Leaking urine and pelvic heaviness after birth are not something you have to live with

A woman came to the clinic with pain across her lower back that got worse when she leaned backward. The pain had started after her first birth, and by then it had lasted six or seven years. The record from that visit also noted that she leaked urine, sometimes felt a mild heaviness in her lower belly, and for several years had often had itching and vaginal discharge. During the birth, she had had a vaginal tear.

The doctor noted the factors that might be contributing to a disorder of her lesser pelvis (the pelvic region): the sacrum, the tailbone, hygiene and the tear from the birth. Instead of rushing to work on her back, the doctor advised her to have a gynecological check-up first and to keep the area carefully clean. Only if her back still hurt after that would the next step be considered.

She came because of her back. The leaking was one of the symptoms the record noted on the side. Many mothers, too, rarely bring this up on their own.

Common, and often hidden

In the first three months after birth, about one mother in three leaks urine to some degree. About 12 in 100 mothers leak every week (Thom and Rortveit 2010). In Norway, 31% of first-time mothers were leaking six months after giving birth (Wesnes 2009).

Common does not mean it will go away on its own. Among the mothers followed in the UK and New Zealand, 24% were still leaking from the third month through the sixth year after birth (MacArthur 2006). Of the mothers still leaking at three months, about 4 in 5 were still leaking 12 years later (Glazener 2014).

A survey of 415 mothers in the Netherlands found that more than half leaked urine, but only about a quarter sought help from a health professional (Moossdorff-Steinhauser 2021). NICE, the body that issues national health guidance in England, notes that women may feel embarrassed to talk about it, so it asks health professionals to raise the pelvic floor themselves at every postnatal check (NG210). In the book by Xia Guicheng (夏桂成), urinary problems after birth are described as “fairly common”, with the advice to treat them promptly, because if left alone they can drag on and affect the new mother’s life (Xia Guicheng, p. 462, 464).

What the pelvic floor is, and what pelvic heaviness is

The pelvic floor is the layer of muscle at the bottom of the pelvis. It supports the bladder, uterus and rectum from below, and the urethra, vagina and anus pass through it.

Pelvic heaviness is a feeling of weight or dragging in the lower belly or inside the vagina. The NHS (the UK’s National Health Service) lists this feeling among the symptoms of pelvic organ prolapse, along with a bulge in the vagina, pain or numbness during sex, and not emptying the bladder fully. A mild prolapse that causes no trouble sometimes does not need treatment yet.

According to the book by Bø and colleagues, a bulge you can see or feel points clearly to prolapse, while a feeling of heaviness points to it much less clearly (Bø, p. 226). Heaviness is therefore a reason to get checked. Only an examination can tell whether there is a prolapse, so please don’t draw conclusions on your own.

Why it happens so easily after birth

Xia Guicheng’s book explains leaking after birth as the baby’s head pressing down as it descends, injuring the bladder sphincter and the nerves (Xia Guicheng, p. 465). Ultrasound in a small group of first-time mothers who gave birth vaginally found that about a third had an injury to the levator ani, one of the main pelvic floor muscles (Dietz 2005). With a forceps delivery (using a tong-like instrument to help pull the baby out), this risk is clearly higher (Friedman 2019).

NICE lists several things that make pelvic floor problems more likely, such as a forceps or vacuum delivery, a pushing stage longer than one hour, a tear that reaches the anal sphincter, giving birth over the age of 30, constipation and a long-lasting cough (NG210). Mothers who leaked during pregnancy are about 2.3 times more likely to still be leaking six months after birth (Wesnes 2009). Having these factors does not mean you will have a problem; it only means you should be asked about it more carefully.

