Fiona McMahon PT, DPT, PRPC
When we think about pelvic floor physical therapy for bladder dysfunction we often think of treatment for leakage, which pelvic floor physical therapy can be very effective in treating but it is important to remember that bladder problems can come in as many different flavors as ice creams at Baskin Robins. Pelvic floor physical therapy can help treat many bladder issues including and beyond urinary leakage.
We can think of bladder issues occupying different domains or categories. Thinking of bladder problems this way is helpful to allow us to narrow in on where to start when we approach treatment. We can encounter issues with storage. Think of leaking urine, whether a little or a lot, frequency, or urgency. Conversely, folks can encounter emptying issues either at the start of peeing (hesitancy) or having the feeling of incomplete urination. Additionally, bladders can become painful either as they are filling with urine or emptying. On its face, bladder problems may seem minor, but having walked many folks through pelvic floor treatment for the bladder, I have witnessed how distressing, inconvenient, and painful bladder issues can be. I have also had the joy of watching folks get better and feel more comfortable in their bodies.
In this blog, I want to take some time to introduce you to the bladder, (which is a highly sophisticated organ that deserves its own blog) as well as some practical tips and resources you can put to use, straight away to start feeling better.
The Bladder
To understand what can go wrong with the bladder and more importantly how to treat it, we must get to know the bladder. Unlike your heart and lungs, you are not born knowing exactly how to use your bladder. We can see this in brand-new babies. Anyone familiar with babies knows babies are not born pre-programmed to be continent. In fact, most kiddos don’t start potty training until 2-3 years of life.
To gain bladder control, we must be able to coordinate many different systems including our central and peripheral nervous system, the smooth muscle of the bladder wall, the urinary sphincters, as well as the voluntary muscles of our pelvic floor.
We first must be aware that our bladders are full. This process requires coordination between your brain and the stretch receptors in the bladder. When the bladder fills to a certain point, the stretch receptors will send the brain the message that “it is time to go”. It is hypothesized that one of the reasons little babies go so frequently is that their bladders are just starting out in learning how to stretch. Sometimes, as adults, the stretch receptors can send the “it’s time to go” message way too early and often, resulting in frequent trips to the bathroom.
So now, you have gotten the message that your bladder is full and it is time to mosey your way to the bathroom and go pee. This process is truly fascinating. When we pee the muscular wall of the bladder, the detrusor, must squeeze to empty. The detrusor, AKA the bladder squeezer muscle, is involuntary, meaning you don’t have to will it to work, it just does when the time is appropriate to pee.
I am guessing that there is a good portion of you reading this blog who are like, “Hey, Fiona, I actually do have to work to pee, what’s the deal with that?” Well, my friend, this is an example of dysfunctional voiding. In a healthy urinary system, we should be able to void by simply relaxing and letting the bladder squeezer muscle do its thing. Some folks will develop the habit of pushing to pee. This can be a very difficult habit to break and over time, the body gets used to using pressure from the belly and not the actual detrusor to pee. If this is you, don’t beat yourself up. One, chances are in your history you had a very good reason to rush your pees, whether it was having a time limit while using the school’s restroom as a child or having an occupation that doesn’t allow for ready access to the loo. Two, though the detrusor may have taken a back seat when comes to urinating, we can retrain the coordination of the detrusor through physical therapy and bladder training.
If you feel you have to strain or push to pee, you may also have trouble relaxing your urinary sphincters. In normal urinary anatomy, we have 2 sphincters, the internal urinary sphincter, and the external urinary sphincter. This is true regardless of whether you have female or male anatomy. Both the internal and external sphincters work together to keep pee in the bladder until it is time to go. They are controlled by different mechanisms.
