Bladder Leakage Is Not Normal and Physical Therapy Can Fix It.
By Kelly Brown Gross, PT, MPT, WCS | Ashworth Chiropractic, Physical Therapy & Acupuncture | West Des Moines, Iowa
You cough, and you leak. You sneeze, and you leak. You jump, laugh, run, or pick up something heavy — and there it is again.
Maybe you’ve started planning your day around bathroom access. Maybe you’ve stopped running, stopped jumping in exercise class, stopped laughing freely with friends. Maybe you’ve just accepted it as part of life — part of getting older, part of having had kids.
Kelly Brown Gross, PT, MPT, WCS has spent over 20 years working with women who’ve done exactly that. Who’ve quietly managed, modified, and accommodated — often for years, sometimes for decades — before finally deciding to ask for help.
Here is what she wants you to know: bladder leakage is not normal. It is common — but common is not the same as normal. And in the majority of cases, it is entirely treatable without surgery, without medication, and without lifetime use of pads.
What Is Stress Urinary Incontinence?
Stress urinary incontinence — SUI — is the involuntary loss of urine caused by physical exertion or increased intra-abdominal pressure. Coughing. Sneezing. Laughing. Running. Lifting. Jumping. Any of these can trigger leakage when the pelvic floor muscles and urethral closure mechanism are not functioning adequately.
The word “stress” here refers to physical stress on the bladder and unlike urgency urinary incontinence, which is the sudden, overwhelming urge to urinate, stress incontinence is mechanical: there is simply not enough support and closure pressure to keep urine in when an external force acts on the abdomen.
The most common causes and contributing factors include:
- Pregnancy and vaginal delivery — which stretch and stress the pelvic floor muscles, connective tissue, and nerves
- Cesarean delivery — which, contrary to what many women believe, still affects the pelvic floor due to the weight and position of the uterus throughout pregnancy
- Hormonal changes at menopause — declining estrogen affects the tissue integrity of the urethra and pelvic floor
- Chronic high-impact activity without appropriate pelvic floor conditioning
- Previous pelvic surgery, including hysterectomy
- Chronic cough, constipation, or other conditions that repeatedly increase intra-abdominal pressure
Importantly, bladder leakage is not an inevitable consequence of any of these. It is a sign that the pelvic floor needs targeted rehabilitation — and that rehabilitation works.
Bladder leakage is a musculoskeletal problem. The pelvic floor is muscle and connective tissue — and like any muscle, it can be weakened, damaged, or poorly coordinated. Like any muscle, it responds to skilled rehabilitation.
How Pelvic Floor Physical Therapy Treats Bladder Leakage
Pelvic floor physical therapy for urinary incontinence is not just kegels. That is one of the most common misconceptions Kelly encounters — and one worth addressing directly.
A pelvic floor that is weak needs strengthening. But a pelvic floor that is tight, overworked, or poorly coordinated needs something different entirely. Doing kegels on a hypertonic pelvic floor — one that is already too tense — can actually make symptoms worse. This is why a thorough evaluation matters before any exercise prescription begins.
Kelly’s approach to bladder leakage starts with a comprehensive assessment that identifies exactly what is happening with the pelvic floor musculature — strength, coordination, timing, and any restrictions — and builds a treatment plan around those specific findings. This typically includes:
- Pelvic floor muscle training — individualized, progressive, and targeted to your specific deficits
- Manual therapy — hands-on treatment to address scar tissue, muscle restrictions, or connective tissue limitations
- Bladder training — behavioral strategies to improve bladder control and reduce urgency alongside leakage
- Functional movement training — ensuring the pelvic floor is working correctly during the specific activities that cause your leakage
- Education and home program — giving you the tools to maintain your progress and stay well long after formal treatment ends
The goal is not to manage the leakage indefinitely. The goal is to resolve it.
What the Clinical Research Shows
Based on articles retrieved from PubMed, the evidence for pelvic floor physical therapy in the treatment of stress urinary incontinence is some of the strongest in all of conservative women’s health care:
8 Times More Likely to Report Cure — Cochrane Review, 31 Trials, 1,817 Women
The most comprehensive review of the evidence is a 2018 Cochrane systematic review published by Dumoulin, Cacciari, and Hay-Smith that analyzed 31 randomized controlled trials involving 1,817 women from 14 countries. The findings for stress urinary incontinence are striking: women who completed pelvic floor muscle training were eight times more likely to report cure of their urinary incontinence compared to no treatment or inactive controls (56% vs. 6%; RR 8.38, 95% CI 3.68–19.07; high-quality evidence).