An ordinary tear is not necessarily the culprit. One study asked mothers again twenty years after a single birth, and found that those who had had a second-degree (grade 2) tear or worse (a tear reaching the muscle layer of the perineum) had no more symptomatic prolapse than those without a tear (Gyhagen 2013). This study is about symptomatic prolapse after twenty years, not about leaking urine. A cesarean birth does not fully protect you either. Among mothers who had only cesarean births, 14% still had long-lasting leakage (MacArthur 2006), and one review concluded that a cesarean cannot be recommended to prevent leaking urine (Wesnes and Lose 2013).

Training the pelvic floor the right way

A correct contraction does two things at once: it squeezes around the openings at the bottom of the pelvis and lifts that area up and in (Bø, p. 111). To find the muscles, POGP, the UK association of physiotherapists working in pelvic, obstetric and gynecological health, suggests lying or sitting comfortably and imagining that you are holding in wind and holding in urine at the same time. Sitting on the arm of a chair or the edge of a table can also make the muscles easier to feel.

While you contract, remember a few points that POGP, the NHS and Kisner’s book all stress (Kisner, p. 949):

• Breathe steadily and don’t hold your breath; you can count out loud;
• Keep your buttocks and thighs relaxed;
• A slight tightening of the lower belly is normal, but don’t actively suck your belly in;
• After each contraction, relax fully before the next one.

Common mistakes are bearing down instead of lifting up, holding your breath, clenching the buttocks, squeezing the thighs tightly together and pulling the belly in hard. Bearing down while training can weaken the pelvic floor further (Bø, p. 112).

Not getting the contraction right at first is normal. About a third of women do not contract correctly the first time, even after careful instruction (Bø, p. 111). These muscles are hidden and small, and few people are ever taught how to use them, so finding them hard to contract is not your fault. NICE advises that women who are leaking be examined to confirm they are contracting correctly before starting supervised training (NG123).

POGP advises against training by stopping your urine stream midway, and Bø’s book also does not recommend making this part of the exercises (Bø, p. 114). “Like holding in urine” is only an image to help you find the right muscles. You can train right after you have finished urinating, while still sitting on the toilet (NHS).

There are two kinds of contraction: long holds (up to about 10 seconds) and quick ones (contract, then let go right away). Build up gradually to about 10 of each kind, at least three times a day (NHS; POGP). NICE sets a level of at least 8 contractions, three times a day, with supervised training for at least three months (NG123).

If you have just given birth and your stitches are still sore, you can start lying down. Kisner advises starting when you feel able to and your doctor or midwife has given the go-ahead, and suggests training while feeding your baby or changing diapers (Kisner, p. 951).

Most women feel better after 3–5 months of regular training, and should keep training every day after that (POGP).

Will training stop the leaking?

For women in general, most of them middle-aged, the evidence is fairly clear. Pooling four trials, 56% of the women who trained reported that their leaking on exertion had stopped, compared with 6% in the groups that did not train (Dumoulin 2018). Also in women in general, training with individual supervision, done regularly and at an adequate level, works better (Todhunter-Brown 2022).

For mothers who are leaking after birth, the results are more modest. A 2020 Cochrane review (a summary of studies done to an international standard) did not find that training made a clear difference at 6–12 months after birth, and the quality of the evidence was still low (Woodley 2020). In one randomized trial, mothers still leaking three months after birth were taught pelvic floor training by nurses, along with bladder training (gradually lengthening the time between trips to the toilet). By the end of the first year, 60% of this group were still leaking, compared with 69% in the group without instruction (Glazener 2001), but 12 years later the two groups no longer differed (Glazener 2014).

In our view, correct training is the right first step, and some mothers do get better. Some still leak after training, and the benefit only lasts while you keep training. If you have trained correctly for about three months without improvement, that is the time to get checked, not the time to blame yourself.

