Squeezing before a cough works for me. Am I supposed to do it forever?

Week six and the single most useful thing I have been given is the squeeze before the cough. She spent about three minutes on it and it does more for my actual day than anything else on the sheet.

Which has left me with a question nobody has answered. Am I supposed to be doing this forever, consciously, before every cough and sneeze and every time I pick anything up? Because I am currently doing it about forty times a day and I have started bracing before things that were never a problem, like standing up.

Is the idea that it eventually becomes automatic and I stop thinking about it, or is this now just a thing I do for the rest of my life? And is doing it before everything harmful or just tiring?

Forty times a day sounds like a lot to me but I am not the person to say. What I noticed with mine is that it went from deliberate to automatic somewhere around the four month mark for the two or three things that actually caught me out, and never became automatic for anything else, probably because it never needed to.

I was taught the same thing before my surgery rather than after, which I gather is the point of doing it beforehand.

For me it was standing up from a chair and getting out of the car, and those two were worth practising deliberately because they happened forty times a day anyway. Sneezing I never got the timing on. You do not get a warning.

The short answer is that the aim is automatic, not permanent conscious effort, and what you are describing at week six is the deliberate stage of something that is meant to stop needing your attention.

A little precision on what the technique is, because the name it goes by varies. It is a pelvic floor contraction taken just before and held through a rise in pressure inside the abdomen, so a cough, a sneeze, a lift, standing up. The point of it is timing rather than force. In continence that is working, the muscle stiffens ahead of the event without anyone deciding to do it, and the leak in stress urinary incontinence happens inside a very short window, so a contraction that arrives after the pressure has already gone through is arriving too late to do anything. That is why it is taught as a sequence: close before, hold through, release after. The release is the part people drop.

What I will not do is give you a percentage for how well it works on its own, because I do not have a figure for it that I am willing to stand behind, and the ones circulating tend to be quoted without a source attached. What is well evidenced is the programme it sits inside. The Cochrane review of pelvic floor muscle training against no treatment, placebo, sham or another inactive control reported cure in 56% of women with stress urinary incontinence against 6% of controls, from 4 trials and 165 women, at high certainty. That is the course, over months, not the bracing.

Two conditions it depends on. The first is that the contraction is the movement you think it is, and this is not a given. In a referred population of 47 women attending for urodynamic testing, 49% achieved an ideal effort after brief verbal instruction and about a quarter did something that could have made matters worse. In a primary care population of 779 women the picture was much better, with most contracting correctly at first attempt. Both are true, they describe different rooms, and the reason the guidelines say supervised is that people already reporting symptoms are the group most likely to be doing something else.

The second is that this is the wrong instruction for some people, and this is where I would answer your last question. An overactive pelvic floor is a muscle that is already struggling to let go, and telling it to clench before forty things a day is adding to the problem rather than solving it. You mostly cannot tell that presentation from weakness by symptoms alone. So bracing before the specific things that catch you out is one thing; bracing pre-emptively before ordinary movement is worth raising at your review rather than continuing on your own judgment. Bracing before a cough or sneeze sets out where it fits and hypertonic pelvic floor and downtraining is the counterweight.

On Gerry's point about sneezes, that is a real limitation rather than a failure of technique. Some events give you no warning and the answer to those is the automatic response the programme is building, which takes months and is measured at review. NICE sets at least 3 months of supervised training for stress or mixed urinary incontinence with at least one review during and one at the end, and you are at week six.

Your own clinician is the one to ask whether forty times a day is appropriate for what she found, and I would put it on the list for the next appointment rather than deciding either way from here.

"The release is the part people drop" has landed uncomfortably. I am fairly sure I have not released properly once in six weeks. Adding it to the list.