study." 2012

Kruger et. al. ICS Poster Presentation, “Intra-abdominal pressure increase in women during exercise: A preliminary study.” 2012

As you know by now if you follow my blog posts, I do not believe that the pelvic floor is the only structure involved in controlling intra-abdominal pressure increases in the body. (This is why I get so annoyed with all of the studies trying to look at the effectiveness of pelvic floor muscle exercises used in isolation in treating pelvic floor dysfunction). The most current anatomical and biomechanical evidence supports the idea that the pelvic floor muscles work in coordination with the diaphragm, abdominals, low back muscles as well as even the posterior hip muscles to create central stability and modulate pressures within the pelvis. In order for a runner to not leak urine or not contribute to prolapse or pelvic floor dysfunction when she runs, she needs the following(well really, more than this…but let’s start here):

  • Properly timing, well-functioning, flexible pelvic floor muscle group.
  • Properly timing diaphragm—that is used appropriately as she runs so she is not participating in breath holding during her exercise
  • Strong and adequately timed abdominals and low back muscles to assist in stabilizing her spine/pelvis and assist in controlling IAP.
  • Flexible and appropriately firing gluteal muscles to support her pelvis during each step as she runs
  • Appropriate shoes to support her foot structure and transfer the loads through her legs
  • A great sports bra to help her use good posturing while running

Now, is there a time when a woman shouldn’t run?

Yes, I do actually think there are times when running does more harm than good and it may be advantageous for a woman to take some time off from running to restore the proper functioning of structures listed above.

  • If a woman has pelvic organ prolapse, for example, she may need to take some time off from running and participate in other exercises emphasizing functional stability with less of an increase in IAP prior to resuming an exercise program. Some women can return to running in the meantime using a supportive device like a pessary or tampon to help support her organs; however, this may not ultimately mitigate the harm if a person is not stabilizing properly as she runs.
  • I also recommending taking a break from running if a woman is leaking significantly during running or experiencing pain with running. I generally believe that once these structures are appropriately restored to function, women can return to running with less difficulty.
  • The other time I will often recommend waiting is when a woman is further along in her pregnancy or early post-partum. At this time, the increased weight on the pelvis as well as the loss of stability occurring due to hormonal changes places a woman at a higher risk for pelvic floor dysfunction. This, of course, varies based on the individual, but in many cases it may be helpful for these women to choose alternative exercises until after they deliver their children.
  • And lastly, I do recommend a woman holds off on running immediately after gynecological surgery (no-brainer here folks). The research does not indicate that said woman should never return to running—but again, I do think she should allow her body to heal and build up the appropriate strength and coordination needed to support her organs and her pelvis when running.

This post got a little longer than I originally anticipated… so to sum it up… is running bad for your female organs? Not always… but sometimes.

Many of my colleagues have some fantastic blog posts regarding exercise and pelvic floor dysfunction. Check out a few of them below:

Vlog by Julie Wiebe providing an alternative to running:

https://www.juliewiebept.com/video/integrative-programming-for-female-runners-with-incontinence/

Safe exercise for those with pelvic pain:

http://www.pelvicpainrehab.com/pelvic-floor-physical-therapy/2058/pelvic-pain-and-exercise-general-fitness-tips/

Tracy Sher, “Pelvic Guru” on Leaking during exercise:

http://pelvicguru.com/2013/06/22/dear-crossfit-and-crossfit-gynecologist-im-appalled-theres-help-for-peeing-during-workouts/

Seth Oberst’s 4-post series on the Diaphragm:

http://www.sethoberst.com/blog/category/breathing

What do you think? Let me know in the comments below!

Written by: Jessica Reale, PT, DPT, WCS

References:

Bo K, Backe-Hansen KL. Do elite athletes experience low back, pelvic girdle and pelvic floor complaints during and after pregnancy? Scand J Med Sci Sports. 2007 Oct;17(5):480-7. Epub 2006 Dec 20.

Bo K, Sundgot-Borgen J. Are former female elite athletes more likely to experience urinary incontinence later in life that non-athletes?

Borin L, Nunes F, Guirro, E. Assessment of pelvic floor muscle pressure in female athletes. PM R. 2013 Mar;5(3):189-93. Scand J Med Sci Sports. 2010 Feb;20(1):100-4

Jácome C, Oliveira D, Marques A, Sá-Couto P. Prevalence and impact of urinary incontinence among female athletes. Int J Gynaecol Obstet. 2011 Jul;114(1):60-3.

Advertisements

“Is Mine Normal?”