At that point, at the clinic, the doctor adds an examination with Applied Kinesiology (AK), which means testing the strength of each muscle by hand. The pelvic floor does not work alone, so the doctor also tests the buttock muscles, the hamstrings, the psoas, the diaphragm and the abdominal muscles. Cuthbert, an AK author, reviewed the records of 21 people with leaking urine who were examined and treated with AK, aged 13 to 90, not only mothers after birth. The pelvic floor muscles tested weak in 14 people, while the gluteus maximus tested weak in as many as 17. The hamstrings, diaphragm, iliopsoas and rectus abdominis were also often weak, in 10–16 people for each group. In 13 people there were scars, including scars from pregnancy, cesarean scars and one appendectomy scar, and when the scar was lightly stimulated, the muscle beneath it tested weak (Cuthbert 2013). That case series shows where to look; it does not show how many mothers will get better.

On stitches and scars, Garten’s AK book advises: if the pelvic floor contracts weakly on one side, think of an episiotomy scar or a cesarean scar that is pulling, and treat it with the Injury Recall Technique (IRT), a technique that has been integrated into AK. Scars from perineal tears and tailbone injuries are also common traces in this area (Garten 2016). At the clinic, you only need to place your own hand on your lower belly, your tailbone or the spot with the stitches or scar, and the doctor retests a muscle in your arm or leg; the doctor does not do an internal examination. During treatment, you keep your hand on that spot while the doctor makes a gentle movement at your ankle, so that the nervous system resets the signal coming from the old injury. This can be done once the stitches or surgical wound have healed and the stitches have been removed or have dissolved; if the area is still red and swollen or oozing, see a doctor first.

AK adds a layer of assessment; it does not replace a gynecological examination. Whether a muscle tore loose during the birth, or whether the uterus or bladder has prolapsed, can only be known through an obstetric and gynecological examination and an ultrasound.

Squeeze before you cough, sneeze or lift your baby

POGP calls this “the Knack”: squeezing the pelvic floor just before you cough, sneeze, laugh out loud, bend down or lift your baby. A small study of 27 women found that after one week of learning to contract before coughing, the amount of urine leaked when coughing dropped clearly (Miller 1998, cited in Bø 2015, p. 30).

What traditional medicine books say

Xia Guicheng’s book divides urinary problems after birth into three patterns: qi deficiency (气虚 / 氣虛, qì xū; qi here means the body’s strength, which has become weak), Kidney deficiency (肾虚 / 腎虛, shèn xū; the Kidney organ system is weak) and damp-heat (湿热 / 濕熱, shī rè; dampness and heat held inside the body) (Xia Guicheng, p. 462–466). In Vietnamese, the words for “qi deficiency” are the same as the everyday word for the vaginal discharge mentioned at the start; the two are unrelated. Explaining the Kidney deficiency pattern, the book quotes Xue Lizhai (薛立斋 / 薛立齋): “Involuntary urination after birth comes from Kidney qi that is not firm.” The classical Vietnamese physician Hai Thuong Lan Ong also recorded leaking urine after birth that cannot be held back, and put it down to “Kidney qi that is not consolidated” (section 36).

Genital prolapse (prolapse of the uterus or the vaginal wall) is called “yin protrusion” (阴挺 / 陰挺, yīn tǐng) in traditional medicine books, which describe a heaviness that gets worse with long standing or heavy work and eases with lying down to rest. According to Xia Guicheng’s book, this condition “mostly occurs after birth” and is also common in older people and those with a weak constitution; the book advises new mothers not to do heavy physical work too soon (Xia Guicheng, p. 528–532).

A Chinese acupuncture textbook (针灸治疗学 / 針灸治療學, Zhēnjiǔ Zhìliáoxué, Acupuncture and Moxibustion Therapeutics) advises people with urinary incontinence (leaking urine) to regularly practice drawing in the belly and tightening the anus. For people with uterine prolapse, it advises training the levator ani, not squatting for long periods and not carrying heavy loads (PDF 216, 266). Discussing constipation after birth, Xia Guicheng’s book also recommends anal squeezing exercises, because the pelvic floor muscles are slack after birth (Xia Guicheng, p. 472). Tightening the anus is close to the “holding in wind” action described above.