The autonomic nervous system controls the internal urinary sphincter and it is involuntary, just like the detrusor. The autonomic nervous system is subdivided into the sympathetic and the parasympathetic nervous systems. To shorten a subject that truly requires its own blog, simply put, the sympathetic nervous system is associated with the fight or flight response or a general revving up of the body in response to a threat. The parasympathetic nervous system is linked to our restorative processes and can commonly be thought of as the rest and digest division of the autonomic nervous system. Most of the time, the sympathetic nervous system is working to make sure that the detrusor is not squeezing and the internal urinary sphincter is remaining zipped up tight, so we can stay continent in our day-to-day lives. When it is time to pee, our parasympathetic nervous system will work to allow the detrusor to squeeze and the internal urinary sphincter to relax. This will allow urine to exit the bladder and allow you to void. Now remember, when we talked about how the sympathetic nervous system gets turned up a notch with stress? And remember how the sympathetic nervous is responsible for keeping the detrusor from squeezing and keeping the internal urinary sphincter contracted? I think you know where this is going. When you are stressed or under a lot of pressure, it can become very difficult to pee. So rushing to pee can make the situation much worse, instead try slowing down and relaxing to pee. Deep breathing can be very helpful.
For those of you who strain, but aren’t stressed, you may be dealing with a tight or restricted pelvic floor. The pelvic floor forms the external urinary sphincter and needs to relax to allow the detrusor to squeeze. The pelvic floor and the detrusor have a reciprocal relationship. Meaning when one is on, the other should relax or turn off. If you have chronic pelvic floor tension or chronically hold your pelvic floor, you may find that you need to strain to pee.
Additionally, many folks with pelvic floor dysfunction can also have what is called paradoxical contraction of the pelvic floor. Paradoxical contraction occurs when you are trying to open your pelvic floor to pee or have a bowel movement, but it closes instead. Many folks are not even aware this is happening. This typically occurs when folks are straining to have a bowel movement; however, this can also occur when you are straining to urinate as well. As you are pushing to pee, you may actually be closing your urinary sphincters, resulting in you having to push much harder than necessary and resulting in putting undue strain on your pelvic organs and ligaments.
To store pee, we must have strong pelvic floors. As the bladder wall stretches, a signal is sent to the pelvic floor from the brain to tell the pelvic floor to gradually increase tension to meet the pressure demands from the bladder. This allows us to delay urination until an appropriate time to do so. As you can see, the detrusor and the urinary sphincters have a reciprocal relationship meaning that if the detrusor is working to empty the bladder, the urinary sphincters should relax and vice versa. This is a principle we can use to our advantage as we discuss bladder issues and how to address them later in the blog.
So What’s the Deal with My Bladder Problem?
As we have discussed, the bladder is truly a highly complex organ. We know from our everyday experience, that when something is more complex, there can be more potential problems. This is where having a working definition of your bladder symptoms can be helpful to guide you and your care team on the appropriate solutions. These problems are considered symptoms. They can be symptoms of pelvic floor dysfunction as well as medical conditions. Oftentimes folks with these symptoms will be frustrated when they fail to receive a medical diagnosis for their symptoms, in this case, it can be extremely helpful to look into pelvic floor physical therapy.
Incontinence/ Leakage
There can be many types of incontinence. We usually classify incontinence based on when it occurs and to a lesser extent, how much urine is lost.
Stress Incontinence
Stress incontinence is what most people think of when they are thinking about incontinence. Stress incontinence typically occurs when the pelvic floor muscles are not strong enough or coordinated enough to counteract increased intraabdominal pressure during activities like coughing, laughing, or sneezing as well as during sports like weight lifting or running.
When addressing stress incontinence, we first must examine the pelvic floor muscles. Both over-tight and overstretched muscles can lack the appropriate strength to keep us dry during these high-demand activities. Additionally, it is important to assess the movement itself if you are leaking during sport to determine if modifications or changes in technique need to be made to reduce the pressure coming from above and reduce the workload on the pelvic floor muscles.
Urge Incontinence AKA Lock-in-Key
Urge incontinence, as the name implies occurs when there is urine loss following a strong urge to urinate. A typical experience of someone with urge incontinence would be, driving home not having to pee at all, but when you turn onto your street and see your house, you are met with the overwhelming urge to urinate sometimes accompanied by urine loss. As we have discussed, the urinary sphincters and the detrusor have a reciprocal relationship. If you are experiencing urge incontinence, sometimes a quick and gentle contraction of the pelvic floor ( a Kegel) can help to buy you time to make it to the bathroom. We don’t want to be doing this all the time, but it can be really helpful in a pinch. We can address urge incontinence more fully in formal pelvic floor physical therapy, but this is a great place to start!
