Proof of the Effectiveness of Yoga for Incontinence

by Ram

Urinary incontinence (UI) is loss of bladder control and is more commonly seen in aged people. While it is a problem in both genders, women experience UI twice as often as men. Men leak urine, too, but the problem is more common in women. Leakages happen when women exercise, laugh hard, cough, sneeze, or when they are pregnant. While some individuals experience occasional minor leaks, others wet their clothes frequently. Incontinence is not a disease but it may indicate an underlying pathological issue and hence requires intervention. Nearly one third of women aged 40 years and older experience urinary incontinence, together with associated conditions, including depression, falls, and fractures, social isolation, and physical inactivity.

UI happens when the bladder muscles become too weak or overly active. The bladder is a balloon-shaped, reservoir-like muscular organ that stores and releases urine. It is supported and held in place by the pelvis. The channel that carries urine from the bladder is called the urethra. Ring-like muscles called sphincters help keep the urethra closed so urine doesn't leak from the bladder before you're ready to release it. Several bodily systems must work together to control the bladder: pelvic floor muscles hold the bladder in place, sphincter muscles keep the urethra closed, the bladder muscle relaxes when urine collects in the bladder and squeezes when it's time to urinate, a set of nerves carry signals from the bladder to the brain know when the bladder is full, and efferent nerves carry signals from the brain to the bladder when it's time to urinate. UI problems occur when any of the above-mentioned features mentioned fail to work optimally. 

Types of urinary incontinence include:

• Stress incontinence. “Stress" is the pressure on the bladder when an individual coughs, sneezes, laughs, or lifts something heavy. If the pelvic and sphincter muscles are strong, they can handle the extra pressure. However, when those muscles get weakened, the sudden pressure pushes urine out of the bladder causing a leak.
• Urge incontinence. If you experience involuntary loss of urine after a strong, sudden urge to urinate, you have urge incontinence. Urge incontinence may be caused by a minor condition, such as infection, or a more severe condition, such as nerve damage, a stroke or an infection.
• Overflow incontinence. An individual experiences frequent or constant dribbling of urine due to a bladder that doesn't empty completely.
• Functional incontinence. A physical or a mental condition that prevents the individual from reaching the bathroom in time to urinate.
• Mixed incontinence. A mix of stress and urge incontinence. 

Although a variety of clinical therapies for incontinence are available, many have limitations particularly for older women who are at greatest risk of developing this condition. Drugs, including anti-cholinergic medications, are moderately effective in reducing urge incontinence, but are associated with several side effects. For stress incontinence, surgery is an effective option, but most women do not desire or are not candidates for surgical intervention. Pelvic-floor muscle exercises and bladder training can be highly effective, but can be difficult for some women to learn without individualized instruction. Thus, there is a need for effective, alternative treatment that is not only accessible but also well tolerated by the large number of incontinent individuals. 

Yoga can be used to help incontinent individuals to identify and strengthen their pelvic floor muscles without traditional pelvic floor rehabilitation. There are several yoga poses that may be beneficial for improving hip and lumbo-pelvic stability, mobility, and alignment, as was described by Shelly Prosko in her two-part series To Leak or Not to Leak and Treatment of Incontinence. 

Not surprisingly, there are quite a few evidence-based research studies on the management of incontinence with yoga. But I was especially impressed with the rationale and results from one particular study that was published a year ago A group-based yoga therapy intervention for urinary incontinence in women: a pilot randomized trial. Despite the small sample size, the study was published in a peer-reviewed journal, suggesting that the reviewers saw merit in the results. Let me also add that despite being a small pilot study, the results were highly significant with minimal variation between the yoga group and non-yoga group. The rationale for doing the study was to check the feasibility, efficacy, and safety of yoga therapy for middle-aged and older women with urinary incontinence. The exclusion criteria were stringent and elaborate, and excluded individuals who displayed severe mobility or if they already underwent yoga instruction within the past year specifically to treat incontinence. Other exclusion criteria included but were not limited to: pregnancy within the past 6 months, ongoing urinary tract infection, neurological issues, including stroke, multiple sclerosis, or Parkinson’s disease, a congenital condition leading to incontinence, fistula in the bladder or rectum, and pelvic cancer or radiation among others. 