While you are feeling heaviness or leaking and are retraining your pelvic floor, avoid squatting for very long, carrying heavy loads and straining hard on the toilet. This advice is drawn from the acupuncture textbook, written for people with uterine prolapse, and from Xia Guicheng’s book; no study has yet looked at this specifically in mothers after birth.

For electroacupuncture (acupuncture with a mild electric current attached), there is one large trial in 504 women with leaking on exertion, average age 55. After six weeks, the amount of urine leaked fell more than in the sham acupuncture group (needling done only for show, as a comparison) (Liu 2017). The women in that trial were not mothers after birth, and studies of acupuncture and moxibustion for leaking after birth are still small and of low quality. For mothers after birth, there is not yet enough evidence to say how much acupuncture can help; if it is used, it goes together with an examination and correct training, not in place of them.

When to tell the clinic, and when to get checked right away

Based on guidance from NICE, the NHS, POGP and traditional medicine books, you should tell the clinic, have an obstetric and gynecological check-up, or see a pelvic floor physiotherapist (no need for the emergency department yet) if:

• Leaking has not improved after about three months of regular, correct training;
• You are not sure you are contracting correctly;
• You see or feel a bulge inside the vagina or coming out of it;
• Heaviness lasts a long time, especially when you stand for long or do heavy work;
• You leak stool or wind, or find it hard to wipe clean after a bowel movement;
• You have pain, discomfort or numbness during sex;
• Urinating is difficult, you cannot empty your bladder fully, or you have to strain to pass urine;
• You have had a tear that reached the anal sphincter;
• Pelvic floor training is painful;
• Looking in a mirror, you see the perineum (the area around the vaginal and anal openings) bulge outward when you contract.

Get checked right away if:

• You cannot pass urine at all, and your lower belly is tense and full;
• You have a fever with burning or painful urination, or pain in your side or lower back;
• There is blood in your urine.

Other signs after birth that need a check-up right away are covered in the article “Warning signs after birth that need care right away”.

Back to her story

About eight months later, she came back because of long-lasting vaginal discharge, and was examined and treated with traditional medicine. After three visits over about two weeks, the discharge was much reduced, with only occasional itching. The records did not mention leaking or heaviness at the later visits, so we do not know whether those symptoms had improved.

Back pain and leaking urine go together in many studies, but it is not clear which causes which. Women who often leak are about 2.3–2.5 times more likely to often have back pain (Smith 2006). Bacterial vaginosis has been found to go with urgency incontinence (leaking because the urge comes too suddenly to hold), but not with leaking on exertion (Xie 2022). The doctor chose a gynecological check-up first and left joint work for later because back pain, leaking urine and gynecological infection may be linked.

Back pain after birth is covered in the article “Back pain after birth: from the pelvic joints, from feeding positions or from an old back problem”. If you are worried that your belly has not gone down, see the article “A belly that hasn’t flattened after birth: check whether it is diastasis recti”. In one study, a postnatal exercise program (mostly pelvic floor training) did not narrow the gap between the two sides of the abdominal muscle any more than no program (Gluppe 2018). So these two issues need to be looked at separately.

What to bring to your appointment

For a few days before your visit, keep a bladder diary: the time of each trip to the toilet, what you were doing each time you leaked (coughing, sneezing, lifting your baby, or an urge too sudden to hold) and what you drank.

Tell the doctor how you gave birth: whether forceps or vacuum were used, whether you tore or had stitches, whether you already leaked during pregnancy, what training you have done and for how long, and whether you have a bulge, leaking of stool, pain during sex or constipation.

Worth keeping

• Leaking urine and pelvic heaviness after birth are common, but they are not a given;
• A correct contraction squeezes around the openings at the bottom of the pelvis and lifts up and in, with steady breathing and full relaxation after each contraction;
• Don’t train by stopping your urine stream;
• Squeeze your pelvic floor before you cough, sneeze or lift your baby;
• If you have trained correctly for about three months without improvement, get checked;
• If you notice a bulge in the vagina, have an obstetric and gynecological check-up;
• If you cannot pass urine, have a fever with burning urination or see blood in your urine, get checked right away.

