Stopping the leaks with coughs and sneezes – What is The Knack?

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Let me ask you a question... have you ever had the experience of needing to stop and cross your legs when you feel a cough or a sneeze coming?

Today I want to talk to you about something called 'The Knack'... which essentially means being able to 'internally cross your legs' before coughing and sneezing!

Instead of gripping with your larger leg/groin muscles to try to stop the leak, imagine if you had the ability to use the pelvic floor internally to help to stop the leak? So much more effective, and less obvious...!
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    Why do we leak with coughing and sneezing?

    Leaking urine with an increase in intra-abdominal pressure (including coughing and sneezing, but also jumping, laughing, running etc) is called 'Stress Urinary Incontinence', or SUI, and is the most common type of incontinence in women under age 55.

    There are loads of multi-faceted reasons why SUI might happen, and it would be simplistic to say that the only reason you would leak with coughing and sneezing is because of a weak pelvic floor.

    But... it is a very common finding, when we do a vaginal exam to check pelvic floor function, that some women have poor 'timing' of their pelvic floor with increased pressures. For example, if we instruct a woman to do a big cough while we have our fingers inside the vagina, we can feel that some women may automatically pre-contract their pelvic floor and hold it on during the cough - and other women, even if they actually have a very strong pelvic floor muscle contraction, don't automatically bring it on at all during coughing. Some, in fact, may accidentally be bearing down significantly while coughing.

    Therefore, pelvic floor training is often done as a first line of treatment for women who have SUI, and this training will often involve practicing and implementing 'The Knack'.

    What is 'The Knack'?

    'The Knack' is defined as 'A strong and well timed contraction of the pelvic floor, done immediately before and during an increase in intra-abdominal pressure such as a cough or sneeze'.

    Ideally, 'the Knack' should be something that happens automatically, without thinking about it. But as a first step, in a woman who isn't doing this effectively or automatically, it may be given to them as part of a home program to practice.

    What would a home exercise program look like for 'The Knack'?

    To start with, 'The Knack' may be given as part of a basic, static pelvic floor exercise program.

    For example, here is a program I gave a woman recently to practice 1-2x/day:

    1 sec on
    1 sec off

    6 sec on
    10 sec off

    Scoop up the pelvic floor, with a focus on 'sucking wee back up the urethra'
    Hold this on while you do a big cough
    Feel the pelvic floor relax after the cough

    The woman would also be encouraged to implement this in her daily life if she feels a cough or sneeze coming on.

    A home exercise program involving the Knack could progress to much more complex movements too! Depending on where and when the leakage happens, home exercise programs might also include practicing the pelvic floor precontraction with movements such as:

    • Sit ups
    • squats/dead lifts
    • step ups/downs
    • lunges
    • hops/jumps

    It's important to note that 'The Knack' only really is relevant and effective for movements where there is an increase in pressure and then a definite rest phase (like a squat or a sit up). You cannot do 'The Knack' for something like running.

    Could The Knack be helpful for you?

    Do you ever leak with coughing or sneezing? Do you ever find yourself having to stop and cross your legs before a cough or a sneeze comes?

    Why don't you give The Knack a go and see if it helps?

    Of course, it may be more complicated than that - you may not be correctly or effectively activating the pelvic floor and you may need to work on this first. You may have other parts of the puzzle that need attention and management, like low oestrogen causing tissue thinning in the vagina, or a vaginal prolapse.

    If you would like to have a thorough assessment for your symptoms of SUI, we have a big team of Women's Health Physiotherapists at FitRight HQ 6 days a week, who would all love to help you!

    You can book here.


    Perth’s Leading Centre for Women’s Health and Exercise

    Physiotherapy, GP services and physio-led exercise classes specifically for women

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