Women were randomized assigned by a computer to two groups: a yoga group (N=10) and a non-yoga waitlist group (N=9). The non-yoga group received a gift certificate for local yoga studio classes at the end of the study (I thought this was a novel way to inspire them to do yoga especially after the encouraging results). The yoga group was enrolled in a 6-week yoga therapy program consisting of two group classes/week led by an experienced, certified instructor as well as an assistant and one weekly home practice. The yoga program designed by Judith Lasater and Leslie Howard focused on providing formal instruction and practice in a variety of yoga postures and techniques. The program, which was based primarily on Iyengar yoga, involved a set of eight postures that could be adapted for women of all ages, including those with decreased flexibility or mobility. It included: Tadasana (Mountain pose), Utkatasana (Powerful pose), Trikonasana (Triangle pose), Malasana (Garland pose), Viparita Karani variation (Legs Up the Wall pose), Salamba Setu Bandhasana (Supported Bridge pose), Supta Baddha Konasana (Reclined Cobbler’s pose), and Savasana (Corpse pose). See the end of this post for photos of the sequence.

Emphasis was laid on strengthening the pelvic floor structures and increasing control over the pelvic floor muscles, in addition to improving general fitness and conditioning, and promoting mindfulness, deep breathing, and relaxation. Participants were also given yoga props and a manual with written descriptions and pictures depicting each of the key yoga postures. Tips were provided on ways to practice each posture safely and comfortably to improve incontinence and pelvic floor function. 

The results from the study were quite impressive. The authors noted the following: 

1. Teaching women to practice yoga to improve their incontinence was achievable and safe, adherence to group yoga classes and home yoga practice was high, and all the participants were quite successful in learning to practice program-specific yoga postures and techniques.
2. The women who did yoga experienced an overall 70% reduction in the frequency of urine leakage, in both total and stress-type incontinence. 
3. The positive change was most notably seen in situations involving stress incontinence, urine leakage triggered by activities that increase abdominal pressure, such as coughing or sneezing.
4. Behaviorally, there was significantly greater improvement in the annoyance of their symptoms, compared to non-yoga participants.

While the authors do note that the primary limitations of the study were a small sample size and a short duration of yoga practice (6 weeks), nevertheless, the study supports the feasibility, efficacy, and safety of yoga therapy to improve urinary incontinence in ambulatory, middle-aged and older women without complicated urologic histories. Since anxiety and depression are often associated with urinary incontinence, the researchers also believe that the yoga's benefits may relate to its emphasis on meditation and relaxation. Additionally, yoga can be practiced by women without continuous or ongoing supervision, thus offering a cost-effective, home-based, self-management strategy for women with incontinence.

Poses from the study follow (we're not sure about exact propping that was used):

Tadasana

Utkatasana

Trikonasana

Malasana

Viparita Karani

Salamba Setu Bandhasana

Supta Baddha Konasana

Savasana

Photos courtesy of Melina Meza from her book Art of Sequencing: Asana Modifications.

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Treatment of Incontinence: The Physio-Yoga Therapy Approach

by Shelly Prosko

Garland Pose (Malasana)

In my last post for Yoga for Healthy Aging To Leak or Not to Leak: Urinary Incontinence, I explored the main types of incontinence: stress, urge and mixed. I emphasized that when addressing any pelvic floor dysfunctions, including incontinence, it is essential to first cultivate a sense of awareness of the pelvic floor and learn to release the pelvic floor muscles (PFM’s) before engaging or strengthening even begins. You can do this by performing some of the yoga postures I shared in conjunction with abdomino-diaphragmatic breathing as well as the Toilet Meditation in the last post. I cannot stress enough how important it is to first learn this awareness and release, regardless of your issue.

Please remember that treating incontinence is not just about doing Kegels by contracting or strengthening the PFM’s, even if your dysfunction is due to weakness. Just like any other muscle in our body, PFM’s need to be both flexible and functional.Yes, they need to be strong when we need them to be. However, alignment, flexibility, strength, control, timing and awareness are all important factors for creating and sustaining a healthy pelvic floor. In fact, it is common that weak PFM’s are also tight (Just because a muscle is tight doesn’t mean it is strong!)

