CrossFit, Your Pelvic Floor and Peeing During Workouts by Antony Lo
This post, written by Antony Lo, is inspired by the video that CrossFit HQ put out, presumably with good intentions, due to an “event” during the deadlift-box jump event at the Central East Regionals.
Pelvic floor dysfunction is real and I would never make anyone feel bad if it happens, but it is not “OK” or normal to pee during workouts – it is a sign of Pelvic Floor Dysfunction
This article hopes to cover the following:
- What is Pelvic Floor Dysfunction
- What is “normal” and what is not
- Things that do NOT help
- Things that you can do that will help
What is Pelvic Floor Dysfunction?
Pelvic floor dysfunction is simply where your pelvic floor is not doing its job properly. The pelvic floor is designed to provide support for your pelvic organs, help control Intra abdominal pressure, control your urine and bowel movements, and help provide pleasure during sexual intercourse..
Signs and Symptoms of Pelvic Floor Dysfunction:
- Accidentally leaking urine (or faeces) when you exercise, laugh, cough or sneeze
- Needing to get to the toilet in a hurry or not making it there in time
- Constantly needing to go to the toilet
- Finding it difficult to empty your bladder or bowel
- Accidentally losing control of your bladder or bowel
- Accidentally passing wind
- A prolapse
- In women, this may be felt as a bulge in the vagina or a feeling of heaviness, discomfort, pulling, dragging or dropping
- In men, this may be felt as a bulge in the rectum or a feeling of needing to use their bowels but not actually needing to go
- Pain in your pelvic area, or
- Painful sex
There are many possible reasons for pelvic floor dysfunction but I want to break it down to the following reasons and explain them:
- You have a weak pelvic floor
- You have an overactive but strong pelvic floor but even stronger abdominal, back and diaphragm and glottis (voicebox) muscles – voicebox you ask? It is how you hold your breath – you close off your throat there!
- You have an overactive but weak pelvic floor
- You have a damaged pelvic floor
- You have a medical condition. This is outside the scope of this article. Your doctor is the best person to clear these conditions as the cause of your pelvic floor dysfunction.
The Weak Pelvic Floor:
There are many reasons why your pelvic floor might be weak but the most common ones are:
- Pregnancy and childbirth
- Surgery and other medical procedures
- Posture and Habits
- Lack of exercise
If you have a weak pelvic floor, then exercises will help! Unfortunately, my experience has been that people are given pelvic floor contractions without being progressed into the high level exercise that CrossFitters are used to...but that doesn’t mean that you can’t...you just have to work with the right therapists to get you back to what you love doing the most – hard WODs!
The Overactive Pelvic Floor:
If you have an overactive pelvic floor, then why would you leak? It seems counter-intuitive doesn’t it? The muscles are working...why wouldn’t they prevent leaking? Well, just because it is overactive doesn’t mean it is strong. In this category, an overactive pelvic floor can either be genuinely strong (or at least strong enough) or genuinely weak.
Well, if you have a “strong” pelvic floor AND you exercise a lot AND you still leak, then chances are that you also have a very strong glottis and can make your thorax and abdomen very strong and rigid.
Bracing when lifting weights = appropriate
Bracing when just standing or sitting only = INAPPROPRIATE!!
I know this because you leak under load. Basically, if you can build up a lot of intra-abdominal pressure (IAP), that pressure has to be contained. Some people “lose” it and you hear them grunt or scream – that is their glottis letting go – either to breathe or it wasn’t strong enough. Some people get an abdominal or inguinal hernia – they actually tear in their abdomen from the pressure. Still others might get a “slipped” or “herniated” or “bulging” disc. That is because the pressure has gone through the weakest part of their system – the low back. But in you, because you leak, I know that the pressure has overcome your pelvic floor.
In everyday life, you probably don’t leak. You can laugh without an issue, you can sneeze without a worry but when you workout and get tired or if you are lifting heavy weights, then trouble can strike. You probably know how much you can lift without a problem and how much is enough to tip you over the edge. You do everything you think you can to minimize the risk of leaking – going to the toilet just before the WOD starts, you won’t drink water for an hour or 2 before the WOD, you won’t drink during a long WOD (BTW, these are BAD strategies to combat Stress Urinary Incontinence – concentrating urine through dehydration can irritate your bladder and increase your urgency!)