References

Sources in Vietnamese

• Hạ Quế Thành. Thực dụng Trung y phụ khoa học (bản dịch tiếng Việt của BS. Tâm). Tr. 462–466, 471–472, 528–532.
• Hải Thượng Lãn Ông. Hải Thượng y tông tâm lĩnh. Hà Nội: NXB Y học. Tập 1, tr. PDF 889.

Sources in English

• Bø K, Berghmans B, Mørkved S, Van Kampen M, editors. 2015. Evidence-Based Physical Therapy for the Pelvic Floor. 2nd ed. Edinburgh: Elsevier. p. 30, 111–112, 114–115, 226.
• Cuthbert S. 2013. Applied Kinesiology: Clinical Techniques for Lower Body Dysfunctions. Gangasas. p. 271–272.
• Dietz HP, Lanzarone V. 2005. Levator trauma after vaginal delivery. Obstet Gynecol. 106(4):707-12. doi:10.1097/01.AOG.0000178779.62181.01. PMID: 16199625.
• Dumoulin C, Cacciari LP, Hay-Smith EJC. 2018. Pelvic floor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane Database Syst Rev. 10(10):CD005654. doi:10.1002/14651858.CD005654.pub4. PMID: 30288727.
• Friedman T, Eslick GD, Dietz HP. 2019. Delivery mode and the risk of levator muscle avulsion: a meta-analysis. Int Urogynecol J. 30(6):901-907. doi:10.1007/s00192-018-3827-8. PMID: 30649566.
• Glazener CM, Herbison GP, Wilson PD, MacArthur C, Lang GD, Gee H, et al. 2001. Conservative management of persistent postnatal urinary and faecal incontinence: randomised controlled trial. BMJ. 323(7313):593-6. doi:10.1136/bmj.323.7313.593. PMID: 11557703.
• Glazener CM, MacArthur C, Hagen S, Elders A, Lancashire R, Herbison GP, et al. 2014. Twelve-year follow-up of conservative management of postnatal urinary and faecal incontinence and prolapse outcomes: randomised controlled trial. BJOG. 121(1):112-20. doi:10.1111/1471-0528.12473. PMID: 24148807.
• Gluppe SL, Hilde G, Tennfjord MK, Engh ME, Bø K. 2018. Effect of a Postpartum Training Program on the Prevalence of Diastasis Recti Abdominis in Postpartum Primiparous Women: A Randomized Controlled Trial. Phys Ther. 98(4):260-268. doi:10.1093/ptj/pzy008. PMID: 29351646.
• Gyhagen M, Bullarbo M, Nielsen TF, Milsom I. 2013. Prevalence and risk factors for pelvic organ prolapse 20 years after childbirth: a national cohort study in singleton primiparae after vaginal or caesarean delivery. BJOG. 120(2):152-160. doi:10.1111/1471-0528.12020. PMID: 23121158.
• Kisner C, Colby LA. 2012. Therapeutic Exercise: Foundations and Techniques. 6th ed. Philadelphia (PA): F.A. Davis. p. 936, 949, 951.
• Liu Z, Liu Y, Xu H, He L, Chen Y, Fu L, et al. 2017. Effect of Electroacupuncture on Urinary Leakage Among Women With Stress Urinary Incontinence: A Randomized Clinical Trial. JAMA. 317(24):2493-2501. doi:10.1001/jama.2017.7220. PMID: 28655016.
• MacArthur C, Glazener CM, Wilson PD, Lancashire RJ, Herbison GP, Grant AM. 2006. Persistent urinary incontinence and delivery mode history: a six-year longitudinal study. BJOG. 113(2):218-24. doi:10.1111/j.1471-0528.2005.00818.x. PMID: 16412001.
