Do you ever get the sudden urge to urinate at an inconvenient time? Maybe you’re in the middle of a Pickleball game, or watching your grandchild’s piano recital, but the fear of peeing your pants outweighs the desire to want to be present.
You shouldn’t have to choose between living life and using the bathroom.
In this article, we will discuss what urge incontinence is, explore why it may be occurring, and share strategies to help manage it.
What is Urge Incontinence?
By definition, urge incontinence is the “involuntary loss of urine associated with urgency.”1
Don’t you love when they use the same word within the definition?
Basically, urge incontinence is when you feel a strong, sudden need to urinate and the bladder contracts or spasms and you leak urine. For some people, this occurs before they are able to get to the toilet, because the urge happens so suddenly.2
This can be frustrating and cause people to feel embarrassed, which may lead to avoidance of certain activities.
This urge may be present during the day and at night, which may also affect one’s ability to get proper sleep.2
So, this condition can really impact all aspects of a person’s life, making it difficult to enjoy (or have the energy for) doing daily activities.
What’s Happening in the Bladder at Rest?
In order to better understand what happens with urge incontinence, it’s helpful to know how the bladder works.
The bladder is also known as a “vesicle”. Basically, it is a storage unit for urine.
Storage and release of urine are influenced by the two branches of the central nervous system (sympathetic and parasympathetic nervous system), the amount of urine in the bladder, the internal and external sphincters, and the pelvic floor muscles.
Let’s Talk About the Bladder Itself
At rest, the bladder is controlled by the sympathetic nervous system. The sympathetic nervous system causes the muscle of the bladder (also called the detrusor) to expand, rather than contract, allowing urine to fill.
As the bladder fills, the walls of the bladder stretch. When there’s very little urine in the bladder, we don’t even know, because there’s not enough urine present to alert the brain.
The amount of stretch is what tells the brain, “Hey! I’ve got to pee!”
The bladder can hold 400-600 ml of fluid.
At about 150-200 ml, the brain receives the first indication that the bladder is getting fuller, which we experience as the first urge to urinate.
The bladder will remain relaxed from 200-600 ml of urine, meaning we don’t actually have to urinate at that first urge (more on that later).
When our bladder has either reached its capacity or we are ready to urinate, the parasympathetic nervous system (PNS) kicks in, telling the bladder to contract.
The Sphincters and the Pelvic Floor
For urine to be stored and released, there are two sphincters (internal and external). They must close and open properly to ensure urine doesn’t leak when we don’t want it to.
The internal urethral sphincter is smooth muscle, which is located (as the name suggests) inside the bladder, at the base. The external urethral sphincter is skeletal muscle that is located below the internal urethral sphincter.
At rest, the internal sphincter is controlled by the sympathetic nervous system, so it remains contracted, not allowing urine out until it is told to relax.
At the same time the parasympathetic nervous system kicks in to tell the bladder to contract, the PNS tells the internal sphincter to relax, allowing urine to move towards the external urethral sphincter.
The external urethral sphincter is controlled by the pudendal nerve and is voluntary, so this nerve acts to contract the muscles of the sphincter and the pelvic floor at rest, or before urination occurs, and allows for the relaxation of those muscles when we are ready to urinate.
Let’s Recap
At rest, the bladder is filling and the sympathetic nervous system tells it to remain relaxed, allowing urine to fill, and tells the internal urethral sphincter to contract, keeping urine in the bladder.
At the same time, the external urethral sphincter and the pelvic floor are contracting, via the pudendal nerve, to keep urine in.
When the bladder stretches to the point it’s ready to release the urine, or we are on the toilet, ready to release the urine, the parasympathetic nervous system tells the bladder to contract and the internal urethral sphincter to relax, allowing urine to move towards the external urethral sphincter.
When we are ready to urinate, the pudendal nerve releases it’s signals and allows the external urethral sphincter and pelvic floor to relax, allowing urination to occur.
What Causes Urge Incontinence?
There are multiple reasons one may experience urge incontinence, which is why it’s important to talk to your doctor (primary care and/or urologist) to know what’s happening in your body.
Some possible reasons include overactive bladder, which is called “idiopathic,” meaning it can happen but there’s no known pathology.
Or there could be an underlying pathology, like a urinary tract infection (UTI) or detrusor hyperreflexia, which is a neurological condition.1
Symptoms of Urge Incontinence
There are a variety of types of incontinence, so once again, it’s really best to talk to your provider to help you identify the cause/diagnosis.
However, people with urge incontinence may experience the following:
- “Leaking urine on the way to the toilet,
- Being triggered to pee by things like running water, change in temperature, putting your keys in the door
- Rushing to get to the toilet
- Bladder emptying without warning”1
Strategies to Manage Urge Incontinence
- Keep a Bladder Diary
- Bladder Clock
- Deep Breathing Strategies
- Drink Water
- Pelvic Floor Strengthening
Bladder Diary
A bladder diary, or a voiding diary, is basically what it sounds like- writing down all of the times you urinate throughout the day.
Additionally, you will want to write down what you ate and drank during the day and how much. Plus, writing down urge felt prior to using the toilet/leakage, and how much leakage you experience throughout the day.
The reason behind documenting what you ate and drank is that there are a variety of foods and beverages that are known bladder irritants.
Examples include: coffee, soda, carbonated drinks, juices, spicy foods, tomato-based foods, and chocolate.3
This is not to say you must cut out all of the above items. However, you want to notice if there are patterns between urge and leakage and what you consumed prior to experiencing those symptoms.
