The relationship between low back pain and urinary incontinence has been observed by physiotherapists for some time and confirmed by many studies. A deeply personal and relentlessly taboo issue, incontinence is rarely divulged—in doctors’ offices or with friends—leaving many women to believe the misconception that leaking urine is part of normal aging.
In fact, regardless of age, there are strategies that can help with urinary incontinence, which affects more than half of U.S. women—a statistic that is growing due to an aging population and the obesity epidemic. It’s such an important conversation that shouldn’t be avoided, experts said, because incontinence is often the “last straw” for caregivers before they relinquish care of a loved one to a facility.
Kim Vopni, a pelvic health coach known online as “The Vagina Coach,” said women sometimes wait six to seven years before seeking help because they’re ashamed.
“They’re told by the media and friends that’s what happens when you get older. It’s embarrassing. They don’t want to embarrass themselves or their care providers,” she said. “They’re not told this is a very treatable set of conditions, a very treatable problem.”
Incontinence has several forms, but all are related to an unwanted loss of any amount of urine. Stress urinary incontinence is when a little urine leaks out with exertion such as sneezing, coughing, squatting, and jumping. It’s the most common type, but almost every type of continence is treated the same way, Vopni said.
Anyone with low back pain and urinary incontinence should talk to their gynecologist. There’s a good chance the two are really symptoms of a weak core, which includes not only the abdomen and back muscles but also those at the bottom of the pelvis that wraps underneath the rectum, uterus, vagina, and urethra.
A 2017 study in Musculoskeletal Science and Practice followed 85 women whose chief complaint was lumbopelvic (low back and hip region) pain and 95.3 percent were found to have some form of pelvic floor dysfunction. A study published a decade earlier in Manual Therapy comparing two groups of women discovered 78 percent of women with low-back pain also reported having urinary incontinence.
Dr. Anna Cabeca, an OB-GYN and best-selling author, said it’s important to arm yourself with questions when you see your doctor. Surgery should never be the first consideration, because lifestyle changes, exercises, and even hormone support are proven remedies.
Her medical training didn’t teach her about these options but rather pointed to surgery. The most common surgery for urinary incontinence is a sling procedure in which a synthetic mesh or human tissue is used to support and compress the urethra. More than 104,000 lawsuits have been filed against manufacturers of mesh due to malfunctions causing pain, urination problems, and organ perforation, according to ConsumerSafety.org.
Cabeca, who no longer sees patients but consults and trains physicians, said there’s a better way for both groups. She used to prescribe vaginal hormones to prepare her patients for surgery, but they often didn’t end up needing procedures because symptoms would disappear.
“That blew my mind because we weren’t taught that. Using vaginal hormones can completely reverse symptoms,” she said. “Don’t go for a surgical procedure if you haven’t had a full, good assessment of what’s the cause of the incontinence.”
The Role of Hormones
Hormones play a key role in muscle strength, and that’s true even for muscles deep within the pelvis. In seasons of life when hormone levels are shifting, muscles—especially those untrained—are susceptible to failure due to collagen loss but mostly hormone depletion.
This is why menopausal women can suddenly have urinary incontinence issues for the first time when estrogen levels drop, though past experiences with incontinence make it more likely. Unlike hot flashes and mood swings, which can improve over time, urinary problems will only get worse if they aren’t addressed.
“We have a lot of estrogen receptors in our vagina. Estrogen keeps things supple and juicy and moist,” Vopni said. In menopause, “those tissues will become drier. The walls of the vagina will start to lose their folds.”
Called rugae, the vaginal folds straighten out—more like a pencil skirt versus a pleated skirt when estrogen declines, she said. The result is vaginal atrophy, which not only causes sensations of burning when urinating and increased urge, but also results in painful intercourse.
These tissues and supporting muscles can rejuvenate with topical estrogen and/or progesterone creams, but because testosterone plays a part in muscle strength, Cabeca also endorses DHEA, a hormone synthesized in the adrenal glands that helps make both estrogen and testosterone.
“You need to give (hormone support) to that area to keep that tissue healthy as we get older,” she said. “Age-trophic changes cause significant problems. If we can reverse it, let alone prevent it, that’s so much better.”
Lifestyle
The modern lifestyle and diet, in addition to habits, are part of the reason so many women are struggling with incontinence.
About 70 percent of urinary incontinence can be significantly improved strictly by changing habits, according to Harvard Health.
Diet can make a big difference, which is why Vopni has her clients keep bladder diaries to find out what triggers might be. Dietary triggers associated with incontinence include artificial sweeteners, alcohol, caffeine, chocolate, acidic foods, spicy foods, dairy, and some vitamin supplements.
“Alcohol is a really big one, especially in the perimenopausal and menopausal age,” she said. “It really doesn’t serve women during that transition. Removing it can make a difference to many symptoms.”
