How often should you pee every day?
Incontinence is a common problem, but one most people needn't put up with, says physiotherapist Elaine Miller. She's determined to educate the world about their pelvic floors – and is using stand-up comedy to do so.
After wetting herself on her doorstep, Elaine Miller thought: "enough". She wasn't going to suffer in silence any more. She was going to tell the world about 'leaky' pelvic floors and how to solve them. Stand-up comedy was her chosen vehicle.
The result - Gusset Grippers - isn't your typical comedy performance. It won 'Weirdest Show at the Fringe' at its Edinburgh debut in 2013. Part stand-up routine, part public health announcement, Miller has been on a mission to encourage women with incontinence to seek help ever since.
"I'm an entirely typical case study," she reveals. "I knew I should be doing my pelvic floor exercises but I didn't do them. I was too tired to remember."
As a physiotherapist who now specialises in pelvic health, Miller says she should've known better. But with three young children at home, she just didn't have time to think about the funnel-shaped muscles and connective tissue that make up the pelvic floor.
"The children were lovely but kept trying to kill themselves in stupid ways every five minutes, whenever I turned my back. You notice you're a bit leaky, but you think 'I'll sort that out tomorrow'. But tomorrow never comes. The trigger for me was the key in the door thing. You put the key in your front door and your bladder goes into overdrive."
"It got worse until, eventually, I had urgency, so I needed to pee right there and then. I couldn't hang on. And that can be really difficult, as it impacts your ability to travel. If the bus gets stuck in traffic, that's a nightmare."
It's not something most people would be keen to share on stage in front of a load of strangers. But Miller knew that while laughter isn't necessarily the best medicine for embarrassing health problems, it can still be a welcome tonic. After Miller's first 'tight five', four women came up to her to say: "it happened to me too". It turns out humour might be a powerful tool in health promotion.
"They didn't know it was my job, and they hadn't spoken to their GP, but they could speak to a stranger in a bar," Miller reveals.
"I thought then that maybe there's a way of using comedy to address something that is really embarrassing but give the audience evidence-based information at the same time. And it's not hard to do this stuff. Comedy is just about putting in tension, making people feel a bit anxious, and then giving them a punchline. There's lots and lots of that within embarrassing situations that people get into. But the knack is making the audience feel accepted and not picked on."
Common but not normal
Urinary incontinence affects millions of people. It's especially prevalent in women - childbirth and menopause can both take their toll on the pelvic floor. But many are too embarrassed to seek help. Miller says this is frustrating, because while urinary incontinence is common, it's not a normal part of ageing or postnatal life. And for most people, it can be significantly improved with a simple treatment plan.
Recently, the Royal College of Nursing (RCN) reported a TV advert to the watchdog for implying incontinence is to be expected after childbirth. The RCN said: "Incontinence is known to be under-reported due to the embarrassment experienced by women living with the condition. But the Tena Silhouette advert inaccurately portrays that it is normal to be incontinent post childbirth, providing no data to support the claim and with no acknowledgement that there is treatment available."
The commercial annoyed Miller too. "It's important not to demonise people who need pads. But the amount of money that these companies make from incontinence is quite staggering. And they are gaslighting women by saying :'oh, this is normal'. And they shouldn't be allowed to say things which are factually incorrect."
Miller knows from personal experience that pelvic floor exercises and simple lifestyle changes work for incontinence. But only 25% of women seek help. It takes an average of seven years to come forward, which is a long time to be miserable.
And misery is exactly what incontinence can bring. It can have devastating long-term consequences, affecting everything from mental health to physical activity. Women are far less likely to engage in exercise if they're worried about weeing themselves.
"Inactivity is now responsible for one in six premature deaths in the UK. So should pad companies be able to say that 'this is normal'? The thing that really angers me about it is that incontinence is the second biggest reason that a woman has to leave her home and move into residential care. I just don't think it's acceptable to trivialise the impact this common condition has on people's lives."
Bad bladder habits
As many as one in three women suffer from incontinence when they cough, sneeze, laugh or jump. But pads aren't the only option. Getting into the habit of doing daily pelvic floor exercises is vital.
It's also important to monitor your alcohol intake (alcohol acts as a diuretic, making you pee more), lose weight if you're overweight and stop smoking.
You don't need to cut down on caffeine if you have stress incontinence, due to weakness of the pelvic floor. But some women with urge incontinence (where you experience a sudden overwhelming urge to empty your bladder, followed by a major accident if you don't get to the loo in time) are sensitive to caffeine. If that's you, it's worth a trial of cutting out caffeine to see if it helps.
And don't restrict your fluid intake, even though it's understandable why you would try to do so.
Miller says: "What people tend to do is stop drinking at all because they're trying to reduce their bladder output and get more control that way. But concentrated pee is actually a bladder irritant so it makes it worse.
"You also need to try going to the toilet less frequently. If you go to the toilet more often than you need, you just end up shrinking the size of your bladder."
'Imagine holding in a fart'
But as we're not taught pelvic floor exercises at school, many of us are clueless as to how you actually do them. What should we be squeezing? What should we be feeling?
Miller can sympathise. She suggests the following commands may help you visualise the desired movement better: "Imagine you’ve got a zip from your bum hole all the way down to the front. Zip it up! Or, imagine lifting your testicles to your spectacles. This one works for both men and women surprisingly," she reveals.
"But the one that works best for most people is 'imagine you're holding in a fart', because that's something you likely do on a daily basis. It's easy to think of a scenario in which you wouldn’t want to fart. And just thinking about it makes you want to squeeze and lift your bum hole, which is the action of a pelvic floor.
"We want people to think about squeezing their bum hole tight shut and then lifting it up. And then keep breathing your tummy in and out. If you can only do it by holding your breath, come to the clinic and I'll show you how to do it properly."
Hold that squeeze for a count of ten seconds. And then practise contracting and relaxing the muscles quickly ten times in a row.
"Do the holding for ten seconds, and then ten flicks, three times a day until you're dry. And then once a day, every day, until you die."
If it doesn't get better after 12 weeks, speak with your GP, who should be able to refer you to a specialist physiotherapist.
It's never too late to look after your pelvic floor, Miller points out. Her motto is: Laugh, don't leak.
"You can't miss the boat. It's not like if you're not dry within the first 12 weeks of having a baby then it's too late. That's a myth. My oldest patient is 84 and she did brilliantly. Before she came to me, she'd had the symptoms for 50 years."
Gusset Grippers is at the Gilded Balloon Rose Theatre Aug 8-25 at the Edinburgh Fringe