Mixed Incontinence
Sometimes you can experience both stress and urge incontinence. In this case, we like to take a divide-and-conquer approach by treating the urge incontinence first before moving on to addressing the stress incontinence. By treating the urge incontinence first, we can improve the bladder’s reactivity and make treating stress incontinence much easier.
Post-Void Dribble
Post-void dribble occurs in all genders but is particularly burdensome in individuals with male anatomy, secondary to the urethra being longer in folks with male anatomy. Post-void dribble occurs when you leak a small amount of urine following a trip to the bathroom. Post-void dribble often occurs when the pelvic floor is tight and causes small amounts of urine to become trapped in the urethra only to later dribble out onto clothing. This is particularly common in folks with male anatomy
Other Bladder Symptoms
Frequency
“You should be able to sit through the film, Titanic, without needing a restroom break.” This adage was something I heard countless times during my education as a pelvic floor physical therapist. I may have uttered this phrase more than once when teaching budding physical therapists myself. Honestly, it’s true if you skip the opening and closing credits. At about 3 hours, Titanic’s run time is at the end of the daytime capacity of most human bladders, with the typical range being 2-3 hours between bathroom trips. If you are finding yourself having to pee over 8 times a day or more than every 2 hours you may be experiencing urinary frequency. An important caveat to note is that if you have consumed a diuretic like coffee or alcohol, or have consumed heaps of water at once, it is perfectly normal to have increased frequency in the hours to follow. That said, if your urinary frequency is distressing and taking from your quality of life, you can address it in physical therapy both with standard urotherapy and pelvic floor-specific interventions.
Nocturia
Nocturia is a type of frequency. Nocturia is a fancy way of saying waking up to pee at night. Waking up to pee more than 1 time at night is the clinical definition of nocturia. Typically, if you are under 65, we like to see you sleep through the entire night ( about 6-8 hours). You can imagine nocturia can be annoying, but beyond that, it can have really serious consequences in terms of health-related quality of life. A Finnish study actually found that health-related quality of life worsens with increased average night-time voids in people with nocturia. Additionally, nocturia is associated with an increased risk of hip fracture. Getting to the bottom of the cause of nocturia is really important as it can be a very treatable condition.
Hesitancy
Hesitancy occurs when you have trouble initiating urination. Oftentimes, you may also encounter a weak or sporadic stream of urine. Hesitancy can be tremendously frustrating, painful, and frightening. Pelvic floor dysfunction can cause hesitancy secondary to the reciprocal relationship between the detrusor and the pelvic floor. If the pelvic floor is unable to relax it can be very difficult to pee. Additionally, the stress and panic of not being able to pee can increase sympathetic tone which keeps the detrusor from squeezing and the internal urinary sphincter from relaxing.
Bladder Pain
Most of the folks who come to pelvic floor physical therapy for bladder pain have a history of feeling confused when their urinary tract infection (UTI) test results come back negative at their doctor’s office. Pelvic floor caused bladder pain can feel exactly like a UTI. You can be left feeling like it’s all in your head. I assure you that it is not. The fascia that surrounds the pelvic floor can radiate pain to the bladder when it is tight which can contribute not only to symptoms of pain but the other symptoms listed above. Additionally, this tight fascia can also give a burning sensation with urination.
You may also experience pain as your bladder fills, driving you to urinate more often than you actually need to. In this case, the pelvic floor can be a culprit in addition to possible sensitivities to what you are ingesting. I will include more thoughts on this below in the solution section. If you have bladder pain I strongly advise against Kegels until you meet with a certified pelvic floor rehabilitation specialist.
