It’s not inevitable that you'll leak a little urine as you age—even when sneezing, coughing, or jumping.

Incontinence is often rooted in the interplay between your diaphragm and pelvic floor muscles. By re-engaging your diaphragm through conscious breathing, you can strengthen these muscles and regain control.

The diaphragm’s role in pelvic floor health is like the keystone in a Roman arch, according to Jana Danielson, pelvic floor expert and Pilates master instructor. It can be helpful to think about the core less like one-dimensional six-pack abs and more like a canister, she said. A strong diaphragm at the top of the canister prevents excessive downward pressure and coordinates a vacuum-like contraction-relaxation effect with pelvic floor muscles that support bladder control.

“When the diaphragm is moving properly through its breathing mechanics, the pelvic floor is going to follow. They work together,” Danielson told The Epoch Times. When the diaphragm doesn’t engage frequently enough, the pelvic floor muscles lose tone.

Your Neck Muscles May Take Over for Your Diaphragm

There are 14 major muscles in the pelvic floor alone that support the bladder, uterus, and bowel. These muscles are designed to contract quickly when we sneeze or cough, helping hold urine and feces back. They relax when we’re ready to use the bathroom.

However, factors such as childbirth, chronic straining due to constipation, physical pressure from excess weight, and hormonal changes, particularly in menopause, can weaken those muscles. They are also vulnerable because our diaphragms are often not used properly, which is linked to posture, Danielson said.

Much of pelvic muscle weakening, she said, stems from poor footwear, particularly the heightened heels found in almost all shoes—including athletic sneakers and children’s shoes—which push additional body weight forward onto the balls of the feet, disrupting the core canister and altering breathing mechanics. The belly hangs out, causing a swayback posture and allowing organs to shift, leading to reliance on neck muscles for breathing, which isn’t sustainable.

Ideally, roughly 60 percent of body weight should be held in the heels. Poor posture can shift breathing from the stronger diaphragm to the scalenes, muscles in the neck that lift the top ribs, and the sternocleidomastoids, larger neck muscles that lift the sternum and upper ribs.

“These little muscles in our neck are willing to do the job, but they get very exhausted very quickly,” Danielson said. “They’re the supporting actors. They’re not the lead actor.”

Further, she said “tech neck”—a posture of slumping the shoulders and spine—reduces core space and recruits neck muscles for breathing, creating a vicious cycle that lessens diaphragmatic use.

The Overly Tightened Core

Weak muscles aren’t the only reason for incontinence. A pelvic floor that stays contracted instead of relaxing, called a hypertonic pelvic floor, affects more than half of women with pelvic pain and can exacerbate incontinence.

Other causes of a hypertonic pelvic floor are chronic stress, patterns of breath holding or shallow breathing, trauma or injury involving the pelvic muscles, chronic pain, poor posture, and prolonged sitting.

“When we think we’re doing the right thing by clenching, squeezing the inner thighs together, crossing our legs … it can help a little bit, but tight muscles are weak muscles,” Kim Vopni, a pelvic health coach known online as “The Vagina Coach,” told The Epoch Times. “And tight muscles can’t generate an adequate amount of force and can’t react timely enough.”

Chronically contracted pelvic floor muscles also have a limited range of motion and get fatigued, she added, because they’ve used up much of their energy. That means a hypertonic pelvic floor might be too tired to react quickly enough to prevent leaking.

Diaphragm Strength Is Critical

The more our bodies engage in diaphragmatic breathing, the more our core naturally builds strength, coordination, and stability.

During inhalation, the diaphragm contracts and descends, widening and flattening, which causes the pelvic floor to relax and the muscles to lengthen downward. On the exhalation, the diaphragm relaxes and moves up, and the pelvic floor muscles lift upward as they contract.

A strong core can manage intra-abdominal pressure from actions such as standing from a seated position, asthmatic breathing, sneezing, or hyperventilating, which require fast-twitch pelvic floor muscles to prevent urine leakage, Vopni said. “All of that happens ideally without us thinking about it.”

It works like any other reflex, similar to our eyelids blinking when something flies near our eyes or our ankles attempting to stabilize us when we trip, so we don’t fall on our face.

Breathing vs. Kegels

Breathing compares favorably to pelvic floor muscle exercises, though ideally it shouldn’t replace them.

A pilot study published in the Journal of Bodywork and Movement Therapies found that, after six weeks, women who did diaphragmatic breathing exercises reported less distress with urge symptoms than those who did Kegels.

Kegels are 30-second contractions of the pelvic floor muscles that men or women can do. It’s important to avoid squeezing the glute, thigh, and abdominal muscles during the exercises. Pelvic floor physical therapists can help ensure you’re isolating the right muscles for Kegels.

Participants did 30 diaphragmatic breaths daily, taking slow breaths that focused on allowing the belly to expand as if filling with air, moving the diaphragm downward, while keeping the chest as still as possible. The breath was also released slowly as the diaphragm returned upward.

A systematic review published in The Journal of American Surgery found pelvic floor muscle training was superior to hypopressive breathing for improving strength, while the breathing exercises improved daily activities, emotional health, social interactions, and physical functioning.

Hypopressive breathing involves exhaling all the air, closing the mouth and nose, and expanding the ribs without inhaling to create an internal vacuum that lifts the diaphragm and improves posture.

“If you take a whole body approach to pelvic floor muscle training—addressing the breath and the posture—pressure management can be helped,” Vopni said. “But a Kegel practice on its own—if you’re not addressing the breath and posture—it’s not going to be as robust.”

Discerning Your Breathing

An easy way to determine whether you are a neck or belly breather is to put one hand on your sternum and one on your belly button and inhale as if you are smelling a freshly baked apple pie, Danielson said. If you are primarily a belly breather, you will feel your waist expand in the front, back, and sides.

Your lower hand should move more than the upper hand, indicating that you are using your diaphragm correctly, she said.

If you find you’re primarily using your neck muscles to breathe, the solution is straightforward. Three times a day—before each meal makes it easy to remember—take eight to 10 focused belly breaths. Inhale through the nose as if you are smelling a pie, Danielson said, and then exhale through the mouth as if you are trying to fog a mirror.

Using your diaphragm to breathe not only regulates pelvic floor muscles but also improves breathing efficiency and shifts the nervous system into the “rest and digest” parasympathetic mode, which can decrease the tendency to overactivate the pelvic floor muscles.

“That breath work is like pushups for your diaphragm,” Danielson said.

Tone Pelvic Floor Like All Muscles

Dr. Joel Evans, an OB-GYN and founder and director of the Center for Functional Medicine, noted that women may battle pelvic floor weaknesses throughout life, as well as potential nerve damage from childbirth that can affect muscle coordination.

He’s found that Kegels and other exercises that strengthen core muscles, including breathing, help train the pelvic muscles to contract correctly and are beneficial. Women especially need to consciously strengthen those muscles, Evans told The Epoch Times in an email.

“This is true for all muscles of the body, but the pelvic floor muscles are frequently neglected.”