No Peeing with Double Unders!

This article is written by Dianna DiToro, aka ‘DTrain!’ She is my partner in crime, a phenomenal mother, CrossFitter, a Doctor of Physical Therapy Student, Marine Corps Major, and good friend!! She is very knowledgeable and passionate about the below topic!

Join the mobility- mob/WOD crew by starting here and doing your KEGELS (nobody will ever know). Now Lift and hold…..1..2..3..4..5..6..7..8..9..10!

read on…..

CrossFitters are talking about the pelvic floor! Not surprisingly, the CrossFit world became atwitter with Emily Beers’ brave work in the March 2013 article, “From Crunches to Climax,” where she introduced the rest of us to the phenomenon of exercise-induced orgasms experienced by a handful of women during certain abdominal exercises. In June 2013, Rory McKernan let the cat out of the bag when he coaxed several high-level female athletes, one gynecologist, and one half-serious Froning, to admit that they pee during tough workouts which is a sign of stress incontinence. This is a dirty, little not-so-secret of CrossFit. I became aware of this phenomenon a few months into my CrossFit journey and just thought it was something that “us mommies” had to learn to live with. I quickly learned, however, that this issue doesn’t plague just “us mommies.” Fit, fabulous, and BC (before children!) women were all slyly admitting to this piddle pattern. What gives? Fast forward a year and a half into chasing a doctorate in physical therapy and I met Cindy Furey, a physical therapist who specializes in pelvic floor function. Her presentation changed up my game of thrones and armed me with some tools to help prevent the puddles.

Through this article, I hope to convey to the readers what the normal functions of the pelvic floor muscles are, their importance, and an easy-to-follow plan for how to keep them from going to pot (pun intended). Before we can talk about how to address this inconvenient issue, we need to identify what is normal.

-Urinating every 2-5 hours

-Urinating 4-5 times a day for men or 5-7 times a day for women

-waking 0-2 times a night to urinate

-controllable urges with the ability to postpone for 30 min to 2 hours

-MINIMAL time of urine stream = 8-10 seconds

-NORMAL time of urine stream = 20-30 sec

– relaxed/seated voiding

-NO LEAKING

I know that some of you are laughing (and leaking while you laugh) at these “normal” values. As we saw on the video with Rory, even the gynecologist reports that peeing during a workout is “ok.” As I learned from Cindy, peeing during a workout (double-unders included) is definitely common but definitely NOT NORMAL. So let’s work towards a solution.

First things first. What are we actually dealing with here? The pelvic floor has five main functions of 1) supporting the organs 2) providing somewhat of a sump-pump effect for the lower trunk 3) sphincteric control (you want this, you really, really want this) 4) sexual function (yay!) and 5) they provide stability. If you’re not sure where they are, a good way to find them (not to strengthen them, just to figure out where they are) is to try to stop the flow of your urine when you’re on the potty next time. The muscles that are responsible for stopping the flow are also responsible for all of the functions I mention above. Interestingly, men and women have very similar pelvic floor muscle designs and functions with men missing a distinguishing anatomical opening. Now that we briefly covered anatomy, it’s business time. Here are some things that I currently believe will help anyone with a pelvis to reduce incontinence, reduce inconvenience, and maybe even improve sexual performance (hooray!) or set a deadlift PR.

SIT IN NEUTRAL SPINE You’re probably sitting as you read this. What are you sitting on? Sure, your butt. But what part? Chances are, despite the 522+ videos of positional goodness produced by the prolific Kelly Starrett, you’re in sacral sitting. You lost your solid, braced position and have fallen back into the chair resting on your sacrum. Other than trashing your spine, what’s the big deal? The big deal is that your little pelvic floor muscles are supporting all of your guts while you’re in sacral sitting. Now that you’re sitting up straight (hopefully after a correct bracing sequence) in a more neutral pelvic alignment your pelvis literally lightens the load for your pelvic floor muscles. How would you ever expect any muscle to “perform” if you never allowed it an opportunity to relax? You wouldn’t. You’d give your legs a rest day. You’d back off from overhead movements for a day or so. But most of us don’t see the importance of allowing the pelvic floor muscles to take a breather until now.

