Urge Urinary Incontinence

Today, we’re talking about how Urge Urinary Incontinence (UUI) is treated. Before we get started, let’s review UUI. UUI is the involuntary loss of urine due to a feeling of urgency, or just not being able to hold the urine in any longer. Still not sure what I’m talking about? Check out this post for more info.

How is it treated?

UUI can be treated using a multidisciplinary approach, just like many other pelvic floor dysfunctions. It is important to first recognize the things that may trigger urinary urgency. For example, do you notice urgency come on shortly after drinking your morning coffee, even though you just peed when you woke up? Being mindful of triggers can help you to figure out what to work on. One way to hone in on your triggers is to fill out a bladder diary.

Another essential part of rehabilitation for urinary urgency or UUI is behavior training. Believe it or not, our actions affect our bladder, and sometimes these actions affect it negatively. Ideally, you should urinate 6-8x per day and 0 times at night (or max 1-2x per night if you are over 60-70 years old).

Each urination should be 2-4 hours apart. If you are urinating, for example, every hour, you are training your bladder to be unable to fill for the full 2-4 hours before needing to empty. This may not be an issue now, or even for years, but over time poor bladder habits will affect your bladder health.

This is another reason filling out a bladder diary can be a helpful tool. You may think you pee 6x per day, but when you fill out the bladder diary, realize you really urinate 9-10x per day. Research shows filling out the bladder diary for 3 days will provide you with a fairly accurate representation of your usual habits (1).

It is also important to avoid urinating “Just In Case.” We call this “JIC-ing,” and it is one of the ways folks unknowingly train their bladders to do the opposite of what we want them to do. If possible, avoid JIC-ing, especially if you suffer from urinary urgency or UUI.

If you notice you urinate frequently (ie more than 8x per day), you can use techniques to decrease the urge to urinate, and improve your bladder habits. These urge suppression techniques will be taught to you in your physical therapy sessions, but include things like fast pelvic floor muscle contractions, distraction, deep breathing, and putting pressure on the space between your legs, called your perineum. Over time, you will develop a more normal voiding schedule and you may not need to use these techniques. If your symptoms return, you can return to use of urge suppression techniques. They are simply tools in your tool belt of ways to fight urinary urgency and UUI.

Next, it is critical to assess your fluid intake habits. Often times, when folks are dealing with any type of urinary incontinence, they restrict their fluid intake in an effort to decrease urinary leakage. Unfortunately, this can do more harm than good. When fluid intake is restricted, the fluid that ends up making it to the bladder is highly concentrated and acidic. This acidic urine is irritating to the bladder, and can cause the detrusor to want to get rid of it—in other words, it can increase incontinence because the bladder just wants to get that acidic fluid out.

Drinking enough fluid, and the right kinds of fluid, can make a big difference in symptoms. Generally, it is recommended that you drink half an ounce of fluid for each pound of your body weight. For example, if you weigh 150lbs, you should be drinking 75oz of fluid per day. (I never realized until just now how American a statement that is—sorry everyone else who doesn't use the imperial system). I typically think a good goal to start with is 64oz of fluid (8 glasses) per day. If you are working out and sweating a bunch, or breastfeeding, take this into consideration and drink a bit more to match what you’re losing.

So, what should you be drinking? Ideally water. Yes, literally just water. I know it is about as boring as it gets, but if you are experiencing bladder issues and you regularly drink things like coffee and soda, changing the fluid you drink can make a big impact. Things like carbonation, coffee, soda, and tea can irritate the bladder. When the bladder is irritated, you are more likely to experience symptoms of urinary urgency and UUI. Many times, when I tell people this, they tell me they don’t want to give up their diet coke, or their regular morning coffee. I get that! I wouldn’t expect you to give up your daily joy. Instead, try to figure out if there’s any way you can reduce your intake of bladder irritants (ie 1 morning coffee instead of 2) and try to alternate with water as much as possible.

Finally, urinary urgency and UUI can be treated with dietary modifications. There are tons of foods that can cause irritation to the bladder. Of course, they’re some of the yummiest foods (strawberries, chocolate)—don’t blame me, I didn’t make the list! If you suffer from UUI, it is worth looking at your regular diet and noting whether any of the foods you are eating often are known bladder irritants. If you cut out a bladder irritant from your diet and notice no difference, then that particular food might not have been causing symptoms. If that’s the case, then it should be fine to add that food back in. Just because there are a bunch of foods on the bladder irritants list, doesn’t mean you can’t eat any of them—it’s simply a starting point to notice things that could be bringing on your symptoms. If you notice urgency every time you eat strawberries, however, this might be a food you try to avoid.

UUI related to bladder overactivity:

We’ve all heard about overactive bladder (OAB). I think when you google “urinary urgency,” OAB must be one of the first results because, as a clinician, when patients come to see me for urinary urgency, they often start by telling me they have OAB. Much of the time, this isn’t the case. However, sometimes it is, so let’s talk about it!

We have discussed previously how the bladder is made out of a muscle—the detrusor muscle. Normally, when the bladder is relaxed, it is able to fill with urine. When it is time to urinate, your brain will send a signal to the detrusor to tell it that it is time to pee, and the detrusor will contract (squeeze) to push out the urine. However, with OAB, the bladder muscle may spasm as the bladder is filling, giving you the sensation that you have to pee. This might lead you to urinate increasingly often (maybe even every 15 minutes), or it might lead you to experience UUI.