Women with stress incontinence who completed PFMT were also six times more likely to report cure or improvement compared to controls (74% vs. 11%). Leakage episodes were reduced by approximately one episode per day. The authors rated the evidence for symptomatic cure in SUI as high quality.
The review concluded that pelvic floor muscle training should be included as a first-line conservative treatment for women with urinary incontinence.
Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654. DOI: https://doi.org/10.1002/14651858.CD005654.pub4
70-74% Reduction in Leakage Episodes at 1 Year
A 2020 randomized clinical trial published in JAMA Internal Medicine (Dumoulin et al.) enrolled 362 women aged 60 and older with stress or mixed urinary incontinence. At 1-year follow-up, both individual and group-based pelvic floor muscle training produced a median reduction in leakage episodes of 70 to 74 percent based on 7-day bladder diary data. The study confirmed that structured PFMT — whether delivered individually or in a group — produces meaningful, durable improvement in urinary incontinence in older women.
Dumoulin C, et al. Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern Med. 2020;180(10):1284-1293. DOI: https://doi.org/10.1001/jamainternmed.2020.2993
Large Multicenter RCT — 600 Women, 23 Clinical Centers
A 2020 multicenter randomized controlled trial published in the BMJ (Hagen et al.) enrolled 600 women with stress or mixed urinary incontinence across 23 community and secondary care continence centers in Scotland and England. All participants received supervised pelvic floor muscle training over 16 weeks. At 24-month follow-up, both treatment groups maintained clinically meaningful improvement in urinary incontinence severity, confirming the durability of PFMT outcomes well beyond the active treatment period.
Hagen S, et al. Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women. BMJ. 2020;371:m3719. DOI: https://doi.org/10.1136/bmj.m3719
The takeaway from the research: pelvic floor muscle training is not an experimental approach. It is backed by the highest levels of evidence in clinical research — Cochrane reviews, multicenter RCTs published in the BMJ and JAMA. Women who complete a structured program are 8 times more likely to cure their stress urinary incontinence than those who receive no treatment.
Who Gets Bladder Leakage — and Who Kelly Sees
The straightforward answer: a lot more people than talk about it.
Stress urinary incontinence affects an estimated 1 in 3 women at some point in their lives. It is most common in women who have had children, women in the perimenopausal and postmenopausal years, and women who participate in high-impact activities without appropriate pelvic floor conditioning. But it can occur at any age and in any body.
Kelly sees patients across the full spectrum:
- Women in their 20s and 30s — postpartum, active, dealing with leakage during exercise or sneezing
- Women in their 40s and 50s — perimenopausal changes accelerating symptoms that have been mild for years
- Women in their 60s, 70s, and beyond — who were told this was just aging and never sought help
- Women who had hysterectomy or other pelvic surgery and developed incontinence afterward
- Athletes — runners, crossfitters, triathletes — dealing with leakage during training that limits performance
There is no right time to come in other than now. Women who have been dealing with leakage for 20 years are as treatable as women who developed it recently. Pelvic floor muscle tissue responds to rehabilitation regardless of how long the problem has been present.
Things Kelly Hears That Are Not True
“This is just what happens when you have kids.”
Having children stresses the pelvic floor. That’s true. But stress does not equal permanent damage. The pelvic floor is muscle and connective tissue — it responds to targeted rehabilitation. Millions of women have resolved postpartum leakage with pelvic floor PT. It is not an inevitable trade-off for motherhood.
“This is just part of getting older.”
Age-related hormonal changes can affect the pelvic floor. But leakage is not an unavoidable consequence of aging — it is a treatable condition that becomes more common as people age, which is a different thing entirely. The JAMA Internal Medicine trial specifically enrolled women 60 and older and showed 70-74% reduction in leakage episodes with structured treatment.
“I already tried kegels and they didn’t work.”
Most women who try kegels on their own are doing them incorrectly, inconsistently, or inappropriately for their specific pelvic floor presentation. A pelvic floor evaluation identifies whether strengthening, relaxation, coordination training, or some combination is what your pelvic floor actually needs. Kegels are one tool — not the whole program.
“I don’t want surgery so I’ll just manage.”