• Moossdorff-Steinhauser HFA, Berghmans BCM, Spaanderman MEA, Bols EMJ. 2021. Urinary incontinence 6 weeks to 1 year post-partum: prevalence, experience of bother, beliefs, and help-seeking behavior. Int Urogynecol J. 32(7):1817-1824. doi:10.1007/s00192-020-04644-3. PMID: 33484286.
• National Institute for Health and Care Excellence (NICE). 2019. Urinary incontinence and pelvic organ prolapse in women: management (NG123). Available from: https://www.nice.org.uk/guidance/ng123/chapter/Recommendations. Recommendations 1.3.4, 1.4.4–1.4.5, 1.7.5–1.7.6.
• National Institute for Health and Care Excellence (NICE). 2021. Pelvic floor dysfunction: prevention and non-surgical management (NG210). Available from: https://www.nice.org.uk/guidance/ng210/chapter/Recommendations. Recommendations 1.1.7, 1.2.1 (Box 1), 1.3.12, 1.4.2, 1.5.3.
• NHS. 2025. Pelvic organ prolapse [Internet; page last reviewed 2025 Jul 3]. Available from: https://www.nhs.uk/conditions/pelvic-organ-prolapse/.
• NHS. 2026. Your post-pregnancy body [Internet; page last reviewed 2026 Jul 20]. Available from: https://www.nhs.uk/baby/support-and-services/your-post-pregnancy-body/.
• Pelvic, Obstetric and Gynaecological Physiotherapy (POGP). 2018. The Pelvic Floor Muscles – a Guide for Women. Available from: https://thepogp.co.uk/Resources/115/pelvic_floor_muscle_exercises_for_women.
• Smith MD, Russell A, Hodges PW. 2006. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Aust J Physiother. 52(1):11-6. doi:10.1016/s0004-9514(06)70057-5. PMID: 16515418.
• Thom DH, Rortveit G. 2010. Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand. 89(12):1511-22. doi:10.3109/00016349.2010.526188. PMID: 21050146.
• Todhunter-Brown A, Hazelton C, Campbell P, Elders A, Hagen S, McClurg D. 2022. Conservative interventions for treating urinary incontinence in women: an Overview of Cochrane systematic reviews. Cochrane Database Syst Rev. 9(9):CD012337. doi:10.1002/14651858.CD012337.pub2. PMID: 36053030.
• Wesnes SL, Hunskaar S, Bo K, Rortveit G. 2009. The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study. BJOG. 116(5):700-7. doi:10.1111/j.1471-0528.2008.02107.x. PMID: 19220234.
• Wesnes SL, Lose G. 2013. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J. 24(6):889-99. doi:10.1007/s00192-012-2017-3. PMID: 23436034.
• Whelan M. 2012. In: Chaitow L, Lovegrove Jones R, editors. Chronic Pelvic Pain and Dysfunction: Practical Physical Medicine. Edinburgh: Churchill Livingstone Elsevier. p. 333.
• Woodley SJ, Lawrenson P, Boyle R, Cody JD, Mørkved S, Kernohan A, et al. 2020. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 5(5):CD007471. doi:10.1002/14651858.CD007471.pub4. PMID: 32378735.
• Xie L, Yu Z, Gao F. 2022. Associations Between Bacterial Vaginosis and Urgency Urinary Incontinence in Women: An Analysis of Nhanes 2001 to 2004. Urology. 170:78-82. doi:10.1016/j.urology.2022.07.053. PMID: 35964786.

Sources in German

• Garten H. 2016. Applied Kinesiology: Funktionelle Myodiagnostik in Osteopathie und Chirotherapie. 1. Aufl. München: Elsevier. S. 428, 494.

Sources in Chinese

• 高树中, 杨骏, 主编. 针灸治疗学. PDF 第 216、266 页.