Some people, particularly women, talk about having a “small bladder” or “weak bladder”.  It seems that they always need to use the bathroom more often than the people around them. Some formal terms related to this experience are:

• Urinary Urgency – the experience of an urgent need to go to the washroom on a consistent basis without accidental loss of urine

• Urinary Urge Incontinence – urinary urgency accompanied by accidental loss of urine on the way to the washroom

• Urinary Frequency – making frequent trips to the washroom often disrupting daily or work life 

• Nocturia – experiencing urgency and/or frequency at nighttime that causes waking from sleep.

• Overactive Bladder – urgency, frequency, and/or nocturia, with or without leaking, in the absence of a UTI or other obvious conditions.

But, what is a typical amount of washroom trips? How do you know if your habits are “normal” or not? 

For most people, peeing every 2-3 hours, or around 5-8 times during the day, is considered normal (depending on how long you are awake, fluid intake, work flexibility, etc).  For people above 50 years old, getting up to go pee once a night is considered typical.  Those under 50 years of age should be able to sleep through the night without having to wake to use the bathroom.

Another important thing: your bladder shouldn’t impact your function and quality of life.  People that experience urinary urgency and/or frequency often find themselves using mental energy to “map” out their life.  They memorize the right highway stops, use stores with available washrooms, plan errands around toilet availability, etc.   

In addition, they often struggle with certain triggers such as unlocking the front door when arriving home, hearing running water, walking by the washroom, and others.  They often experience increased anxiety around travel, outdoor activities, going out for meals out or movies.  Lastly, frequent sleep interruption and struggle with fatigue can be an even greater hardship on top of it all. In summary, urinary urgency and frequency can be frustrating, disruptive, and extremely limiting in various areas of life.

The good news is something can be done! Urgency and frequency symptoms do not necessarily come from a “small bladder,” but occur more often due to pelvic floor muscle dysfunction and bladder signalling dysfunction. 

1. Pelvic Floor Muscle Dysfunction

Your pelvic floor muscles (PFMs) are a group of muscles inside your pelvis that work to control bladder and bowel function, participate in sexual function, and provide support and control against forces through your body from gravity or movement. Your PFMs are related to your bladder in a few ways:

• The PFMs act as sphincters and close to hold in urine, stool or gas. Their performance plays a large role in your confidence getting to the washroom on time.
• The PFMs are part of the Bradley Loop Reflexes that control urinary function. A full relaxation of the PFMs stimulates the bladder to contract to squeeze urine out, and the ability for the PFMs to contract allows the bladder to stretch and fill. 

Essentially, the ability of the PFMs to contract and relax through their full range of motion helps bladder function and control.  Dysfunction occurs, for example, if your PFMs do not relax fully, which prevents the bladder from fully emptying.  Or, if your PFMs are not able to contract and hold against a filling bladder properly, the bladder may not fill well before you feel that initial normal cue to void.  Urine may leak as a result. 

2. Bladder Signalling Dysfunction

The other contributing factor to urgency and frequency symptoms is the bladder itself.  The bladder is a reservoir that is made up of an involuntary muscle called the detrusor.  Normally, as the bladder fills, the feeling of stretch against the bladder walls creates signals to your brain that results in a series of urges:

• At 4-5 oz or 150 ml, you feel the first warning urge (“I should look out for a washroom somewhat soon”), and it often goes away, especially if you ignore it or get distracted.
• At 7-15 oz or 200-450 ml, you feel the second warning urge and often need to voluntarily contract muscles to hold (“I should find a washroom shortly”). 
• As the bladder gets closer to full capacity, typically 10-20 oz or 300-600 ml, you feel an emergency urge and do everything you can to hold it (“I’m going to pee my pants if I don’t get to the washroom now”). 

Dysfunction occurs when this series of signals gets mixed up between your brain, bladder and PFMs – ie. the bladder thinks it’s full when it’s not, or certain warning signals are skipped.   This altered signalling can be due to prolonged, repetitive patterns like going “just in case”, or holding behaviours where urges are ignores.  Both these habits override and disrupt the typical signalling and warning patterns that regulate normal sense of urge. 

Altered signalling may also be due to frequent heavy lifting, chronic coughing, chronic straining with constipation, abdominal surgery (including c-sections and “tummy tucks”), and/or birth trauma, all of which can cause nerve compromise.

Regardless of your symptoms, the cause, or the severity, there are a few things to consider:

• Behaviour: What are your learned patterns around going to the washroom? Does your job impact your ability to respond to urges? Do you often go “just in case”? Do urges feel like a light warning or an emergency?

• Water Intake: The fluid in your bladder can impact bladder muscle contractions. If your urine is very concentrated, the lining of the bladder gets more irritated and sends urgency signals to remove it from the body. Drinking adequate water dilutes your urine, making it less irritating for the bladder lining. While it is counterintuitive to drink more water when you feel like you are peeing all the time, withholding water can actually make urgency and frequency worse

• Food and fluids: Some foods and fluids can be irritating for the bladder lining, including caffeinated and carbonated beverages, citrus, tomato, artificial sugars or food colouring. This doesn’t mean you cut everything out at once, but it may be worth looking more closely at what you take in and what your body is processing.

• Stress / Anxiety: In addition to the emotional, mental, or spiritual impact of stress, our body also has a physiological response, which often includes holding tension in our jaw, shoulders, back, fists, stomach and the pelvic floor.  If you are struggling to cope with stress, identify as a more “wound up” person, or experience high anxiety around the washroom, your PFMs are likely impacted.  Breathing exercises, stress management strategies, mindful practices like yoga, prayer/meditation, or certain types of movement and exercise can be helpful, both generally and specifically to your PFMs.

Pelvic health physiotherapy can often help and/or resolve urgency and frequency through:

• Assessing the state of your pelvic floor muscles and prescribing the right type of treatment. Kegels are not always the answer, and can sometimes make things worse.
• Assessing the state of other tissues (fascia, scars, muscles) related to PFM function in your abdominal wall, hips, and inner thighs and restoring normal function.
• Discussing ways to change altered signalling of the bladder, improving flexibility of the bladder muscle to expand and contract, and addressing any negative contribution of the nervous system to the bladder and PFMs.
• Examining fluid and food intake to reduce irritation that may be contributing to urgency and frequency related symptoms.

We at The Mama’s Physio would consider it a privilege to help you live a life where you are in control of your bladder rather than the other way around.

By Sophia McLean – PT, DPT

Sources:

Forget, Marie-Josee and Sheila Zelmer. “Level 1: The Physical Therapy Approach to Female and 

Male Urinary Incontinence.” Pelvic Health Solutions. Vaughan, ON, May 2019.

Montiero, Silvia, and Cassio Riccetto, Angelica Araujo, Laryssa Galo, Nathalia Brito, Simone 

Botelho. “Efficacy of pelvic floor muscle training in women with overactive bladder syndrome: a systematic review.” International Urogynecology Journal 28 no. 11 (2018), 1565-1573.