It is my intention in this post to share a few more yoga poses and physical therapy exercises you can use to address incontinence issues. Keep in mind that these poses are not specific to a particular individual’s needs, but are generic in addressing some of the overall body alignment, tightness, and weakness issues surrounding common pelvic floor dysfunctions.

It is very important that you first find out which type of incontinence you have from a pelvic health specialist and that you have one on one instruction on how to perform a PFM contraction, if that is indicated as part of your overall treatment plan. Some of these poses and exercises could potentially make your incontinence or pelvic health dysfunction worse. I highly recommend that you find a Physical Therapist (PT) in your area that specializes in pelvic health (see Canada or USA).

Once you have an assessment and know which type of incontinence you have and what specifically needs to be addressed in the surrounding areas of your body that may be influencing your incontinence, then you can have your PT communicate these needs to your yoga teacher. Together you can choose some yoga asanas, awareness meditation, and breathing methods that are safe and effective for you and your pelvic dysfunction.  If you are fortunate to find a pelvic PT that is also a Yoga Therapist, then that is icing on the cake! This is an example of how combining both physical therapy and yoga approaches can help optimize the success of your treatment.

Here are a few yoga poses and Physical Therapy exercises that may be beneficial for improving hip and lumbo-pelvic stability, mobility and alignment (which can all play a role in stress or mixed incontinence).

Yoga Poses

• Goddess pose/Fierce Angle pose (Utkata Konasana)
• Powerful pose/ Chair pose (Utkatasana), with a block between your thighs
• Bridge pose (Setubanda Sarvagasana), with a block between your thighs
• One-Legged Bridge pose (lift one leg off mat, keeping pelvis level and neutral)
• Cat/Cow pose (Bitilasana)
• Half Moon pose (Arda Chandrasana), Tree pose (Vksanana), Warrior III pose (Virabradrasha III), Triangle pose (Trikonasana)
• Crescent Lunge (Alanasa)

Physical Therapy Exercises

• Clamshell (lying on your side with the soles of feet together, open your knees like a clamshell)
• Straight Leg Circles (lying on your side)
• Four-point (on your hands and knees) arm, leg lifts & fire hydrant (on your hands and knees, performing lower extremity abduction as a dog would lift its leg and urinate keeping lumbo-pelvic alignment neutral)

Here are a few yoga poses that may be beneficial for addressing hip and pelvic floor tightness (which can be present in urge, stress or mixed incontinence): 

• Happy Baby pose (Ananda Balasana) and Half Happy Baby pose
• Cow-Face Pose (Gomukhasana)
• Pigeon pose preparation (Eka Pada Rajakapotasana), bending forward
• Cobbler’s pose (Baddha Konasana), Reclined Cobbler’s pose (Supta Baddha Konasana)
• Extended Child’s pose (Balsana)
• Dropped Knee Lunge/Hip Flexor Stretch
• Garland pose (Malasana)
• Eye of the Needle pose (Sucirandhrasana), lying on your back or seated with your back to the wall, as you cross one ankle over the opposite thigh, and bring your thigh to chest.

For any in the second set of poses, I have my clients observe the natural rhythm and motion of the pelvic and respiratory diaphragms as they relate to inhalation and exhalation. This is where I focus on awareness meditation of the pelvic floor. As you inhale, both diaphragms naturally descend. As you exhale, they ascend back to their resting positions. With supervision and proper instruction, you can attempt to activate your PFM’s as you exhale (in keeping with the natural rhythm of the diaphragms).  I have heard this natural motion be referred to as the “Reverse Kegel” because the pelvic floor/diaphragm actually goes downwards as you inhale, not upward. Try to simply watch and observe the natural rhythm. If you feel yours is opposite, there is a strong chance that you are breathing inefficiently or holding when and where you don’t need to. This could be contributing to any issues you may be experiencing in a variety of areas of your body!

Here's a video I made to demonstrate this form of breathing (see youtube). In it, I demonstrate the Pelvic Diaphragmatic Breath aka Pelvic Diaphragmatic Rhythm or Reverse Kegel. I perform it in Garland pose (modified), Extended Child’s pose, and Reclined Cobbler’s pose. I hope you find it useful.

