Hey, Bestie. Let’s talk about urinary incontinence. It’s probably a term you’ve heard before, but you might be surprised by all of the nuances that go along with it. In fact, while it may seem fairly specific, urinary incontinence describes a wide variety of potential symptoms. In this post, we will talk about what urinary incontinence is, the different types of potential UI, and different treatments that have been shown by research to improve each type of urinary incontinence. Here we go!

Let’s start with some basic bladder anatomy. The bladder is really a muscle, called the detrusor. The way the bladder functions is by contracting when it wants to expel urine, and relaxing when it wants to fill with urine. The ureters deposit urine into the bladder and the bladder holds the urine until it is time to get rid of it (aka pee). The bladder is connected to the urethra, which is the pathway urine uses to exit the body. The detrusor muscle is innervated by spinal nerves, and these nerves, in the simplest terms, tell the muscle when to contract and when to relax.

What is Urinary Incontinence (UI)?

Urinary incontinence, or UI as we will abbreviate from here on out, is the involuntary loss of urine. This means urine is leaked out of the urethra when it should not be. Urine can leak out in small amounts of only a couple drops, it can leak out in medium amounts that might soak the underwear, and it can leak out in large amounts, releasing the full contents of the bladder. The main types of UI include stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and overflow incontinence. We will take a deeper look at each of these types below.

There are many reasons for UI, and not all of these involve the pelvic floor. For example, one reason someone is incontinent could be due to a spinal cord injury. For certain spinal cord injuries, the nerves the innervate the detrusor muscle are affected, causing there to be an inability to regulate the action of the muscle. However, many types of UI are related to the pelvic floor and its relationship with the bladder. We will be focusing on these in this chat.

What is Stress Urinary Incontinence (SUI)?

Stress urinary incontinence, SUI from here out, is the involuntary loss of urine due to an increase in intraabdominal pressure. Basically, the pressure inside the abdomen that presses on the bladder is greater than the forces keeping urine from leaking out. The pelvic floor muscles and the urethra are both involved in keeping urine inside the bladder until it is time to urinate. This leakage could occur during activities such as laughing, coughing, sneezing, running, or jumping. Note that, this type of incontinence is due to a physical stress or pressure placed on the bladder, and not related to emotional stress.

To really understand this, let’s take a closer look at the anatomy of the pelvic floor. The pelvic floor is not just one muscle, but a group of muscles that form an almost-bowl-shaped structure within the pelvis. They function by squeezing together while also lifting upwardly and anteriorly, or toward the pubic bone.

The pelvic floor muscles are not the strongest or biggest muscles in our bodies, but they’re some of the most important. They have a multitude of functions, one of which is helping us to maintain urinary continence. Hold on—what does the pelvic floor have to do with our bladder—aren’t they two different things? Great question. The pelvic floor and bladder are completely separate structures, but they work together a lot of the time.

Let’s go back a couple of steps. During typical activities, the urethra generally provides enough pressure to maintain continence. This means, the resting pressure of the urethra holding itself closed is more than the pressure of the fluid-filled bladder. Because of this, the inside pressure doesn’t override the outside pressure, so nothing escapes or leaks. However, during activities that cause increased intraabdominal pressure, the pelvic floor can help to provide even more outside pressure, by placing pressure on the urethra, so that, again, nothing leaks out. When the pelvic floor is weak, tight, or otherwise dysfunctional, it may not be able to place this same pressure on the urethra, which may result in SUI.

If you are suffering from SUI, you may have pelvic floor weakness, pelvic floor dyscoordination, pelvic floor tension, or another type of pelvic floor dysfunction. We’ll discuss treatments for each type another time.

It should be noted that while SUI is common, it is not normal. Any type of urinary leaking can be treated and you should see a pelvic floor specialist to find out where the problem is coming from. Your doctor may or may not recommend pelvic floor physical therapy, so be sure to ask for a referral if you have any symptoms of UI. Most states also offer direct access to physical therapy, which means you can see a physical therapist without first getting a referral from your physician (insurance-dependent).

What is Urge Urinary Incontinence (UUI)?

Urge Urinary Incontinence, or UUI as we will refer to it from here on, is the involuntary loss of urine due to a feeling of urgency, or just not being able to hold the urine in any longer.

Imagine this: you’ve just had a two-hour drive home from a friend’s house. On the way, you picked up a venti iced latte from Starbucks (obviously), and guzzled it down in 12 minutes flat. You’ve been feeling fine this entire car ride and barely notice your bladder starting to get full. However, the second you go to unlock your front door, you feel an overwhelming sense of urinary urgency and you aren’t sure you are going to make to the toilet in time. Maybe you’re racing to pull your pants down and swearing to yourself “Why the f*** didn’t I wear a dress today?” This is urinary urgency. If you had lost any urine involuntarily prior to making it to the toilet, that would be UUI.

