Pace Setter : July 2021

How to Stop Going When You're on the Go

by Stephanie Mumford Brown

We may or may not talk about it, but eventually, we all do something about it. Peeing at the wrong time or place is a fact of running life, especially if you’re female. We use tactics like wearing dark shorts to hide wet spots, waiting in long lines at the Portajohn to avoid a second time before the race starts, strategizing about how much to drink, and putting pads in our panties. There must be a better way, right?

I talked to Dr. Maria Voznesensky of Capital Region Urology, part of the St. Peter’s Health Partners, to find out why leakage happens and learn more about options for addressing it.

 Why do we pee when we don’t want to?

The most common runner problem is stress incontinence. The thumps of our strides cause abdominal stress that can overwhelm the sphincter muscle’s ability to hold urine in the bladder.

Then there’s urge incontinence, the gotta-go feeling after you started your race day with a healthy helping of coffee, and now you’re excited, nervous, waiting for your turn in the Portajohn, and fighting your sphincter to the finish.

Why do women leak more than men?

One study concludes that half of all women experience some form of incontinence, compared with a single-digit percentage of men. Even in their 70s and 80s, when men max out, their rate is half that of women. As for sports, more than 40% of elite female endurance athletes reported leaking during high-impact activities, according to a study of 112 professional runners and cross-country skiers.

“We’re far more complicated,” Dr. Voznesensky says. “We have all this extra stuff in our pelvis.”

Much of what’s going on with that stuff can put pressure on the female bladder. Pregnancy is the most notorious culprit, both during and postnatal. Then menopause kicks in.

The good news is that you can boost your holding pattern with workouts to build your sphincter strength, just as for any other muscle. The bad news is that Kegel exercises call for the same sort of disciplined accuracy and frequency as any other strength training.

What makes men leak less?

Most adult bladders, regardless of gender, hold about 300-400 ml of urine, a little under a pint. But other aspects of male anatomy provide a belt-and-suspenders approach to retention.

Men have two sphincters managing flow—an external one like women and an internal, involuntary one up by the prostate. Then there’s that outflow tube, which is about five times longer than a woman’s.

But this male system has its downsides, too—BPH (benign prostatic hyperplasia) can sabotage urinary wellbeing. In half of men over age 50, the prostate gland enlarges enough to pinch the urethra it surrounds, causing a host of annoyances that make urination more difficult and the urge to do so more frequent.

Also, prostate cancer is the most common non-skin cancer in American men and those who opt to remove the organ experience incontinence. Dr. Voznesensky says Kegel exercises can help, especially if begun before surgery.

Female pelvic organs—a lot going on in there—and male—belt and suspenders approach to bladder control. (Wikimedia Commons)

So what exactly are Kegel exercises—and do they work?

Kegel exercises, named for the gynecologist who devised them, are the first-line offense against incontinence. Your goal is to strengthen the pelvic floor muscles, the sling that holds up your guts and clamps your urethra shut. The American Urological Association provides an easy-to-follow guide to pelvic floor exercises for both women and men. It is important to clench the correct muscles in a limited area, not the entire butt or abdomen.

How well these exercises work depends on your diligence. Dr. Voznesensky recommends 30 Kegels three times a day when you’re waiting at red lights, watching TV, or sitting in meetings—the perfect Zoom pastime if done discreetly.

There is a range of aids at various prices to help women engage the correct muscles. The Elvie Trainer goes in the vagina and connects to a smartphone app to guide the user through “fun, five-minute exercises.” INNOVO shorts automate the whole deal with electrical connections “designed to deliver 180 perfect Kegels for you” in 30-minute daily sessions. Pelvic physical therapy offers the human touch, and one runner I talked to swears by the benefits she gained from it after her two pregnancies.

And speaking of human touch, the long-established, least costly gadget is Ben Wa balls, which you may have heard of in a different context. Look it up, if you haven’t. The benefits of boosting pelvic floor grabbiness were recognized centuries before Dr. Kegel did.

                      Dr. Maria Voznesensky, urologist

How much should you drink?

The particulars of hydration for elite competitors are the realm of sports physiology. Still, Dr. Voznesensky says for weekend amateurs the basic rule is simple: drink when you’re thirsty, including while you run. If your urine is clear or pale yellow, you’re drinking enough.

The particulars here are NOT the realm of pop-culture consumption “rules” like the classic eight-cups-a-day or the trendy gallon challenge. Your body knows what it’s doing, she says, so listen to its demands, not the internet. The kidneys constantly gauge the amount of water and electrolytes in the bloodstream, sending excess to the bladder or hanging on to what’s there, depending on intake and activity.

Can your body use urine to hydrate in a long hot race?

No. Urine is a kidney-crafted waste substance that only departs the bladder in one direction. Nor should you do the Bear Grylls thing and drink it, Dr. Voznesensky cautions.

How much of this problem is in your head?

A lot, if we’re talking about your sympathetic nervous system and urge incontinence. That’s why drugs can work on this form of the problem, unlike stress incontinence, which only responds to physical interventions like pads, Kegel exercise programs, and surgery.

Urge incontinence is considerably more complicated than the stress form, Dr. Voznesensky says, because so many factors can lead to bladder-lining irritation that causes the urge to void. Still, there are things you can do—and not do—to reduce it.

Caffeine is the No. 1 culprit for bladder stimulation, followed by several other substances runners enjoy consuming in the hours before a race: alcohol, orange juice, tomato sauce, spicy food, and hot sauce. Even constipation is a potential factor, she says, since a full bowel can pressure the bladder.

You can inadvertently train your system to pee too often by over-indulging in toilet visits. You can reverse this by stretching the interval between voids (conducting this education near a bathroom). Dr. Voznesensky notes that the extreme version of holding training is “nurse’s bladder,” the medical nickname for the retention habits of workers who have no time to use a toilet.

How bad does it have to be before you go to a doctor?

If you’re using more than a pad or two a day, Dr. Voznesensky says, you might consider talking to a urologist about solutions like surgery to repair your pelvic floor. Urology has become a high-tech field making extensive use of robotics and laparoscopy to minimize invasiveness.

Your decision to address incontinence is a matter of personal choice, she emphasizes. Consider the patient for whom nothing was working very well until Dr. Voznesensky scrutinized the woman’s diet. It turned out she was a fanatic hot sauce user, dousing everything she ate and even putting sriracha on her ice cream.

“She had a fire going on both ends and expected to address only one of them,” says Dr. Voznesensky. “But I had to ask, what gives you happiness?” Ultimately, whether or how to deal with incontinence is a personal choice. She says: “Nobody ever died from wetting their pants.”

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Stephanie Mumford Brown is Chief Wiseacre at Wiseacre Press, where she’s trying to compile the missing assembly instructions for the second half of life.

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