Question

For guys, there is often a lot more openness when it comes to their external genitalia. Unfortunately for women, we too often hear the message that that area is private, or even dirty or shameful. And so, a lot of anxiety can exist when it comes to a female’s external genitalia. With so many things in life, we all want to be normal, look normal, and not have anything funny going on with us. It’s not uncommon for a teenage girl going to her first gynecologist appointment or a woman going to get a wax to think, “Is mine normal?” In fact, we often have ladies ask us this very question when they start seeing us in Pelvic PT.

 So, when it comes to your private parts/lady parts/vagina/vajayjay/coochie/hoo-hoo/hoo-ha/flower, how well do you know yours?

Some women may look at their genitals regularly, while others would never dare to grab a mirror and look. Regardless of where you fall on the spectrum of your comfort level with looking at your own “vagina,” if it’s news to you that what is commonly referred to as the “vagina” is technically the vulva, keep reading!

So, when it comes to your private parts/lady parts/vagina/vajayjay/coochie/hoo-hoo/hoo-ha/flower, how well do you know yours? Some women may look at their genitals regularly, while others would never dare to grab a mirror and look. Regardless of where you fall on the spectrum of your comfort level with looking at your own “vagina,” if it’s news to you that what is commonly referred to as the “vagina” is technically the vulva, keep reading!

As Dr. Lindsey Doe illustrates in her YouTube video (you will never look at a hooded sweatshirt the same after watching) the vulva refers to the external female genitalia and can be thought of as the vagina’s neighborhood. So what all is in this neighborhood?

 Mons pubis – the fat pad over the pubic bone that is normally covered in hair

Labia majora – the outer folds or “lips”

  • Run from the mons pubis in the front to the perineum in the back
  • Composed of thicker skin, fat, and connective tissue
  • Normally covered in hair

Labia minora – the inner folds or “lips”

  • Run from the fourchette (frenulum of the labia) in the back and then split at the front to form both the prepuce and the frenulum of the clitoris
  • Composed of thin skin
  • Not covered in hair
  • Lots of variation in size, shape, and coloration (even in the same woman)

Clitoris – the main erectile tissue in the female (from the same embryological tissue as the penis)

  • Plays a role in sexual function only
  • Glans – the head of the clitoris (the clitoris has a body, and legs on either side, too, but they are internal); can vary in size and shape
  • Prepuce – the “hood” of tissue that covers the glans to protect it; formed by the labia minora

Frenulum – where the labia minora meet at the front, right below the clitoris

External urethral meatus – the opening to the urethra which is the tube emptying your bladder

Vestibule – the area inside the labia minora (the “porch”), between Hart’s line and the hymen

Hart’s line – separates the labia minor from the vestibule; marked by a change in coloration (this is an imaginary line)

Glands (you won’t see these) – secrete fluids important for lubrication with intimacy; may become clogged

  • Bartholin’s glands – inside the vestibule
  • Skene’s glands – on either side of the urethral opening

Hymen – the mucosal tissue that partially or entirely covers the vaginal opening at birth; may be disrupted by various means (vaginal penetration whether through sexual intercourse, masturbation, use of a tampon; surgery; trauma; vigorous sports). Remnants of the hymen will vary significantly between women. Talli Rosenbaum, physical therapist and sex therapist, has a fantastic article about the hymen here.

Introitus – the opening to the vagina; normally closed when legs are not spread

Posterior Fourchette – where the labia minora meet in the back, behind the introitus

Image

But while a cartoon can be a great way to visualize and learn anatomy, we are not cartoons! So if you’re worried that your labia are too big or that you have funny wrinkles somewhere, remember that your vulva is just like your face – everyone shares common features, but the details are different.

If you’re still worried, check out British artist Jamie McCartney’s installation “The Great Wall of Vagina.” He has cast hundreds of vulvas, and through art has made “the sexual nonsexual.” No two look the same. Included in the collection are several male-to-female and female-to-male transgendered individuals, but chances are you couldn’t pick them out because of the vast differences among all vulvas.

 So don’t fret, your vulva is normal, just the way it is.

Note: Please know that this post is not meant to imply that ALL variations are normal. Knowing what your vulva looks like when it’s healthy can be helpful so that you can recognize any changes that may occur. Dermatological conditions and sexually transmitted infections (STIs) may change the appearance of your vulva or cause pain, itchiness, or burning in this area. If you are concerned about a potential disease process, please consult your physician. 

*For more resources on pelvic anatomy, check out this excellent post by our friend and colleague, Tracy Sher, on Pelvic Guru!

Image

This guest post is written by Leigh Welsh, a third year Doctor of Physical Therapy student from Duke University, currently completing a 12-week rotation with Proaxis Therapy in Pelvic Health with Jessica Powley, PT, DPT, WCS. Leigh has been an excellent addition to our team, and we are confident that she will make a fantastic clinician.

%d bloggers like this: