I Really, Really, Really, Have to Pee…Oops I Peed

There are several types of incontinence including:  stress, urge, overflow, functional, and mixed.  I have talked about stress urinary incontinence in females (The incontinence myth) and in males after prostatectomy, and I’m going to spend some time talking about urge and mixed urinary incontinence today.

Urge Incontinence

Urge urinary incontinence (UUI) is defined as the loss of urine that is associated with a strong, uncontrollable need to void.  Characteristically, the individual is unable to delay voiding and this loss of urine can be small or large.   Similarly, individuals can have urgency (I’ve got to go now) and frequency (voiding more than eight times during waking hours), that is usually accompanied by night waking to void, that is either dry (no leaking), or wet (incontinence episodes).  This is commonly referred to as Overactive Bladder (OAB).  Clearly, both of these have a substantial negative impact on quality of life.  Mixed urinary incontinence (MUI) is urine loss with increases in intra-abdominal pressure (stress incontinence) and with an intense urge to void.

How the Bladder Works

To understand urgency a bit better, it’s important to have an understanding of how the bladder works.  The bladder is not only a reservoir to hold urine, but it’s also a muscle!!  If you think you have a small bladder; that does not at all mean you have to have a small bladder moving forward.  Just like your bicep, with some consistent dumbbell curls, that biceps grows in size—your bladder is trainable and modifiable too!!  Did you also know that there are tubes (ureters) that are always dripping urine from your kidneys into the bladder?  It’s just part of being human to never have a completely empty bladder:  there is always one to two ounces of fluid hanging out in there.  This amount of fluid, however, is below the threshold that we can sense.  In this storage or filling phase of continence, there is dominant influence from our sympathetic nervous system.  As the bladder fills, even with a little bit of fluid, there are stretch receptors in the bladder walls that notice fluid accumulating.  The sympathetic nervous system inhibits the activation of these stretch receptors because there is still so much room left in our bladder to accommodate more pee!  Unfortunately, for people with symptoms of urgency, the sympathetic nervous system does not do its job; and with even minute amounts of urine in the bladder, these people feel like they have to go NOW!

I have to pee!

It takes 4-5 ounces of fluid accumulation in the bladder to trigger a signal to the brain making you aware that you need to void.  BUT:  just because you could does not mean you should (“Just in case” peeing throws this whole system off).  The bladder is supposed to stay relaxed until it reaches a volume of seven to fifteen ounces (again, for people with urge symptoms, their bladder may begin contracting prematurely).  When this level is reached, there is a system in place to delay the need to go to the bathroom!  Two rings of muscle (known as urethral sphincters) around the urethra (tube that carries pee from your bladder to the outside) begin to contract harder to keep the pee inside your bladder.  One of these rings, called the external urethral sphincter is partially controlled by your conscious contraction of pelvic floor muscles, as these muscles comprise this sphincter.

I can’t delay

The next phase of continence is called the transition phase and it is all about your voluntary inhibition and postponement of bladder emptying.  People with urge incontinence notice a decrease length of time in this transition phase.

At last!

The last phase of continence is emptying.  At ten to twenty ounces of fluid accumulation, you must void at this point.  Now, instead of the sympathetic nervous system being dominant, the parasympathetic nervous system takes over.  The bladder and pelvic floor are always meant to work together in opposite function, and the timing of this coordinated effort makes all the difference!  To empty, the walls of the bladder contract while simultaneously the pelvic floor muscles and urethral sphincters relax and open.  So for those who have that “key in door” syndrome and just can’t seem to ever run fast enough to the bathroom, your pelvic floor muscles aren’t coming on at the right time or strong enough to fight against the improperly functioning reflexes and premature brain signals.

There’s Hope…and Help!

But, I have good news!   Your bladder is happy to learn how to work normally again!  You can retrain reflexes that signal when you actually have to go and you can strengthen muscles in your pelvic floor that keep your pee in your bladder until you are ready.  In the meantime, as you are building strength and coordination, you can also practice some techniques that will help to control and suppress that urge feeling.  Don’t let symptoms of urge get in the way of your life anymore.  A pelvic health physiotherapist would be more than happy to help you!  I urge you (ha-ha) to call Ireland Manual Physiotherapy for an assessment or check out Pelvic Health Solutions (www.pelvichealthsolutions.ca) to find a pelvic health physiotherapist near you!