Figure 1 Sacral sitting. Note that the bladder is suspending only by the muscles of the pelvic floor that lie underneath the balloon. There is no boney support.

Figure 2 In neutral sitting, the bladder can rest against the pubis thereby giving the pelvic floor muscles a little rest.

GAME OF THRONES–SIT DOWN TO PEE Again, most of you are laughing at reading this, especially my mommy friends. Yes, I’ve seen plenty of bathrooms at plenty of boxes and they are in various states of cleanliness. I’ve been a Marine officer for 11 years, so I’ve seen my fair share of downright gross toilets. We’re going to need to get over this one culturally if we don’t want to start wearing adult diapers in our WODs. Put the toilet paper down on the toilet seat. Use the rice-paper like cover that you usually only use as a back-up for TP when you find the stall is not well-stocked. Enjoy the bareback experience in your own home and sit down to pee or, if you’re a dude, stand, but stand in a relaxed manner and go with the flow. Remember those “normal” values of how long it should take to pee? Many of us are so ingrained that we “hover” and 3…2…1…go! Urinating becomes a timed event and we attempt to force out the pee as quickly as possible. There are several problems with this approach. 1) It’s actually NOT a race, so sit down and take the 20-30 seconds to pee while you’re scrolling through your Instagram feed. 2) It confuses the pelvic floor! You need to relax the pelvic floor in order to pee, but standing, particularly “hovering” activates the pelvic floor to contract. A recent study discovered that the pelvic floor muscles are activated indirectly by the anatomically nearby obturator internus, a hip external rotator. (remember that, we’re coming back to that) Hovering over the toilet activates the hip external rotators and in turn activates the pelvic floor. So they get confused. Contract or not to contract? As falling over would be more immediately dangerous, the pelvic floor shorts itself of the sphincteric control and closes down the urine stream before you’re truly done and you end up with a little left in the tank even after voiding. This sets us up for leaking and for going to the bathroom more frequently than 5-7 times a day.

Figure 3 Bad, Not-as-bad, and Better (notice not “best,” you need to squat for that) positions for the best seat in the house. Notice in the second figure that I am still using my hip external rotators to keep my shorts up and off of the floor. In the central figure, I’ve assumed a more relaxed position! Rx+? If you’re blessed with long shin bones, you may just be able to lean forward to get an even more relaxed angle, if you have shorter shins, Google the SquattyPotty or watch here:

PEE ONLY WHEN YOU NEED TO PEE As ladies, our current culture doesn’t really help us out here. Remember potty-training? Your brother was allowed to pee into the bushes, but you were prompted to pee, “just in case” every time before leaving the house. Habit much? Many of us still do this. We do the “just in case” pee before bed, before sex, and before the WOD. You think this kind of approach does anything for pelvic floor muscle strength and endurance? Negative, GhostRider. It also reduces the bladder’s natural sensation for what is “full.” If you’re a habitual abuser of the “just in case” potty break, your bladder will accept that it’s “full” even when it’s only partially full because you’ve trained to relieve it with much smaller volumes. Now, for the love of Christmas, pee when you need to pee. Don’t hold it in uneccessarily, as that can create a different kind of dysfunction. (just ask your favorite NICU nurse or middle school teacher how many times they can get to the bathroom during their shifts and what that does to them)

BEYOND THE WHITEBOWL This part should be easy, as we CrossFitters are obsessed with recording, posting, and improving our times. You need to write down how many times you’re peeing, as well as how long you’re peeing. Do this for at least 3 days. I bet that some of you are going twice as much as what is considered “normal.” This can change! This will get better! Just don’t expect your body to adjust to it overnight. Like proficiency with the Olympic lifts, this change is going to take some time. Invest in the process by recording your “events.” Make the leaderboard !

