Do you ever find yourself wondering “why do I pee when I sneeze or cough?” 

Picture this: it’s a beautiful spring day, you are walking around the park, the flowers are blooming, the birds are singing, pollen is everywhere, you sneeze and out comes some pee. What a way to ruin your lovely stroll! 

Or maybe it's flu season, you caught the bug and you are laying in bed miserable. Not only are you coughing and sneezing, but now you are leaking too?! Ugh!!

Don’t worry - if either of these scenarios sound like you, rest assured you are not the only one having this issue. And we are here to explain why you pee when you sneeze or cough. 

When someone leaks pee during a cough or a sneeze, we call that stress urinary incontinence. This happens due to a sudden increase in intra-abdominal pressure (the pressure that exists in the space created by the diaphragm, abdominal muscles, and pelvic floor). Physical activities that increase this pressure include 

• coughing
• sneezing
• laughing
• straining
• exercising

While many people believe this is only an issue that pregnant folx experience, leaking pee with a cough or sneeze can impact anyone. However, it is a common symptom during pregnancy and postpartum due to the anatomical, hormonal, and postural changes that occur. Despite being common, it does NOT have to be your ‘normal’ as pelvic floor therapy can be a great place to start treating this pesky symptom!

Let’s dive deeper.

Looking at the image below, we see the anatomy of the respiratory canister. The diaphragm (or breathing muscle) is at the top, the transverse abdominis core muscle wraps like a corset from the front to the back, and the pelvic floor muscles form a supportive sling at the bottom. 

• When we take a breath in (left), the diaphragm lowers, the abdominal wall expands outward and the pelvic floor moves downward. 
• When we breathe out (right), the diaphragm relaxes to lift up, the abdominal wall and pelvic floor muscles shorten to return to their resting positions. 
  

All of these components work together to help manage pressure that can occur with daily activity, like a cough or sneeze, and reflect how the pelvic floor and core play an important role in prevention of leaking pee.

So why does leakage with a cough or sneeze occur?

First, imagine having a full water balloon in your hand and you are simply holding it closed. Then someone comes up and pushes down on it. If you weren’t prepared for that, it's likely that some of that water leaked out.

Each time we cough or sneeze, there is increased pressure in the abdominal space that we saw above. Looking at the image below, we see how this added pressure in the abdomen will also add pressure down on the bladder. To prevent leaking pee, we require our pelvic floor muscles to help keep the urethra closed when this increase in pressure occurs.

Leaking pee due to stress urinary incontinence is typically thought to be the result of weak pelvic floor muscles, however this is not always the case. Sometimes the ‘why’ behind leakage is due to a variety of factors outside of the pelvic floor as well. 

Common reasons urinary leakage occurs include:

• Core weakness - This is especially common for pregnant and postpartum folks due to the stretch of the abdominal muscles from a growing baby. If core muscles are weaker, their ability to help manage pressure along with the pelvic floor muscles is impacted.
• Try this fix: exhale on the effort with core exercises. This means be sure to keep breathing when you are doing core exercises with a focus on exhaling during the hardest part of the exercise.

• Pelvic floor muscle weakness - If the pelvic floor muscles are weak, they lose their ability to support the urethra and bladder and provide closure at the urethra to prevent leakage. 
• Try this: Pro tip: this doesn’t automatically mean do more kegels! We have seen plenty of patients who can contract their pelvic floor with a ‘kegel’ in isolation but they struggle to put it together with functional movements - lift, squat, run - this is where pelvic PT comes in. If you aren’t sure if your pelvic floor muscles are weak or not, give us a call to schedule an evaluation and we will figure it out with you!

• Pelvic floor muscle tension - On the flip side, if the pelvic floor muscles can have too much tension this impacts the muscles’ length-tension relationship which is PT talk for the muscles are not able to relax fully to then be able to contract again. When a muscle only contracts through part of its range it is not as strong or as efficient as contracting through its full range. Think of this like trying to walk across the room but you can only take half steps instead of your full stride. Yu will still cross the room but not as quickly and it took more effort because you took more steps. 
• Try this: It’s all about balance! Be sure that you are fully relaxing your pelvic floor muscles and don’t neglect stretching. Not sure how to length your pelvic floor muscles?  We can help!

• Pelvic floor muscle discoordination - Our pelvic floor muscles typically engage to close the urethra just prior to a cough or sneeze, we call this a ‘knack’. The ‘knack’ however can become diminished during pregnancy, following childbirth, or even if you’ve had a chronic cough or cold. In pelvic floor therapy we will assess this knack contraction and provide you with training to increase your body’s ability to perform it if your coordination isn’t where it should be. 
• Try this: try to squeeze your pelvic floor muscles before you cough, laugh or sneeze - every time!