Lastly, I want to discuss Mula Bandha. As I previously mentioned in my last post, I am far from a bandha expert. But the way I teach Mula Bandha does not necessarily equate to a PFM contraction. And many yoga teachers agree it is an “awareness” and an energetic sensation of the pelvic diaphragm—not a squeeze or contraction. This is because we do know that more holding, tightness, and tension can potentially do you more harm than good. This overuse and holding can fatigue the PFM’s, so that when it is time for them to perform their duties and actually contract to stop the flow of urine, they fail. Additionally, this holding can create or exacerbate a variety of pelvic pain disorders.

If Mula Bandha isn't something you are familiar with or use in your current practice, do not worry about it. If you do use it, perhaps seek guidance from your health care professional to ensure it is appropriate to use for your specific condition, and that you aren't doing anything to jeopardize the health or function of your PFM's. I simply recommend exploring the pelvic floor (whether you label it as “Mula Bandha” or not) as a mindful observation of the natural rhythm of your pelvic diaphragm as you breathe, in a variety of positions or yoga poses. Explore what releasing the PFM’s means to you, again, in a variety of yoga poses.

Perform your Toilet Meditation (see Yoga for Healthy Aging To Leak or Not to Leak: Urinary Incontinence). Then, after you have a sense of awareness and what it means to release, you can start to explore what it means to engage your PFM’s. Explore engaging PFM’s as you exhale. Current research supports that PFM strengthening is not performed correctly when taught in group settings. It is therefore recommended to receive one-on-one instruction and supervision from your health care professional when you are ready to start the PFM strengthening part of your pelvic rehab program, and if it is indeed indicated in your specific case!

Unfortunately, I have heard some yoga teachers give the instruction: activate Mula Bandha as you take a deep breath in. This type of rhythm can contribute to an unhealthy paradoxical breath pattern (which is an entirely other topic to discuss!), which can result in a plethora of states of “dis-ease” in our bodies. As explained above, the natural rhythm of our pelvic and respiratory diaphragms is to descend as we inhale, not the opposite. I really like Leslie Kaminoff’s perspective. See his videos Bandhas in a Modern Practice: A Historical Perspective  and Juggling Effort and Release: Where do Bandhas Fit in?.

“If everything we’re trying to accomplish in our practice is somehow fundamentally linked to this simple process of inhale/exhale, then we’re usually fine.” — Leslie Kaminoff

This resonates with me because I have seen this “trying too hard to do too much” attitude of “more is better” in my clients and my own personal practice. As a result, thinking about adding yet another process, like Mula Bandha can create more obstacles and tension. I’m not saying to ignore it; in fact, I’m saying the opposite. I want you to be more aware of the pelvic floor than you ever have, but without the expectation of trying to contract it or do something to “fix it” or “make it better.” 

Disclaimer: This article is not meant to diagnose, treat or act as medical advice. Please consult your health care provider for clearance and guidance before following or participating in these activities. 

Shelly Prosko is a Physical Therapist, Yoga Therapist and a Certified Pilates Instructor. She received her Physical Therapy degree at the University of Saskatchewan, Canada in 1998, her Yoga Therapist training through Professional Yoga Therapy Studies in North Carolina and her Pilates certification through Professional Health and Fitness Institute in Maryland. 

Since 1998, Shelly has been integrating yoga principles and methods into her physical therapy treatments. She has treated a wide variety of musculoskeletal, neurological and cardiorespiratory conditions while working in private orthopaedic clinics and long term care facilities across Canada and the United States.


Currently, Shelly resides in Sylvan Lake, AB and travels across Canada and the United States offering specialty Physio-Yoga Therapy workshops, classes, private sessions, lecturing at University and College programs as adjunct faculty of Professional Yoga Therapy Studies, teaching at YTT’s and actively promoting the integration of medical therapeutic yoga into our current healthcare system. She believes that bridging the gap between Western and Eastern healthcare philosophies is essential in order to achieve optimal health. Her treatments are individually based and are a unique blend of both approaches.

Please visit www.physioyoga.ca for more information about Shelly’s mission and services, and to read a variety of testimonials of how PYT has profoundly influenced many people’s lives.

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