What’s the Issue?

Recently, a CrossFit video, entitled, ‘CrossFit – Do You Pee During Workouts?’ was released on YouTube. CrossFit participants were interviewed at the Central East Regional competition.

 “CrossFit is the principal strength and conditioning program for many police academies and tactical operations teams, military special operations units, champion martial artists, and hundreds of other elite and professional athletes worldwide.” CrossFit website

Watch this video to see what the controversy is all about:

Yikes!!

Why am I Shocked About the Video?

• Any video that starts out with an announcer stating THIS is not going in a good direction: “we’ve seen blood today and now we see urine and that’s what it takes if you want to be the fittest woman on the planet.”
• A GYNECOLOGIST that participates in CrossFit states in the interview: “We need to invent something to help these women. I’m one of ’em. Do about 10 double unders, I’m standing in a puddle. It ain’t pretty.” Invent something?? What? There are numerous options available to women (starting with pelvic physical therapy) that have been extensively researched and SHE should know this. 
• The GYNECOLOGIST states further and emphatically: “Ladies, in my professional opinion, it is okay to pee during double unders.” Let’s set the record straight here. Leakage can definitely happen when doing a jumping maneuver and women shouldn’t feel ashamed. But, there are options for help. One should not just assume they have to wear pads for life and that’s the only option. Why is the GYN advocating this without other options? Ugh!
• Another women says “…2 kids that does it to ya”. Yes. Childbirth is the leading cause of stress urinary incontinence, but it sounds like she has resigned to the mentality of “that’s the way it is”. There’s help, after you have had 1 kid, 10 kids or 20 years after having kids. 
• The final mantra that each woman says proudly into the camera is “I pee during workouts”. It’s wonderful to stand in solidarity and bring this topic out. This is something women (and men) should be able to talk about and find solace in knowing they are not alone. BUT, this felt to me like it was a valued, prized quality – If you pee during a CrossFit workout you “put out” and you are super intense. Wrong message! This means their pelvic floors (and other parts of their bodies) are not supported with heavy loads or jumping. This should not be celebrated. There’s help. Yup. There’s help.
• One woman states at the end: “[peeing is] a correlate of intensity…maybe Heather and I are just going harder than everyone else.” No, no, no! We should not associate urinary leakage as a ‘correlate’ of working harder, better, and stronger. Wrong message! Let’s not make urinary leakage (and potential for increased pelvic organ prolapse) a goal to achieve as a marker of intensity!

The good news: The video has sparked lots of discussion.  It’s wonderful to bring the topic of urinary (and fecal) leakage into mainstream discussion. Women AND Men can have this. Stress urinary incontinence (SUI) during exercise happens, but we don’t always discuss it. We now have an opportunity to share that there’s help available for this and individuals don’t have to just say “well it’s what I get for having kids” or “my mom had it so I guess I have it now too.” Quick Facts: “Urinary incontinence is the unintentional loss of urine. Stress incontinence is prompted by a physical movement or activity — such as coughing, sneezing, running or heavy lifting — that puts pressure (stress) on your bladder.” More info Statistics: “Stress urinary incontinence (SUI) has an observed prevalence of between 4% and 35%” (2004)  Article Here “Stress urinary incontinence is common and affects many women globally. About 50% of women with urinary incontinence report symptoms of stress incontinence” (2011). Abstract here “Specifically, there are two types of SUI: urethral hypermobility and intrinsic sphincteric deficiency (ISD). In the case of urethral hypermobility, the urethra shifts positions with an increase in abdominal pressure, allowing urine to exit the bladder.” Stress urinary incontinence is usually associated with weak pelvic floor muscles coupled with too much pressure from above. This can also be complicated by factors such as extra abdominal weight, pelvic organ prolapse, and chronic constipation. However, an individual can also have tight/short pelvic floor muscles (with or without associated pelvic pain). In this case, the pelvic floor muscles aren’t necessarily weak, but they can’t activate properly when a force such as a heavy lift or jump happens (we see this with gymnasts, for example). * There are other factors as well, explained in ‘Take Home Points’. 