• Ligamentous laxity - Ligaments provide support in our pelvic area to our bones and organs, including the bladder. When a ligament has laxity, it is too loose which can result in too much mobility of the joints or decreased support of the organs. This occurs during pregnancy due to hormonal changes to allow for a growing baby, as well as hypermobility conditions, including Ehlers-Danlos Syndrome. Laxity in the ligaments that attach to the joints of the pelvis, hips, and spine can decrease ability to support the bladder and may be a contributing factor with urinary leakage due to difficulty closing off the urethra or as a result of prolapse (or dropping of the bladder, uterus, or rectum from it’s normal spot in our body). 
• Try this: This depends on where your ligamentous laxity is coming from. If it is due to pregnancy, then know this is temporary and it is important to work with a pelvic health provider to learn strategies to minimize the impact of laxity. If it is due to a connective tissue disorder, then we need to be extra mindful as this is not temporary and it is vital that you have strategies to help you cope with loose ligaments. 

• Inefficient breathing mechanics - A cough or sneeze is considered a forceful exhale and if breathing support is not managed well, this could result in added pressure down on the abdomen and bladder and leakage symptoms. A common breathing pattern that results in this added pressure is called paradoxical breathing. This type of breathing occurs when the chest expands during inhalation and the abdomen is drawn inwards, and then during exhalation the abdomen is pushed outwards. Added pressure on the abdomen can increase pressure on the bladder and contribute to leakage due to the pressure on the bladder being greater than the pressure created by the urethral sphincter.
• Try this: work on a diaphragmatic breath instead. Try laying on your back with one hand on your belly and the other on your chest. Take a deep breath and feel which hands moves first and moves most. We want to work on this until you feel the hand on your belly move first and move the farthest. A little movement at the chest is totally okay but it shouldn’t be your main movement!

• Postural changes - Postural changes can occur in every body, especially with the way our bodies have changed to adapt to the technology world. We see posture changes with pregnancy due to a growing baby pulling the abdomen forward and in postpartum, with the addition of repetitive tasks like feeding, lifting, and carrying a new baby. Other than pregnancy, postural changes can occur due to injury, surgical procedures, aging, and repetitive prolonged positions, such as sitting at a desk during your workday (think of that ‘end of workday slump’ you may notice). These postural changes may result in weakness of certain muscles, typically the core, gluteal, and back muscles, and decreased flexibility or mobility of certain joints in the spine, hips, pelvis, and rib cage. These changes can impact how pressure is dispersed throughout our canister and may result in added pressure on the bladder during a cough or sneeze due to inefficient positioning of the diaphragm in the abdominal cavity. 
• Try this: aim for a stacked posture! This means keep the weight in your heels, stack your shoulder over your pelvis and your pelvis over your feet. Be sure your ears are in line with your shoulders so your head isn’t held too far forward. 

How can pelvic health therapy help me stop leaking pee when I sneeze or cough?
Pelvic health therapy is a great place to start so we can perform a detailed evaluation to learn more about your specific symptoms, identify the root cause of your symptoms, and develop a treatment plan tailored to you!

A comprehensive evaluation will include the assessment of your:

• Spinal, hips, and pelvic mobility
• Posture and daily ergonomics
• Strength and flexibility of your core, gluteal and hip, arm and scapular, and even knee and ankle muscles
• Breathing mechanics
• And of course the pelvic floor muscles! 
• Your therapist can include a standing pelvic floor muscle evaluation to evaluate the coordination and engagement of your pelvic floor in a weight-bearing position as most of our patients report more leakage in an upright position, like sitting, standing, or walking versus lying down

Following an evaluation, your pelvic health therapist will integrate various treatment techniques tailored to your specific symptoms. Common treatment strategies a pelvic health therapist may include:

• Improving strength of the ‘kinetic chain’- this may include targeted strengthening of specific core muscles, like the transverse abdominis and/or oblique muscles, as well as certain gluteal, hip, and scapular support muscles
• Addressing pelvic floor muscle weakness and/or tension, and improving pelvic floor muscle awareness & coordination for improved ability to provide ‘bottom up’ support during a cough or sneeze
• Looking at breathing mechanics and postural support techniques to improve the ability to manage pressure in the abdominal cavity which will directly impact the bladder
• Integrating specific mobility exercises or stretches to improve lumbo-pelvic mobility and the body’s ability to adapt and move during a cough or sneeze to prevent leakage
• Improving bladder habits, including fluid management and toileting routine support

Finally, if you feel you need more help addressing your specific needs, we highly recommend working with a pelvic health therapist! Pelvic health therapists are here to listen to your symptoms and identify the best treatment techniques and strategies to support you. 

If you are ready to schedule your first appointment, reach out to us here.

If you’d like to learn more on this topic we recommend reading:

• The Five Types of Urinary Leakage
• The 3 Treatment Methods of Pelvic Therapy
• The Ultimate Guide to Pelvic Floor Physical Therapy

Dr. Marlena

@pelvicpride