“Platform ready!”

You take a deep breath, clasp your belt, and walk out. This is your first powerlifting competition and you’re kicking ass so far. It’s your final deadlift attempt and you know you got this. You step on the platform, set your feet, and wrap your hands around the bar. The crowd of spectators are screaming at you to lift it up and just as it clears the floor you feel a strange, new sensation. Thinking maybe it’s just your nervous bladder, you keep pulling on the bar and get 3 white lights! Later when you look at the video of your attempt, you see that there is something leaking in between your legs.

This is a common example of Stress Urinary Incontinence (SUI), or the leakage of urine during times of increased stress on the bladder and pelvic floor.

We all know moms who cross their legs whenever they cough, laugh, or sneeze, but this can happen even in folks who have never been pregnant or had children. If you’re a powerlifter, you might be familiar with this happening in the deadlift, but it can occur anytime there is increased intra-abdominal pressure. In Crossfit this is most commonly seen during double unders, box jumps, or running. Ultimate players might experience this when coming down from a jump, laying out, or during incidental contact with other players.

Contrary to some of the information circulating in the strength world, peeing while lifting is not a marker of intensity, but a neuromusculoskeletal dysfunction that can be prevented and treated! Conversely, SUI does not mean you are a weak person, but ignoring these symptoms can likely lead to further problems and injuries down the line.

Why does this happen?

SUI can result from a decreased strength or endurance of your pelvic floor muscles (PFM) as well as impaired motor control and coordination. You have 8 primary pelvic floor muscles and just like anywhere else in the body they can get injured, become weak or tight, and need to be trained.

In the U.S. more than 25 million people suffer from urinary incontinence. Although it is not exclusively a “female problem”, women are twice as likely as men to experience SUI. This increased prevalence is associated with things like hormones, pregnancy, and menopause. For men, one of the largest contributors to incontinence is prostatectomy due to prostate cancer.

While this is a fairly common problem that affects people across the lifespan, most keep their struggles to themselves. Due to society’s branding of anything related to the pelvis as taboo, there is often embarrassment, shame, and isolation felt by those experiencing pelvic floor dysfunction. When they do confide, many are told by family members or friends that it’s just a normal part of life. Not to mention seeing advertisements for panty liners, bladder supports, or adult diapers can reinforce the idea that you’re doomed to struggle with this forever.

The PFM have 5 primary functions that, due to their location, have a tremendous impact on your quality of life.

• Sexual function: dysfunctions here can result in painful sex, difficulty achieving orgasm, erectile dysfunction, premature ejaculation

• Support: maintaining proper positioning of the organs and preventing prolapse

• Sphincteric control: urinary, fecal, and gas continence

• Stabilizing the lumbosacral spine: these muscles are actually part of the core and prevent back/hip/abdominal pain

• “Sump pump”: helping to move blood and lymphatic fluid in the lower body back up towards the heart

So, I should just do some Kegels right?

Ahh, the Kegel. If you Google anything related to the PFM, there will be countless links discussing this exercise. A Kegel is merely a contraction of your PFM, sometimes described as engaging the muscles you would use to stop the flow of urine (please don’t actually try to do this while peeing or you could wind up with a UTI). Contrary to popular belief, people of all gender identities have pelvic floors and should be able to do a Kegel. However, this exercise is not a blanket treatment applicable to everyone. Kegels are a fantastic exercise for someone with a weak and over-lengthened pelvic floor. But just like every other muscle in the body, PFM can be weak and tight. Sometimes doing the opposite of a kegel, a pushing down and out to lengthen the muscle or a "reverse Kegel" is more appropriate. Different issues require different interventions and a one-size fits all approach could exacerbate the problem for some.

For those who could benefit from Kegels, isometrics are just the beginning. One research article suggests that working up to a minimum of 50-60 sustained Kegels per day is enough to help 88% of patients improve their incontinence. While that may be sufficient for some, it likely is not aggressive enough for many others. Ultimately, progressing PFM exercises will be needed and variations can be achieved by simply using Kegels concurrently with other movement.

What about non-cishet folks?

I was fortunate enough to be introduced to pelvic floor PT early on during my 1st semester of graduate school. The topic immediately interested me, but most of the discussion revolved around learning about the effects of pregnancy on the body. During some independent research, I became fascinated by the hormonal/biological differences between men and women that influence their risks for various ailments. For example, ACL injuries are 2 - 10 times more common in female athletes than male athletes playing the same sports. Additionally, there is an established association between knee laxity and hormonal changes during a menstrual cycle as well as a relationship between testosterone and improved athletic performance.

Prior to this lecture, I never considered the idea of something like our sex hormones having such a great impact on our musculoskeletal health. I became curious about how the exposure to both testosterone and estrogen would affect people who are transgender. This extended into a broader interest in the topic of trans health care, including the biological and psychosocial components of providing high quality treatment.

There are many instances in which someone’s identity as transgender could impact the pathology a PT addresses with their intervention. For example, some people who are FTM practice binding their breasts, which can lead to compressed ribs, collapsed lungs, and back pain. If a patient who is FTM undergoes removal of both breasts, PT could be indicated to improve scar mobility, prevent keloids, and maintain upper extremity range of motion during healing. A survey from the Williams Institute at UCLA claims that “54% percent of respondents reported having some sort of physical problem from trying to avoid using public bathrooms, all of whom reported that they ‘held it,’” including dehydration, UTI’s, and kidney infections. Any pathology of the genitourinary system can have a negative impact on the pelvic floor resulting in secondary injuries.

Other ways that pelvic floor PTs can help TGNC individuals include dilation and maintenance of the vagina after bottom surgery to improve comfort with sexual function or manual therapy and re-education improve function of the neo-penis.

Summary

Pelvic floor health is not just for pregnant women anymore and it is possible to do any and all of the activities you love pee-free. If you are experiencing symptoms of pelvic floor dysfunction, it would benefit you to see a PT who specializes in this area. Queer folks in particular may avoid discussing this region of their body with medical providers and are at increased risk for pelvic floor issues due to having more barriers to care. Having an individualized assessment and plan of care can help address your specific deficits in order to meet your goals. While SUI may be a common problem and is absolutely nothing to be ashamed about, it is definitely not normal, and not something you just have to deal with on your own.

Disclaimer: I can only represent the part of the community that I identify with. The views expressed are my opinions and may not be generalizable to all LGBTQ persons. I am thankful to be given a platform to address a topic that is so rarely discussed, but if I have made any errors or misrepresentation, please forgive me.