The exercise “Double Under” is referenced. It’s essentially an advanced jump rope exercise. What concerns me about Crossfit? Is it only the pelvic floor and “pee”? No. This video is an example of Crossfit-gone-wrong again. Look at the impact poor lifting has on the body. Am I bashing CrossFit? No. Many of the power lift moves and fitness components can be performed safely with proper instruction. But, they should only be performed when the individual is ready and strong enough to perform the movements without compensation. Also, not everyone is a candidate for CrossFit and there are many other ways to get in great shape. Am I concerned about Crossfit? YES! Who are the trainers? What is their level of knowledge and education regarding safely instructing and progressing exercises? Is there a mentality that more is always better at the expense of poor form and risk of injury (and embarrassment)?

So, What Can You Do?

What IF you leak when exercising – Crossfit OR any other exercise?

• Realize this happens to many people and you’ll likely feel better if you remove feelings of shame, embarrassment, and blame. Seek professional help. This is something you don’t have to just “deal with” or “ignore”. If you need to wear pads or liners, that’s a short-term option, but the ultimate goal is for you to feel empowered get rid of leaking.
• Always try conservative treatment first (without immediately seeking medicine or surgery). Pelvic Physical Therapy (Women’s Health Physical Therapy) is one of the best options. We train extensively in helping patients with SUI with a very high success rate. (one of many articles). We use a variety of techniques and approaches (not just Kegels!). There are also nurses and other fitness professionals, specifically trained in exercises to support the pelvic floor.
• With a conservative approach by a Pelvic Physical Therapist, you will learn if you are, in fact, contracting the right muscles of the pelvic floor and sphincters. We assess much more than the pelvic floor- how’s the whole system functioning? The pelvic floor does not function in isolation. We must consider bowel (such as constipation) and bladder function, strength, length and/or function of the diaphragm, deep back and abdominal muscles, gluteal muscles, breathing, surgical history, fitness level, and much more! We help improve the function of all of the supporting muscles, improve your movement and form for all exercises to decrease stress/excess pressure at the pelvic floor (and all areas), and provide education regarding bowel and bladder habits that can have a major impact on your progress. Sometimes we utilize pelvic floor biofeedback or pelvic floor electrical stimulation, if appropriate.

Take some great advice from my colleagues – pelvic physical therapists (physiotherapists) and other experts in the pelvic field:

Diane Lee’s PDF: Explains the relationship between the pelvic floor, the “core” and the “canister”. READ THIS: Understand Your Back And Pelvic Girdle Pain Julie Wiebe, PT:  ‘Female Athlete’s Best Kept Secret’ Julie talks about: Training the Pelvic Floor for Fitness, Part 1 Training the Pelvic Floor for Fitness, Part 2 An example of the type of electrical stimulation unit used for stress incontinence (this is discussed with your healthcare professional to see if it is appropriate for use in your case) Pelvic Floor Biofeedback: Great slide show all about: Pelvic Floor Biofeedback by the Cleveland Clinic (there are all sorts of ways of doing “biofeedback”. This shows external surface EMG, internal sensors, perineometer, and weights. Here’s another great video introduction regarding biomechanics and the pelvic floor: Aligned and Well “Down There for Women” by Katy Bowman http://www.youtube.com/watch?v=OrMU2tQ2SUk&w=560&h=315 You see? It’s a lot more than just Kegels!? Resources: Want to find a Pelvic/Women’s Physical Therapist? Check out the APTA Section on Women’s Health (we treat men too!) therapist locator The World Confederation of Physical Therapy – Physical Therapy Organizations around the world. They can connect you to women’s health/pelvic physical therapists. Society of Urologic Nurses and Associates American Congress of Obstetricians and Gynecologists (ACOG) National Association of Certified Professional Midwives (NACPM) * There are also numerous exercise, pilates, and yoga professionals who are very knowledgeable about the pelvic floor. **Admittedly, I don’t participate in CrossFit. I have tried some of the WODs (Workouts of the Day).  I have years of experience in a variety of sports and lifting weights .I’m a physical therapist (specializing in pelvic floor and orthopedics), a personal trainer, and teach internationally on these topics. I used to teach national courses to personal trainers about proper body mechanics, physiology, and kinesiology involved in all forms of exercise. I made a point to include information about the pelvic floor so that trainers were aware. ***This is not an article addressing all forms of incontinence. SUI is one form. Also, I try to stay away from comments such as”you should never pee in your pants”. I think that may promote a form of shaming. How about, “You don’t have to settle…there’s help!”? ~ Tracy

