Bladder (or urinary) urgency can be a very annoying problem. It is defined as a sudden and very strong need to urinate that cannot be delayed, and it may or may not be accompanied by leakage of urine. It is sometimes called ‘overactive bladder’. My patients with tetchy bladders tell me their bladder can take over their life. They have to wee more often during the day and night, and may limit how much they drink, in an attempt to control the urgency. Some know where every public toilet is located, and have to plan any long trips carefully, to ensure regular toilet stops.
Teaching pelvic floor muscle exercises is one of the mainstays of my work. These exercises can be helpful in some cases of bladder urgency, especially if you also experience leakage (urge urinary incontinence). However, pelvic floor exercises are not the right thing for everyone to be doing, which is why seeing a Pelvic Health Physio is important. And when it comes to the urgent feeling itself, there is a lot more that can be done.
My next two blogs will look at different ways Pelvic Health Physiotherapy can help with bladder urgency. The good news is there is a lot you can do, with a little bit of guidance and some practise. The main conservative options for treatment (apart from pelvic floor exercises) are
We will look at each one in a bit more detail.
To work out if there are lifestyle factors contributing to your bladder urgency, it is really useful to understand your current bladder habits and fluid intake. Your Physio will probably ask a lot of questions, but will also often ask you to do a bladder diary. This involves recording when and how much you wee, and all fluids you drink for 2-3 days in a row. I know bladder diaries can be annoying to do, but they are extremely useful for accurate diagnosis and treatment. More than one patient has figured out for themselves what they are doing wrong just from completing a bladder diary!
The bladder diary will show if your fluid intake may be contributing to your problem. Ideally, most people need around two litres of total fluid every 24 hours. Too much or too little fluid can make bladder urgency worse. There are some funny myths out there about fluid intake. To be clear: it is NOT necessary to drink two litres of water on top of everything else, and caffeine is not “negative fluid”! However, the type of fluid is still important in some cases. Some bladders are very sensitive to things like caffeine or artificial sweeteners, so if most of your fluid is tea, coffee or diet drinks, this may be contributing to the problem. Water should be the main source of fluid ideally.
Bladder diaries will also show up any bad habits you may have developed. For example, going “just in case” regularly without really feeling the need to wee may encourage your bladder to get used to emptying at low volumes. This is a pretty normal thing to do once just before bed, or if you are about to go on a very long car or plane trip. However, doing this regularly can make it feel more “urgent” when your bladder then fills to a more normal amount. Bladder diaries can also reveal patterns such as getting urgency every time you have a shower, or whenever you arrive home – more on this later.
While we are talking about bladder diaries, there are a number of other things they can reveal. For example, if your overall urine production is higher than expected, or a greater percentage of urine is made at night than is usual for your age group, this can point to other medical issues that may need investigating by your GP or specialist. Hopefully your doctor has already tested for a urinary tract infection and requested a bladder scan to ensure your bladder is emptying properly. Both of these tests are recommended as standard screening for bladder urgency. If they have not been done, your Physio may recommend them.
Your Physio may also recommend seeing your GP about different medication options. Women who are post-menopausal or early post-partum (and therefore low in oestrogen) sometimes benefit greatly from vaginal oestrogen, which is different to HRT. This local application of oestrogen, with a cream or little tablet inserted into the vagina, can be a life changer for some women with bladder urgency or leakage. Others may benefit from certain medications to help reduce the urge feeling while they work on other factors. Your GP can help with any of these options. So, even before you start pelvic floor exercises, there may be a lot of “lifestyle” or other suggestions your Physiotherapist can make to improve urgency.
While some may ultimately still be given pelvic floor exercises to help with bladder urgency, many are surprised to learn they will be given a very different form of “exercise” called bladder training. Even though bladder training is not truly an exercise, a lot of people find it more challenging, as it involves breaking old habits and practising new ones.
Have you ever tried learning a new language? Or maybe you have had to re-learn how to do something in a different way – such operating a new phone or computer? It can be tricky and takes a lot of practise. Initially you have to concentrate a lot, and you will probably make mistakes and fall back into familiar habits from time to time. But if you are determined, you will keep trying and learn from any errors, and over time these things become second nature. Retraining a tetchy bladder is much the same. But I see many people who give up quickly, don’t take the time to practise, or berate themselves when things go wrong. When things go wrong with a misbehaving bladder, this invariably means an embarrassing leak. This is obviously more bothersome than accidentally pocket calling your friend, but maybe just as awkward as accidentally calling someone a prostitute in French (I’ve done that). Bladder training does take some practise, because it involves changing your old bladder habits, which may have been that way for many years
Bladder training involves using techniques to calm or defer the urgent feeling – perhaps initially just for enough time to get to the toilet dry – and to gradually extend the time between every wee. For bladder training to be successful, it is first useful to know what triggers the urgent feeling. Remember the bladder diary from earlier? It’s helpful here too. Working out the trigger can direct which bladder training strategy may be most beneficial. Let me explain this further.
If you find that certain situations, such as coming home or turning on the tap trigger your urge, or the more you think about needing the toilet, the worse it gets, distraction techniques may work well to defer the urge. Both mental and physical distraction techniques can work. Mental distraction involves deliberately thinking of something that makes you concentrate hard, for example doing the alphabet backwards, or doing mental arithmetic. Physical distraction aims to perform an action which stimulates a similar nerve pathway to the messages coming from the bladder. It is believed to change the available sensory input from the bladder to the brain by providing another sensation along a similar path. For example, using the tibial nerve by curling your toes or stretching your calf can work well for some people to calm their urgency. I will explain more on why stimulating the tibial nerve (a nerve in the leg and ankle) may help bladder urgency in my next blog on TENS.
On the other hand, if you find urgency makes you feel very anxious, or if stressful or nervous situations seem to trigger the urge feeling, you may benefit from breathing or other calming ideas to settle the urgency. I noticed a big jump in urgency or regression of symptoms for a lot of my patients at the height of the Covid pandemic, and wrote a blog about the link between urgency and anxiety, which you can read here.
The blog goes into more detail on the link between anxiety and urgency. But the short version is anxiety or stress can make any of our nerves more sensitive. In the case of the bladder, if the nerves from the bladder to the brain are more sensitive, they may activate the “full bladder” warning at lower than usual volumes. Breathing or relaxation strategies help return nerve sensitivity to more usual levels, thus helping to settle the urgency. This can also work very well for some people who have tense pelvic floor muscles associated with their bladder urgency, for whom pelvic floor muscle strengthening if often not appropriate.
We have now looked at a number of different ways we can manage bladder urgency with Physiotherapy guidance. I hope this has given you some ideas to work on. However, if you have urgency, these things often work best under the guidance of a Pelvic Health Physiotherapist. We will continue this topic in the next blog, which is about TENS for bladder urgency, so stay tuned for that one.
In the meantime, stay warm and healthy! Jenny.