In order for the bladder to fill completely, the detrusor needs to be able to stay relaxed. Bladder overactivity can be treated in pelvic floor physical therapy. The nerves that innervate the detrusor muscle also innervate the muscles of the pelvic floor. In pelvic PT, your therapist might teach you how to draw attention to the pelvic floor muscles in an attempt to use them to calm the overactivity of the bladder. Research shows that strong and fast contractions of the pelvic floor muscles will send a nerve signal to the bladder helping it to calm down (2). In physical therapy, you might also talk about the use of a TENS unit (rumor has it that RuPaul was nodding to pelvic PT when she said “TENS across the board”).

TENS Across the Board (source)

 A TENS unit stands for “Transcutaneous Electric Nerve Stimulation” unit. When dialed to specific settings, and placed in the correct spot, the TENS unit has been shown to reduce over activity of the bladder. In fact, it has been shown to work just as well as more invasive procedures such as PTNS (posterior tibial nerve stimulation) (3). The electrical pads for the TENS unit can be placed over the sacral spine, above the pubic bone (ie over the bladder), or along the lower limb (see graphics below).

Please note that the TENS unit should not be used in those with certain conditions including pacemakers, active cancer, and more, so it is imperative that you talk with your provider prior to initiating this treatment. My favorite TENS unit can be found on Amazon for $30, though the pads and batteries will need to be replaced every so often. Once you get the TENS unit up and running, you’ll use it daily for 30-60 min—it is one of the few passive physical therapy treatments that works well.

Finally, for bladder over activity, your medical doctor might prescribe you a medication. This could be Ditropan (oxybutinyn), Detrol (tolterodine), myrbetriq (mirabegron). Each of these treat urinary frequency (peeing a lot), urinary incontinence, and urinary urgency. However, they are not all created equal. Each of them comes with side effects that lead most folks to stop taking them after about 1 year of use. They target different things, so the side effects can vary depending on the type of medication you are taking.

The best, (and by that I mean the one with fewest side effects) in my experience, seems to be Myrbetriq. However, it is also the most expensive of the medications, which is a barrier for many. Taking oral medication for urinary urgency or UUI can be a great starting place and very effective, but research shows it works best when combined with pelvic floor physical therapy (4). So, if your medical doctor prescribes you one of these meds, make sure they’re also prescribing you a bout of PT—it’s best practice!

UUI related to tight pelvic floor muscles: 

Occasionally, tightness in the pelvic floor musculature can worsen your urinary urgency. Let us recall the way the pelvic floor muscles work. They are at a constant state of slight contraction to aid in continence. They contract and lift when there are times of increased intraabdominal pressure and they relax and lengthen during urination. If the pelvic floor muscles are “tight,” they may be pressing on the bladder and causing an increase in pressure on the bladder. This can then lead to worsened urinary urgency or even UUI. The bladder likes to have freedom to expand and contract as necessary, and urgency can occur when this freedom is compromised.

Similarly, if you have increased lower abdominal scarring from a laparoscopic surgery or cesarean section, this increased scar tissue can impede the regular movement of the bladder and cause urinary urgency. If your therapist determines your urinary urgency and UUI is related to pelvic floor tightness, you will likely work on exercises that emphasize pelvic floor muscle lengthening, stretches, and potentially even the use of vaginal dilators.

If you are suffering from urinary urgency or UUI, talk with your healthcare provider about what steps to take to combat your symptoms. There are so many possible treatment strategies which means there is definitely something out there for you. You’ve got this!

XOXO,

Your Pelvic Bestie

References:

1. Cameron AP, Wiseman JB, Smith AR, Merion RM, Gillespie BW, Bradley CS, Amundsen CL, Yang CC, Lai HH, DeLancey JOL, Helmuth ME, Bradley MS, Agochukwu N, Andreev VP, Kirkali Z, Clemens JQ; LURN Study Group. Are three-day voiding diaries feasible and reliable? Results from the Symptoms of Lower Urinary Tract Dysfunction Research Network (LURN) cohort. Neurourol Urodyn. 2019 Nov;38(8):2185-2193.

2. Adélia Correia Lúcio, Christiane Boaventura Lourenço, Benito Pereira Damasceno, Maria Helena Baena de Moraes Lopes, Carlos Arturo Levi D’ancona. The effect of pelvic floor muscle contraction on detrusor overactivity pressure in neurogenic and non-neurogenic women during urodynamic study. American Journal of Physical Medicine & Rehabilitation, 2018; 1

3. Ramírez-García I, Blanco-Ratto L, Kauffmann S, Carralero-Martínez A, Sánchez E. Efficacy of transcutaneous stimulation of the posterior tibial nerve compared to percutaneous stimulation in idiopathic overactive bladder syndrome: Randomized control trial. Neurourol Urodyn. 2019 Jan;38(1):261-268.

4. Burgio KL, Kraus SR, Johnson TM 2nd, Markland AD, Vaughan CP, Li P, Redden DT, Goode PS. Effectiveness of Combined Behavioral and Drug Therapy for Overactive Bladder Symptoms in Men: A Randomized Clinical Trial. JAMA Intern Med. 2020 Mar 1;180(3):411-419.

 *The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a qualified health provider regarding any questions you may have about a medical condition or health objectives.