Take Home Points

(if you made it this far):

• CrossFit might be a great workout for some, but not everyone is ready for it. I have concerns about the instructors. The potential for injury is HUGE! * This can be true of many other forms of exercise too with poor or no instruction.
• Let’s NOT glorify “peeing” when you lift! This means there are intrinsic weak points that should be addressed. The pressure system and strength are not working and adding weights and or jumps to this is not good.
• There’s help! Start with conservative treatment. Pelvic Physical (Physio) Therapists are experts at this!
• Healthcare professionals, particularly gynecologists, should be aware of options available for dealing with stress urinary incontinence. It was appalling to hear the GYN speak as if she was totally unaware of what one can do to stop leakage. She should be the ambassador of change for everyone there!
• And…even if many people are leaking, let’s not assume that’s a “cool” thing or an intensity goal to achieve. Let’s not glorify a dysfunction. Let’s educate and empower when there’s a solution. This should NOT be “what it takes to be the fittest woman on the planet”.
• Added 6/25/13- Stress Urinary Leakage (SUI) is NOT just about pelvic floor weakness! This can certainly be one or the only factor, but not always. We must consider the whole “pressure system” of the body (what’s happening with breathing/diaphragm, pressure from poor form, pelvic organ prolapse from above, constipation, hormonal (age-related changes, birth control, progesterone, etc.) and endocrine effects, and genetic/collagen laxity in general. We often see patients who require a multimodal approach with therapy and medicine. It can be common, for example, to see a patient who has pelvic pain with pelvic floor shortening, poor mechanics, history of constipation, childbirth with tearing and weakened pelvic floor,  AND hormonal changes locally or systemic.
• Added 6/25/13 – The most common myth is that most people can do a “Kegel” (just one part of this larger picture). Statistics show up to 35-50% of women do not know how to perform a pelvic floor contraction (or relaxation or bulging without straining) correctly. The popular magazines tell us to do 600 repetitions of these every day while standing in the grocery store line or while at traffic lights. This does not work if you can’t access the right muscles; and if you are weak, you have to start in a position such as lying on your back and do 30 repetitions a day (not 600!).
• What if you aren’t leaking, but currently do lifting or exercises like CrossFit? This is a great opportunity to learn proper biomechanics of exercise and “preventative” execution and form from a qualified professional (orthopedic and pelvic therapists rock at this!). You can learn how to breathe correctly during exercises (oh, what a difference that makes!) and correct weakness or compensatory patterns that could lead to injury or dysfunction in the long-term. The other key elements to learn NOW are: 1. how the pressure system works in the body, 2. how to be aware of your pelvic floor, and 3. how to activate/contract the pelvic floor AND relax it.

  Tracy Sher, MPT, CSCS owns a private physical therapy practice in Orlando, Sher Pelvic Health and Healing. She is an international instructor and faculty member in the area of pelvic physical therapy and is the Founder of Pelvic Guru.  Consider following Pelvic Guru on Facebook too for regular “pelvic” discussions and very regular updates regarding research or articles (and fun stuff too).   Tracy Sher on Linkedin and @pelvicguru1 on Twitter. If you are interested in more pelvic health education, please see our online platform, Pelvic Guru Academy for some amazing courses like The Female Athlete Level 1 with Antony Lo.