There's an old saying, purported to be a Chinese proverb, but apparently of English origin: “May you live in interesting times”. After the past 6 months, we all recognise this as a terrible curse. I think we’ve seen enough of “interesting” for one year!
Given the anxiety and fear created by the Coronavirus, it’s probably not surprising to learn that many people with chronic pain conditions had flare-ups over this time. After all, there is a well-known link between stress or fear and pain. You can read more on that in a past blog I wrote on this topic. But, as I returned to seeing more patients face-to-face, I was also not surprised to find many patients reporting an increase in urinary urgency. This is a sudden desire to urinate that is difficult to put off, often causing people to hurry to the toilet more frequently as a result. It may or may not be accompanied by urine leakage. So why would that get worse during times of stress and worry?
For many years, urinary urgency was thought to be purely related to pelvic floor muscle weakness and age-related changes in the pelvic tissues and bladder. Our pelvic floor muscles, like all our other muscles, tend to lose strength as we age. In fact, all of our soft tissues become less elastic and supportive with age. For women, the reduction in oestrogen after menopause makes this worse too. When combined with damage that may have occurred years earlier from childbirth or chronic straining, this can all lead to a significant loss in support for the pelvic organs, including the bladder and urethra, causing problems such as prolapse (dropping of the pelvic organs) or urine leakage, and may be factor in urgency. So, for women with these factors, the traditional treatments of pelvic floor muscle strengthening and applying local oestrogen to the pelvic tissues are usually very helpful.
However, this never explained the full picture. For example, it didn’t explain the common triggers many urgency sufferers will report – experiencing a sudden urge when putting their key in the door or turning on a tap, for example. It never explained why younger women, who had never had children, or indeed men, could still report urgency. Or the transient urgency many people will experience when feeling nervous, such as before an exam. Obviously, there was more to urgency than tissue and muscle weakness.
More recent research now shows links between urinary urgency and increased sensitivity in the nerve messages that travel between the bladder and brain. When nerves become more sensitive, they tend to send messages at a much lower threshold than usual, and with a greater amplification. So, for example with urgency, the sensitive nerves may be telling the brain that the bladder is “full” when it’s actually only a third full, and it will make that message seem very compelling – hence the term urgency. Interestingly, very similar changes in nerve sensitivity are reported with chronic pain. Remember I mentioned the link between pain and stress? Well the same can apply to urgency as well.
When we experience any kind of stress or threat (emotional or physical) our sympathetic nervous system is activated. This is our “fight or flight” response. Various different hormones are then released to help us react, including adrenaline and cortisol. This is not so much a problem if the stress is short-lived. But ongoing stress can mean high levels of cortisol keep circulating in our bodies. Chronically high cortisol can make nerves more sensitive than usual. This helps explain why you can feel absolutely busting with urgency, but when you rush to the toilet you only pass a mere trickle. The sensitive nerves were giving the wrong messages to the brain, and it was not a true reflection of how full your bladder really was.
Why then will turning on a tap or arriving home trigger urgency? Well these become learned responses. Have you ever heard of Pavlov’s dog? Pavlov taught his dog to salivate when offering it both food and ringing a bell. Over time he withdrew the food but kept ringing the bell, so the dog learned to salivate just at the ringing of the bell. Our brains are a bit faster at learning than a dog’s brain. Sometimes just one experience of arriving home and struggling to get to the toilet with a full bladder, or weeing in the shower, can be enough for your brain to continue to associate arriving home or running water with a sudden desire to go to the toilet. And when the nerve messages are more sensitive than usual, this can trigger a very strong and sudden urge sensation.
However, we know high cortisol does more than make our nerves sensitive - it has other ways of influencing bladder urgency too. One way is by increasing the speed of urine production by the kidneys. When urine is made more quickly, the bladder fills faster, and we need to empty it again in less time than usual. We see the same pattern in people who drink a lot of caffeinated drinks, or just too much overall fluid. Both will cause an increase in urine production, making you need to urinate more often – but in this case, you WILL have a lot to empty. However, for some people with urgency, it is also thought that faster bladder filling also causes the bladder to stretch more rapidly, which might contribute to spasms in the bladder muscle. These bladder spasms (or contractions) may be called an “overactive bladder” and have been linked to some forms of urgency. Our bladder muscle should only normally contract when it is emptying. A bladder that contracts as it is filling can trigger a strong desire to get to the toilet pronto!
Another side effect of high cortisol can be constipation. When our bowels are not emptying regularly and easily, the build-up of stool in the rectum causes extra pressure on the bladder. This can irritate the bladder, making it more sensitive to filling pressure, and possibly also contributing to bladder spasms (or overactivity) as we saw before. In fact, constipation for any reason has been strongly associated with bladder urgency, and we know this is one important factor to manage when treating urgency.
We have seen now that there are a number of ways that stress may contribute to bladder urgency, in particular by the effect of the hormone cortisol. However, there is another factor to consider – the effect of stress on our muscles. Have you ever had a sore neck when you feel stressed? If so, how the muscles feel in the tops of your shoulders? Pretty sore and tight, right? Well the same thing can occur with any other muscles in our bodies, including the pelvic floor muscles. When our sympathetic nervous system is activated by stress or threat, it can also cause tension in our muscles as a protective response. This is a normal, healthy response. But, if the stress is prolonged, our muscles may become tight and tense much of the time. They then become tender to touch, and this tenderness can trigger an even greater protective response.
If this occurs in our pelvic floor muscles, they not only become tender, but they can also interfere with bladder and bowel function, making it difficult to empty the bladder and bowel properly. This is one of the reasons you may be recommended to have a bladder scan when you have urgency, as we need to make sure your bladder is actually emptying properly. But we also know that tense pelvic floor muscles can also be a driver for even more sensitivity in the bladder and nerves. In cases where pelvic floor muscle tension (or overactivity) is involved in bladder urgency, some sufferers will report they experience PAIN if they don’t empty their bladder quickly. Doing pelvic floor muscle strengthening exercises will make the symptoms worse, not better – meaning the traditional treatment will be ineffective.
So, in summary, the causes of urinary urgency can be varied, and stress can certainly play a significant role. If you have bladder urgency, it is important that the causes and contributing factors for your symptoms are determined, as the same treatment will not work in all cases. But it would be nice to know some ways you can help yourself too.
This week happens to be World Continence Week, and this year the focus is on 5 healthy habits we can all adopt to promote bladder and bowel health. Many of these apply well for general advice to assist bladder urgency:
If you experience any bladder urgency or have any questions about this blog, I encourage you to get in touch with me.
Yours in good health