Pelvic floor physical therapy is the evidence-based first-line treatment for stress urinary incontinence — specifically recommended before surgery is considered. If you are managing with pads and restrictions because you don’t want surgery, PT is exactly where you should start. Surgery is typically reserved for cases that have not responded to conservative treatment.
What to Expect at Ashworth Chiropractic
Kelly Brown Gross, PT, MPT, WCS is one of fewer than 700 Women’s Health Certified Specialists in the United States — and one of only about five in Iowa. The WCS designation represents the highest level of specialization in pelvic health and women’s health physical therapy. She has received referrals from Mayo Clinic and the University of Iowa Hospitals and Clinics for complex pelvic floor cases.
Every patient begins with a one-hour evaluation. Kelly will:
- Take a thorough history of your symptoms, their onset, their severity, and what makes them better or worse
- Discuss your goals — whether that’s returning to running, stopping pad use, or simply not planning life around bathrooms
- Perform a pelvic floor assessment to evaluate muscle strength, coordination, tone, and any contributing structural factors
- Explain what she found and what she recommends before any treatment begins
Follow-up sessions are 45 minutes of focused, individualized care. Kelly sees one patient at a time — always. No waiting, no rushing, no divided attention.
Most patients see meaningful improvement within 6 to 8 sessions. Many resolve their symptoms entirely. The home program Kelly provides gives you the tools to maintain that progress on your own — which is the whole point.
No referral is needed. Iowa is an open-access state for physical therapy. You can call us directly.
Questions Kelly Hears Most
Does the evaluation involve an internal exam?
A pelvic floor assessment often includes an internal examination — this is how we actually evaluate what the pelvic floor muscles are doing. It’s similar to a gynecological exam. It’s always explained in advance, always your choice, and always done with your full comfort in mind. It’s the most accurate way to understand what your pelvic floor actually needs.
I’m embarrassed to talk about this.
Kelly has heard this more times than she can count. Bladder leakage, pelvic pain, and sexual dysfunction are medical conditions — not anything to be embarrassed about. Her job is to make the conversation feel normal, because it is. The embarrassment is one of the main reasons women wait so long to seek help. You don’t have to.
Is this covered by insurance?
Pelvic floor physical therapy is covered by many insurance plans, including Medicare. Coverage varies by carrier and plan, so we recommend calling your insurance to confirm your benefits before your first appointment. We are happy to help with this process.
What if I’ve already had surgery for incontinence?
Prior surgery does not disqualify you from pelvic floor PT. Many women continue to experience symptoms after surgical intervention, or develop new symptoms over time. Kelly works with post-surgical patients regularly and can address both the residual dysfunction and the pelvic floor rehabilitation that surgery alone doesn’t provide.
Clinical References
The following peer-reviewed studies were retrieved from PubMed and cited in this article.
- Dumoulin C, Cacciari LP, Hay-Smith EJC. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 2018;10(10):CD005654. DOI: https://doi.org/10.1002/14651858.CD005654.pub4
- Dumoulin C, et al. Group-Based vs Individual Pelvic Floor Muscle Training to Treat Urinary Incontinence in Older Women: A Randomized Clinical Trial. JAMA Intern Med. 2020;180(10):1284-1293. DOI: https://doi.org/10.1001/jamainternmed.2020.2993
- Hagen S, et al. Effectiveness of pelvic floor muscle training with and without electromyographic biofeedback for urinary incontinence in women: multicentre randomised controlled trial. BMJ. 2020;371:m3719. DOI: https://doi.org/10.1136/bmj.m3719
- Wang X, et al. Pressure-Mediated Biofeedback With Pelvic Floor Muscle Training for Urinary Incontinence: A Randomized Clinical Trial. JAMA Netw Open. 2024;7(11):e2442925. DOI: https://doi.org/10.1001/jamanetworkopen.2024.42925
About Kelly Brown Gross
Kelly Brown Gross, PT, MPT, WCS is a physical therapist at Ashworth Chiropractic, Physical Therapy & Acupuncture in West Des Moines, Iowa. She holds the Women’s Health Certified Specialist (WCS) designation — one of fewer than 700 in the United States, and one of only about five in Iowa. Kelly has over 20 years of experience in pelvic health, orthopedics, postpartum rehabilitation, and vestibular therapy. She sees one patient at a time, every visit, and has received referrals from Mayo Clinic and the University of Iowa Hospitals and Clinics for complex pelvic floor cases.
