People call. They are embarrassed that they have leakage. They are concerned that the only solutions are medications, surgery, or giving in and wearing pads. They are tired of not doing activities, or are tired of having leakage with activities. They want answers and solutions to what is a common….but not normal…problem!
When we begin the discussion, we should talk about what CONTINENCE is and how the urinary system team works!
Continence is about storage and then determining WHEN to void or empty (you deciding…not the urinary system!). It’s about not leaking urine! In a nutshell, here’s how we would like to see it work:
- The bladder fills with urine from the kidneys. The bladder (detrusor) is a distensible muscle; it relaxes as it fills.
- As the bladder fills, the urethra remains closed and there is higher pressure in the urethra than in the bladder. This pressure increases during activities like laughing and sneezing, and with active contractions of the pelvic floor muscles. The urethra responds and holds, preventing leaks.
- First urge in the bladder as it fills occurs at around 40% full (approximately 200ml). Typically, you are able to manage or turn down this urge and allow the bladder to continue to fill.
- When your bladder is filled to about 75% (350-500ml of urine), the bladder stretch signals turn on, giving a strong urge to urinate (and when the system is working ideally…no worries! You are able to get to the bathroom and empty!).
Here’s what happens when you void/empty the bladder:
- You get to the appropriate location. You SIT or SQUAT (note…NOT hover)
- The pelvic floor and urethral sphincters relax
- The bladder does some great stuff, creating a funnel at the base into which the urine flows.
- The bladder contracts, the urethra opens and urine flows until the bladder is empty (it does not require straining or pushing…so PLEASE don’t!!)
- The bladder muscle relaxes. Urethral closure pressure is restored, the bladder returns to resting state and begins to fill again.
Additionally, the Autonomic Nervous system plays a role in continence, and we have sensory control as well as somatic (via spinal nerves), all communicating with the micturition centers (yes, more than one area) in the brain.
Cool, right? All of thisallows us to not leak with activity, with breathing/coughing/sneezing, and to be continent while we sleep!
So if this is continence, what is Urinary INCONTINENCE (UI)? ?
There are MANY reasons for and descriptions of UI, but the ones that I see most frequently in clinic are:
- Stress UI. Defined as involuntary loss of urine on effort, exertion, cough, sneeze, laugh and more. “I laughed so hard I peed.” Common. Not normal.
Stress UI can occur for many reasons, but the short story is the inability of the urethra to close adequately. It might be limited after birth injury to the pelvic floor (think long pushing stage, assisted delivery, tear or episiotomy, large baby), habitual and strong straining with lifting or with constipation, changes in hormonal levels with menopause and more. It’s a support problem. And one that we can address!
- Urge UI. Defined as the report of leakage at the same time as or immediately after a strong desire to void. Simply, you feel like you must pee, and are unable to control or manage the urge and subsequent leakage. This can be contributed to by medications and by chemicals such as caffeine (sorry!), voiding habits such as “go just in case” (nope…not a good habit!), and more. Again, something that we can treat!
- Mixed UI. Stress and Urge occurring together. Many of the same concerns can contribute to Mix UI. You are concerned about leakage, so you begin to go “just in case” thinking that you will leak less (often not). The bladder learns to not do it’s job. So many things may contribute to Mix UI! Yep, sometimes in addition to exercise, we work on habits and retraining the messages between the body and the brain.
- We also see “overactive bladder”, Frequency, pain with urination, and more. You should not feel that you must live with them. There are solutions.
Why is this important? For so many reasons!
- UI is estimated to affect at least 14 million women!!! Up to 69% of women report having incontinence of some type (and that is the REPORTED numbers. How many are not asked or are embarrassed to say?)
- UI is expensive! Pads and protection can range from approximately $18 to more for a package of 30! The medical cost of UI related to infections and injuries is also high (Incontinence is a leading contributor to falls).
- UI takes the fun out of life! People with UI often limit their social activities. It has been reported that over 1/3 of the women who begin a gym program or class stop because of fear of leakage. AND no one wants to be the person who doesn’t go out if no bathroom, OR who knows where every bathroom is!
YOU should be in charge of your life, activities, and schedule. NOT your bladder and pelvic floor!
The good news is that all of the types of incontinence that I describe above are treatable. Often with conservative methods. Without medications or surgeries. And without fancy gadgets and equipment that you might see advertised!
The key to effective treatment?
- Having a clinician spend time with you to do a thorough history. What is going on? When are you experiencing this? What have you tried? What has worked or not worked. AND what are your goals? Not leaking getting up from chair or the floor, not leaking while swinging a gold club… or lifting a child….or to be able to swim without fear of leakage. What is it you aren’t happy about?
- Examination of the pelvic floor, core, diaphragm and how you are moving and breathing.
- UI is NOT a matter of “just do kegels”! It is a storage and pressure system issue. We need to determine what is not working as effectively as we would like and make changes. That means noting pelvic floor strength, tissue integrity, tension, stiffness, and laxity. Exercise, posture and positions, habits, soft tissue mobility all can make a difference. Your PT might utilize Rehabilitative Ultrasound to visualize the pelvic floor muscles and bladder from the outside in. This is a form of assessment, retraining, and biodfeedback to re-educate your bladder, pelvic floor, and core. (We utilize this at Embody.)
- And although I did not mention it in descriptions above, constipation and bowel habits can contribute to UI
- Communication with your PT.
***And seeking treatment. UI does not go away on it’s own. We want you to do the things you need to do and that you love without fear of “gotta go”, leakage, or not drinking fluids!
This IS a cool system! Let’s get yours working more efficiently for YOU!
Embody Physiotherapy & Wellness is a physical therapy practice that specializes in the care of people with pelvic floor, core, spine and mobility concerns. Rebecca Meehan PT WCS PYT is the founder and owner of Embody. I treat various forms of UI, pelvic pain, pelvic organ prolapse and more, helping my patients and clients return with confidence to life, lifting, running and jumping!
You can reach me at email@example.com or 412-259-5342
This was written about Female Incontinence. We work with people of all genders as ALL can have problems or concerns with UI. Please ask!
If you are in search of a PT in your area who specializes in Pelvic Floor and Bladder, you may use these search tools to assist you:
APTA: https://aptaapps.apta.org/APTAPTDirectory/FindAPTDirectory.aspx (use pelvic health as a filter)
Pelvic Guru: https://pelvicguru.com/directory/
Pelvic Rehab: https://pelvicrehab.com/ Note that therapists who have completed specialized training through this program are listed first. That does not mean that the others are not qualified; they have done their specialized training elsewhere.