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.”
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 orthopedic 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.