Another change that’s rather simple is correcting unhelpful bathroom habits that can be rooted in childhood. Cognitive behavior modification can retrain the body to recognize cues for a full bladder, rather than using the bathroom at certain times of the day or before leaving the house—habits formed that don’t help us understand our bodies.
Some women learned to hold their bladder too long in order to attend to the needs of a demanding career or children. Others avoid drinking enough water out of fear of having to use the restroom too much.
“People who are afraid of leaking, oftentimes their muscles become guarded. It can create weakness. It can create pain in their muscles,” Vopni said.
The bladder is designed to signal the brain as it nears fullness and the signals get stronger the more it fills. When you urinate, a steady stream for at least 10 seconds and more like 15 seconds indicates you had a full bladder. Anything less than that can be a sign that you are emptying your bladder too soon.
Intermittent fasting might be another behavior modification that helps, Cabeca said, as it clears toxins and restores kidney function.
“It’s built into every religion around the world, the fasting benefits, but we’ve lost that in our American lifestyle,” she said. “We are designed to walk in nature, eat from nature, heal in nature, detox in nature. We’re supposed to fast to get rid of the toxins.”
Another thing we’ve lost is a lot of functional movement, including our bathroom habits. Most Americans are increasingly sedentary, even on toilets. Modern toilets put our bodies in postures that put more strain on our elimination muscles. Meanwhile, our legs are relaxed, something most of the world doesn’t experience since they hold a squat to go to the bathroom.
“That’s part of their lifestyle,” she said. “You have to have a pretty strong core and pelvic floor, and legs.”
Other lifestyle factors include smoking, poor sleep, and stress. For both back and pelvic pain, Cabeca said a multidisciplinary approach might include acupuncture, exercise, and chiropractic adjustments. “Yoga is essential for all of us, especially as we get older, and core exercises,” she said. “Until we die, we need to be doing our kegels.”
Strengthening the Pelvic Floor
The activation and relaxation of pelvic floor muscles is named after Dr. Arnold Kegel. He first noticed some women felt disconnected from their muscles or had a limited range of motion. This activation and relaxation response is central to enabling the urethra to react at the right time with the right force for urine flow.
For years, doctors have simply told patients to go home and do Kegels when they abashedly confess to incontinence issues. That’s problematic since most women don’t know how to do them correctly or have incorrect posture, fear, trauma, or scar tissue. Women might also have hypertonic muscles and need to be trained in relaxation techniques rather than a focus on contractions.
This is why Vopni said every woman ought to see a physiotherapist or pelvic floor physical therapist at least once a year. She calls it a gold standard of care, and it could potentially prevent a lot of incontinence cases.
The foundation of pelvic floor exercises is the breath. Vopni calls it the core breath, and it yokes the inhalation with the relaxation and widening of pelvic floor muscles and the lowering of the diaphragm. On the exhale, the pelvic floor muscles draw together and upward as the diaphragm pushes upward.
It helps to envision the breath and vaginal movement as a jellyfish moving up and down. Vopni also cues the movement to her clients this way: inhale and blossom the vulva or buttcheeks; exhale and imagine picking up a blueberry with the vagina or anus.
“Once they can do Kegels correctly, we need to layer it into movement,” she said. “We need to train the pelvic floor to respond in a movement that mimics standing up from a chair or while lifting weights.”
In other words, Vopni teaches women how to Kegel while doing the types of movements that normally involve leakage—lifting weights, running, jumping, and squatting. She said it’s more fun but also more effective. Because women are exercising their bodies, too, they are more likely to do the Kegels. And those other exercises are strengthening the rest of the core in movements such as planks and bridge poses.
“The pelvic floor is a key part of the core and is never talked about,” she said. “When we optimize its function, that in and of itself can strengthen our core, can flatten our midsections, and help with back pain.”
Focusing on keeping the core and lower extremities strong and flexible is even more important as we age, Cabeca said.
Our bodies aren’t designed to be in pain, she said, and anyone is capable of slowing down to listen to messages it might be sending. While many conditions can be reversed, it’s easier to deal with situations before they impact our quality of life. Speaking up is vital.
“Don’t limit yourself because you’re too old. Keep challenging yourself. Keep taking care of yourself,” Cabeca said. “There’s no shame around it. We have to do more than wearing continence pads and laughing it off as a passage of time. We have to aggressively reverse this.”
Complementary and Alternative Treatments
Foods and Beverages to Eliminate or Reduce
- Coffee, caffeinated and decaffeinated
- Tea, caffeinated
- Carbonated beverages
- Alcoholic drinks
- Citrus juice
- Tomatoes and tomato products
- Spicy foods
Mind-Body Interventions
- Pelvic floor training
- Bladder training
- Biofeedback
- Yoga
Other Modalities
- Massage
- Energy therapies such as qigong
- Acupuncture
From “Synopsis in the Management of Urinary Incontinence,” IntechOpen, 2017.