The good news is that your pelvic floor is strong...you just need to know how to make it work as part of the whole team that is your body. My friend Julie Wiebe has a nice video on this -
Learning how to coordinate the proper cycles of breathing, activation and relaxation is simply like learning how to snatch – when you first begin, you don’t think it is possible to do everything you need to but then you keep practicing and it slowly comes together...pelvic floor retraining is the same
If you pelvic floor is overactive and weak, then you will have to learn to relax AND strengthen the pelvic floor. It is a combination of the weak pelvic floor retraining and the overactive relaxation/activation/coordination/breathing retraining.
The Damaged Pelvic Floor:
Your pelvic floor might have been through a lot. Childbirth, cancer and radiotherapy, and other conditions can contribute to tearing, scarring and damage to the pelvic floor muscles. The nerves to the area can be damaged, the muscles themselves can become detached from the pubic bone, scarring from surgery and childbirth can cause asymmetrical contractions.
If this is the case, then you really need an internal examination to determine the extent of the damage and to see what your options are. The damaged pelvic floor is beyond the scope of this article...please see a pelvic floor physical therapist for assessment and an appropriate treatment plan which may include a surgical consult with a specialist.
What is a “Normal” Pelvic Floor?
A normal pelvic floor is simply one that can do all its functions – maintain continence, support the pelvic contents and contribute towards optimal movement during functional tasks.
For the average person, that means you only need to go to the toilet about 6 times during the day and you should be able to get through the night without a toilet trip – of course, this varies based on the amount of fluid you consume, the food you eat and the amount of exercise you have done.
You should be able to squeeze your vagina without “bearing down” – you can test this on your own by using clean hands and inserting 1-2 fingers (yours or your partner’s) into your vagina. When you squeeze, you should be able to generate pressure on the tampon or fingers without squeezing them out of your vagina.
You will be able to cough, laugh, sneeze and jump without fear of leaking. You will be able to feel the urge to go to the toilet but not be overly concerned about dropping everything to go to the toilet NOW!
You won’t feel heaviness in your vagina or feel anything protruding where it should not be. During heavy lifting, you will feel comfortable and will be able to withstand the pressures on your pelvic floor.
What You Can Do To Help - Train "Raw"
I am a big believer of lifting “raw” – unsupported. I do not like belts, braces, wraps, or supports – not even tape. I accept that my patients will use these things and I understand the place and importance that they have in sport. However, in the ideal world, I would prefer that my athletes train using their weakest link as their limiting factor. That means if your back flexes strains under heavy squats, then you need to keep that weight at a level that your back can cope with until it is strong enough to progress...even though you have the legs for 30kg more. I see a lot of injuries because athletes do not follow this simple rule.
No Supports - Just Perfect Technique
One of the biggest offenders in contributing to CrossFit-related pelvic floor dysfunction is the weight belt. It is designed to go around your belly and back and is worn by many athletes as a way of support their back.
The way that you are taught to use them is to push out against the belt and use it to help support your back and tummy. But when you do that, you generate MASSIVE amounts of intra abdominal pressure which does help your spinal stiffness but at the expense of your pelvic floor. Because it is made of unyielding leather or synthetic materials, the pressure won’t be going through the belt – it will be leaving via your pelvic floor or diaphragm.
Pressure on a system always leaves via the weakest point...which is why pressurised containers have a release valve – to control the pressure. The diaphgram is a very strong muscle and rarely does it fail – if it does, you will find it pretty hard to breathe! The back and the abdomen are supported by the belt which only leaves the pelvic floor – the smallest of the muscles – left to hold the massive load of pressure placed upon it.
Check that Ego at the Door
Ego is another thing that does NOT help. If we ignore the fact that you leak during a WOD, then yes, you are an amazing athlete. But the fact is that you have a technique flaw that is making your weakest link fail. “Work on your weaknesses” is something that we all know and do. If you have trouble in the squat, you work on it – you hit the roller and ball to get more mobility, you practice your squat technique, you turn that weakness into a strength! But why don’t we do that for the pelvic floor? If you actually limited your WODs to the amount of “perfect reps” completed, then you would actually perform better in the long run...and by perfect reps, I mean the amount of reps you can do WITHOUT leaking.