There is a whole slew of reasons you might be experiencing urinary urgency. One common reason for a sense of urinary urgency is urinary tract infection (UTI). If you notice a new onset of urinary urgency with potentially painful urination, it is a good idea to get checked out by your medical doctor before starting physical therapy to rule out UTI or receive the medication necessary for treating UTI. Other reasons for urinary urgency and UUI can include issues relating to the pelvic floor muscles, the bladder muscle, nerve abnormalities, and more.

We will chat about physical therapy for urinary urgency another time because I’ve got a lot to say about it and I want to make sure we have time for all the deets.

What is Mixed Urinary Incontinence (MUI)?

Mixed urinary incontinence (MUI) is a form of urine leakage that includes both SUI and UUI. If you lose urine during periods of increased intraabdominal pressure, as well as due to a feeling of overwhelming urinary urgency, you likely have MUI.

How is it treated?

MUI can be treated in physical therapy, just as SUI or UUI would. Since it is a mix of SUI and UUI, the treatment will likely consist of any combination of the treatments for those types of incontinence. This could include pelvic floor muscle strengthening or relaxation training, biofeedback training, breathing techniques, coordination activities, stretches, and core/hip strengthening exercises. You might also use a TENS (transcutaneous electric nerve stimulation) unit or your therapist may perform manual therapy. The treatment will be specific to your symptoms and the root cause of your symptoms.

What is Overflow Incontinence?

Overflow incontinence occurs when there is too much fluid in the bladder for the bladder to hold it all. In this case, the urine in the bladder leaks out through the urethra because the bladder is at maximum capacity. When and how does this happen? To better understand, we need to go back to the topics of normal bladder capacity, normal fluid intake, and normal daily voids.

You should void 6-8 times per day; in other words, you should be urinating 6-8 times per day. Appropriate fluid intake is one half ounce of fluid for every pound of body weight. Remember, fluid you get from your food (watermelon, cucumber, soup) counts toward your total fluid intake. If you are exercising/sweating or breastfeeding, you will need to factor in more fluid to make up for fluid lost to breastmilk or sweat. In summer months when you are sweating more, you will likely need a higher intake of fluid.

Every bladder is unique, but the average bladder capacity is 300-600 mL or about 16 oz of fluid. This means your bladder can hold about 2 cups of fluid before it has to expel urine. Typically, you will experience the urge to urinate when your bladder is filled with about a cup (240mL) of urine.

If the amount of fluid exceeds the entire capacity of the bladder, this is when overflow incontinence can occur. This could result from having difficulty emptying the bladder, such as in cases of an enlarged prostate. It could also occur if you are not using the bathroom frequently enough throughout the day. If you are regularly drinking 64oz of fluid per day, but only urinating 2 times per day, you may experience urinary leaking related to overflow.

Finally, this can occur when one loses the ability to sense the need to urinate. As we have discussed previously, as the bladder fills, it sends signals to the brain, letting you know it is time to pee. When the brain receives this message, it tells you to get to a bathroom in order to eliminate. Occasionally, the nerves that signal the brain of a full bladder do not function properly. In this case, one will not realize they need to eliminate, and this can result in exceeding the bladder’s capacity. This can occur in certain neurological conditions where the nerves are affected.

How is it Treated?

Overflow incontinence may be treated in different ways depending on the cause. If this type of incontinence is occurring is related to bladder and toileting habits, a toileting schedule may be implemented. This would force the patient to use the bathroom at least once every 4 hours in an attempt to avoid too much accumulation of fluid in the bladder. Something similar to this may be implemented in patients with busy schedules that have a difficult time getting to the bathroom regularly (ie nurses, teachers) or in patients that are not receiving a signal to urinate (ie those with neurological conditions).

If the OI is related to a neurological condition and poor nerve sensitivity, the therapist might try using a TENS unit to help stimulate the nerves of the bladder to improve their nerve sensitivity and therefore improve signals to the brain. Your therapist will also likely provide you with a bladder diary to fill out to get a better sense for your fluid intake and toileting habits. It is probable that some combination of the above treatments will be provided during physical therapy treatment.

As you can see, urinary incontinence is more complex than it seems on the surface. This is why just doing as many kegels as you can per day will not fix urinary incontinence. It is absolutely essential to talk with your doctor or physical therapist about the reason behind your urinary incontinence so that you can get the treatment that is right for you.

Can’t wait to talk again next time.

XOXO,

Your Pelvic Bestie

*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.

Urinary Incontinence