It may help your symptoms drastically to reduce or cut out a known bladder irritant.
It’s also very helpful to keep a void diary for a week and bring it to your healthcare provider and they can also help you identify patterns.
Here is an example of what a bladder diary looks like (also, click the link below to download bladder diary template):
Bladder Clock
In the bladder diary above, you will see the different levels of urge from 1-3 recorded.
A rating of 1 is the first time you notice you may need to urinate. Maybe you’re out gardening and you get that first slight urge, but you can override it through continuing with your yard work.
A rating of 2 is the second notice you’re receiving, and this is where you need to stop what you’re doing and get to the bathroom.
A rating of 3 is when you NEED to get to the bathroom right away. Think after a long car ride or first thing when you get up in the morning.
Ideally, we want to void (or pee) when we’re at that level 2 rating. Many people have been taught to not “hold it in” so they go as soon as they get that level 1 urge, but that’s just training our brain and bladder to over-react and pee too often.
In a recent course I took by Herman and Wallace, they call this type of peeing “Just in case-ing” or “JIC-ing”. This is when you’re about to go out for lunch and you pee “just in case” you have to go. This is fine to do when you know there won’t be bathroom available for an extended period (like before a long car ride), but should be avoided when at home or when a bathroom is readily available.
A person should typically pee between 5-8 times per 24 hours.
Also, it’s ideal that a person pees every 3-4 hours. Keep in mind this is not a goal, but a range. Meaning, if you pee every 3 hours you don’t need to try to make it to 4. But if you’re peeing every hour, it may be beneficial to work on bladder training with the bladder clock.
I know right now you’re thinking, But I have a small bladder! And maybe you do. Those with overactive bladder may have less capacity than typical, but the reality is bladder size doesn’t decrease with age, so we can train the bladder to store for longer without increasing leakage.
A bladder clock is shown below. The plus signs represent the times you void. The clock on the left is where you would start. Begin by going every hour (or at an interval that may be a slight challenge but doesn’t cause excess leakage). Once you get to a point that you can maintain that schedule without extra leaks, increase the interval by 15 minutes. Over time, you may be able to get to the clock on the right. (Of course talk with your practitioner about a goal that works for you.)
The point is that we are able to increase the interval between urination gradually and effectively (meaning we aren’t leaking as a consequence of the increased intervals).
Deep Breathing
Remember when we discussed how there’s a voluntary component of bladder control (if not, see above for explanation on the external urethral sphincter and pelvic floor)?
That means we actually do have some control of when we urinate, which is good news!
Just like we can override that level 1 urge when we’re busy doing a task, we can work with our brain to override an urge as needed.
Let’s say you’re on lakeside vacation with your family. One day, you decide to go out for a hike in the woods with your grandkids. Then you come across a small brook of running water.
That sound causes you to feel like you suddenly need to pee.
Instead of panicking, which may cause you to leak. You can focus on your breath.
Try a box breathing practice to help you trigger your parasympathetic nervous system to help calm you down.
Inhale for a count of four, hold for a count of four, exhale for a count of four, hold for a count of four. Repeat.
Shifting the focus to the breath will help our body relax and we can remain more in control.
Drink Water
Now, I know for many people this seems counterintuitive, right?
If I’m having a difficult time getting to the bathroom quickly, why would I add more fluid to my system?
The thing is that water is essential for a healthy bladder.
In fact, without enough water, our urine becomes more highly concentrated, which can irritate the bladder. This can cause pain and for us to feel like we need to urinate even more often.
The general rule is drink half your body weight in ounces per day. Meaning, if you weighed 120 pounds, you would need at least 60 ounces of water daily.
This does not mean chug water. Overloading the body with water too quickly will not help, and will likely make the urge worse.
Drink your water throughout the day. If you know how many ounces you need daily, you can figure out how much you should be drinking every hour or so, which may help you space it out appropriately.
If getting the recommended amount is too much for you right now, start with a smaller goal. Just take four more sips of water every hour than you normally would.
Pelvic Floor Strengthening
Remember that the pelvic floor relaxing is the last step in the urination release process.
So we need to make sure our pelvic floor has the strength to maintain the proper contraction and allow for relaxation when appropriate and needed.
Some people have over-active pelvic floor muscles, which make it difficult for the muscles to relax. While others have under-active muscles, which make it difficult for contraction to occur.
If you’re unsure which you have, seek out a pelvic health physical therapist.
If your pelvic floor needs strengthening, we want to practice contracting the pelvic floor, as in with a Kegel.
Keep in mind that many of us were taught to do 1,000 Kegels a day and that may lead to the over-active pelvic floor, which we don’t want either (so once again, check in with your pelvic floor PT).
To ensure you’re doing a pelvic floor contraction correctly, take a small Pilates or yoga ball and place it between your legs (yes, really get it up there).
Then slightly bend your knees and as you straighten your knees imagine you’re lifting the ball inside your pelvis. You should feel your pelvic floor turn on.
Repeat 10-20 times.
Getting your pelvic floor stronger will not only help with leakage in general, but you can also perform one of these contractions when you feel the urge to pee. Like breathing, doing these contractions helps override the urge signals and get us into that voluntary control mode again.
Check out THIS video for a demonstration on how to ensure you’re doing a proper pelvic floor contraction.
Have the Strength to Live Life to the Fullest!
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Sources:
- Herman and Wallace booklet
- https://my.clevelandclinic.org/health/diseases/22161-urge-incontinence