Things that you can do that will help.
- Contact a physical therapist that understands the pelvic floor...preferably one that can do internal examinations or has a special interest in women’s health. I have a special interest in it and I work with other therapists who do the internal work while I do the whole body assessment and programming back into full function.
- Let your limiting factor be your pelvic floor. For example, how many double unders or box jumps can you do before you feel a bit of a leak? I would recommend that you find that out...and then treat it like a strength set. 5 sets at max perfect reps with 2-3mins between sets. If you leak, you end the set there...preferably just before you leak. Keep a journal of your exercises and do them at least 3 times per week. Because the pelvic floor muscles are relatively small, you will fatigue them a lot quicker than your legs – that’s ok! Your pelvic floor just needs to catch up to how awesome the rest of your body is!
- Train raw – learn how to coordinate your body into positions of dynamic stability – what that means is that you need to learn how to move and coordinate control of your whole body which includes the pelvic floor. That means getting your posture right, and not blowing out your belly or holding your breath to get the pelvic floor to work.
- Be patient – just like it took you ages to get 1 strict pull-up (if you can’t do 1 but you do kipping pull-ups, you are asking for trouble!), so it will take you a while to get your pelvic floor to catch up to the rest of your body...but it can. Be patient.
In another post, I will be putting up some sample exercise programs ranging from those who have quite weak pelvic floors through to those who want to lift heavy and jump...this will be a collaborative effort so please be patient with us!
For healthcare professionals who are interested in learning more, here are some helpful online courses:
- The Female Athlete by Antony Lo
- Stop Hurting Women with Exercise by Antony Lo
- Diaphragm/Pelvic Floor Piston for Adult Populations Module 1 by Julie Wiebe
- Diaphragm/Pelvic Floor Piston for Adult Populations Module 2-7 by Julie Wiebe
- Piston Science Part 2: Bridging the Gap Between Rehab and Fitness by Julie Wiebe
- From the Glottis to the Pelvic Floor: Making Clinical Connections by Julie Wiebe
For the general public, here are some helpful online courses and resources:
- It is not “OK” or normal to pee during workouts. If it happens, please recognise it as a problem that can be helped.
- There are many reasons why pelvic floor dysfunction occurs. The best person to talk to is a suitably qualified pelvic floor physiotherapist (also called a physical therapist) and your doctor.
- Work with a team of qualified physiotherapists. I usually ask my patients to see a pelvic floor physiotherapist up to a certain point and then I usually take over the strength and conditioning aspect where I integrate it back into heavy lifting, jumping and high level sports.
- Treat your pelvic floor dysfunction as a weakness to work on. If you can do this well, you will actually get stronger, be able to do more unbroken reps and lift more.
- Avoid weight belts for so many reasons!
- Talk to someone. If you don’t know who to talk to, just ask me – comment below. The information is out there and there are many well-trained healthcare professionals who can help. You just have to find the right person for you!
Please leave a comment and let's start this long-overdue discussion!
About the Instructor:
B. App.Se (Physio) (USyd), Masters in Manual Therapy (UWA)
Antony Lo is a physiotherapist from Australia and runs The Physio Detective service. He earned his degree from the University of Sydney and has been in practice over 21 years.
He completed his post-graduate masters in Manual Therapy (Musculoskeletal Physiotherapy) from the University of Western Australia and commenced his Specialization training in Musculoskeletal Physiotherapy.
He has been involved with treating CrossFit athletes for 7 years and has helped some of the world’s best CrossFitters at the highest levels through to beginners of all ages. He loves and participates in CrossFit and is a strong advocate for the sport. Through participation and through his work as a Physiotherapist at all levels of CrossFit, he has developed a model of treatment that utilizes the best from Sports Science, Musculoskeletal/Sports Physiotherapy, Pain Science, and Women’s Health research to provide a realistic holistic model of care balancing the biopsychosocial model of healthcare.
He is NOT an employee of CrossFit, he does not represent or work for them in any way and his views and opinions are entirely his own. He holds a CrossFit level 1 – Trainer Certificate and is a CrossFit Football Coach/Consultant (now CrossFit Sports Specific Application). Antony has a wife and 3 beautiful children in the best city in the world – Sydney, Australia