AVOID BLADDER IRRITANTS Simply put, don’t piss off your bladder so that it doesn’t piss on you. Stay hydrated, yes STAY HYDRATED. Becoming even slightly dehydrated irritates the bladder and can cause it to signal to your brain that it needs to void a bit prematurely. If you’re one of the folks that can’t seem to gulp down the classic 6-8 glasses a day (most of us), take small sips, not gulps, of water throughout the day. And here’s a list of items to avoid that are known bladder irritants:

-caffeine

-nicotine

-alcohol

-dairy

-citrus

-carbonated beverages

-high sugar foods

-artificial sweeteners

-highly acidic foods

I’m useless before my morning coffee, but I try to pay attention to the timing of my coffee intake relative to the WOD. Sometimes I just go through the WOD in a semi-useless state with the coffee enjoyed on the back-end in order to reduce the bladder irritation potential.

KEGELS AND DIAPHRAGMATIC BREATHING It’s not by accident that this is the first time that I’m mentioning kegel exercises. Truth is that most of us are doing them wrong. The kegel is a wonderful exercise that includes squeezing in AND up with our pelvic floor muscles. KStar and company address this

The pelvic floor needs to be able to contract quickly (double-unders) and maintain a sustained contraction(that slow deadlift PR pull). Make sure the speed and duration of your kegels match what you need the pelvic floor to do.

But there are many of us that can’t even perform the kegel. Is all hope lost? Not quite. The New Englad Journal of Medicine suggests that you could seek out a physical therapist trained in pelvic floor muscle techniques. While you wait for your appointment, you have others muscles that can help. The pelvic floor has a few muscle buddies in the multifidi of the back and transversus abdominus in the abdominal muscle group. Simply put, they fire together to provide the important support function mentioned above. If you can’t train the pelvic floor directly, you can still train it via diaphragmatic breathing. Mulabanda breathing practices in yoga are a great expression of this and any serious yogi (or youtube) can demonstrate this to you. You may find some difficulty in achieving this breathing pattern. If so, you can reference Jill Miller and KStar for some prepratory gut-smashing.

While you’re at it, make sure you’re not making the pain face. Turns out that a clenched jaw is usually associated with a clenched pelvic floor in the body’s natural protective measure. If you need some unclenching help, KStar is back to the rescue with this little gem:

KNEES OUT Now, once your pelvic floor is functional and ready to work, how do you activate it? I’ll reference Kelly’s first video above but also include a nugget from earlier in this article. Remember when we talked about the pelvic floor being indirectly activated by one of the hip external rotators? What I’m about to say you’ve heard before from Burgener, Rippetoe, Glassman, Starrett, and Fu, “KNEES OUT.” Chances are, you’re not going to be able to think about lifting your pelvic floor while you’re cranking out that deadlift or squat PR. But you should be thinking about “knees out.” If you follow Dr. Starrett’s prescription of creating torque by screwing your feet into the ground before and during your lift, you’re also indirectly activating your pelvic floor muscles tapping into their supportive power as well as sphincteric control.

Don’t take my word for it. Follow Dr. Starrett’s lead of “test and re-test.” Try the techniques above for a solid 6-weeks and report back. As always, if something feels sketchy, painful vs. uncomfortable, or you feel like your insides are falling out, please go see your physician. This is not a cure-all, just some education that I felt compelled to pass along. I’m still a student and have much to learn. I just hope that we can start a dialogue about the proper and NORMAL function of the pelvic floor muscles without too much giggling or wiping up the gym floor. Here’s a quick re-cap to take with you…

About the author: Dianna DiToro holds a master’s degree in exercise science and health promotion and is currently pursuing a doctor of physical therapy. She is an average student, a below average CrossFitter, and an above-average coffee snob. She juggles (poorly) the roles of mom, an officer in the United States Marine Corps Reserves, coach, and student. In order to maintain efficiency, she might be doing kegels right now…

This article is written with grateful acknowledgement to the work and expertise of Cindy Furey, PT and Dr. Kelly Starrett, PT. To learn more about Cindy and her practice, please visit www.comprehensivetherapy.com. If you’ve been under a rock, please direct your interwebs to www.mobilitywod.com to learn more about Kelly.

Additional resources and references:

American Physical Therapy Association, Section on Women’s Health www.womenshealthapta.org

Herman & Wallace www.pelvicrehab.com

SquattyPotty! www.squattypotty.com http://www.youtube.com/watch?v=pYcv6odWf

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