Practical Solutions
This is the part we have all been waiting for! Practical solutions for bladder issues. Remember that we are all very complex individuals and not all of these solutions may be right for you. I highly recommend them as a jumping-off point to discuss with your physical therapist or healthcare professional.
See your Doctor
If your symptoms are new and you haven’t already done so, see your doctor. Sometimes it’s a very easy solution and going to your doctor can save you time and pain as well as rule out anything potentially more serious.
Fill Out a Bladder Diary
A bladder diary is one of the first-line interventions for bladder problems across healthcare specialties and is an important component of standard urotherapy. It allows us to track fluid intake, and voiding behavior and allows us to make recommendations to improve your symptoms. Though it is absolutely not necessary, by filling out a bladder diary before your visit you get a jump on an assignment you are likely to get from either your doctor or pelvic floor clinician and you can get feedback at your very first visit.
Here are my recommendations for filling out your bladder diary:
Count the duration of your urination by using the “ 1 Mississippi, 2 Mississippi” counting technique. We should see normal voids of at least 8 seconds with a strong flow
Record on a busy day and a not-so-busy day. This will allow us to see how distraction and stress affect your voiding habits.
Record how much you are drinking in ounces or milliliters. This can provide a really helpful jumping-off point, in terms of modifying fluid intake if necessary.
I personally really like this bladder diary here.
Investigate Bladder Irritants
This is where I will first urge you to self-reflect. For some of us with restrictive eating histories, this may be something that you chose to have professional guidance on or decide to skip for now. Be safe and be gentle with yourself.
Some foods for some people can increase bladder pain and symptoms. It is really important to remember that one food may irritate one person but not necessarily the next. Below I have included a list of bladder irritants. If you chose to review the list, decide if any of the foods listed seem like likely culprits. If you see a suspicious item, avoid it for a day and then reintroduce it. If you experience bladder symptoms within 3 hours or so, it may be a bladder irritant for you. I would not recommend associating any bladder symptoms in the days following ingesting a potential bladder irritant with that specific irritant.
Common Bladder Irritants ( Source: Johns Hopkins)
Alcoholic beverages
Apples and apple juice
Cantaloupe Carbonated beverages
Chili and spicy foods
Chocolate
Citrus fruit
Coffee (including decaffeinated)
Cranberries and cranberry juice
Grapes
Guava
Milk Products: milk, cheese, cottage cheese, yogurt, ice cream
Peaches
Pineapple
Plums
Strawberries
Sugar especially artificial sweeteners, saccharin, aspartame, corn sweeteners, honey, fructose, sucrose, lactose
Tea
Tomatoes and tomato juice
Vitamin B complex
Vinegar
Don’t Push
As we discussed earlier, pushing to pee can result in dysfunctional voiding and place strain on your pelvic floor muscles and pelvic organs. Remember stress can make it more difficult to pee. If you are experiencing chronic hesitancy try deep slow breathing to activate the parasympathetic nervous system to help with bladder emptying. Remember new onset hesitancy should be investigated by a doctor.
Don’t Just in Case Pee
We all do it. Even pelvic floor physical therapists will engage in the occasional just in case pee. Just in case peeing or (JICing) means peeing when you don’t have to so you don’t get interrupted later. Our bladders are smart and can be easily trained. If you regularly go to the bathroom when you don't have to go, your bladder will learn to send the signal to pee way earlier than it needs to. Avoid making JICing a regular habit.
Manage Constipation
The bladder and rectum are next-door neighbors. Folks who become constipated will have excessive pressure on the bladder from retained stool, potentially increasing pain, frequency, urgency, and leakage symptoms. In pelvic floor physical therapy, we will treat constipation first and often find that resolving constipation goes a long way toward resolving bladder issues.
Don’t Put It Off
Though bladder symptoms can be distressing, they can be treated. The quicker you get to treatment the easier it is to get rid of those pesky bladder symptoms.
If you are experiencing bladder issues call or email to arrange your free 15-minute phone consultation: 551- 244-1186 or Fiona@emebrphysicaltherapy.com with me, Fiona McMahon PT, DPT, PRPC
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