(You can also learn more about bladder problems by watching this recording of a webinar I did for the Fascial Manipulation Association entitled “Urinary Incontinence & Other Bladder Issues.“)
There are a LOT of diagnoses associated with bladder problems: urinary incontinence (UI) which is further classified as stress/urge/mixed, urinary hesitancy/difficulty initiating urine flow, difficulty emptying completely/retention, neurogenic bladder, interstitial cystitis (IC), benign prostatic hyperplasia (BPH), nocturia (nighttime urination), overactive bladder (OAB), recurrent infections (UTI), bladder and kidney stones, bed-wetting, constipation (yes, it can cause bladder issues), and perhaps more. Each of these has its own set of symptoms, ICD codes, tests, pills, surgeries, exercises, and approaches. They all can be disruptive, embarrassing, isolating, and expensive, causing many people to navigate their lives around them. I want to look at these collectively as I believe they share an often overlooked common denominator that is at least part if not all of the problem: the connective tissues and the fascia.
Looking at the stats, a 2011 study on UI showed that in the US 51% of women and almost 14% of men (often after prostatectomy) suffer from some form of UI. BP are also expensive, with the estimated cost in the US in 2007 of OAB and UI combined at $65.9 billion, with projected costs of $76.2 billion in 2015 and $82.6 billion in 2020. While men deal with BP too, women are far more likely (~75% of all UI) to suffer with it for a variety of reasons: childbearing, hormones, and anatomy (the female urethra is much shorter than the male). Or at least women are more likely to seek help for it, which is how things get tracked. Yet while these are legitimate influences on women, they don’t explain it all: very young women can develop BP prior to childbearing or the hormonal fluctuations of menopause (ask around a high school, especially the track team); women (and men) who have never had children can develop BP too. UI and BP in general impact all races, genders, and ages.
People often say, “Sure, I have some BP but nothing abnormal.” My response to that is none is normal! Any difficulty is a sign of a problem. I hear these explanations a lot:
- At my age I thought this was natural…..
- After X number of children…..
- It only happens when I sneeze, cough, jump rope, run, shout, laugh, or jump on a trampoline….
- I’m OK as long as I don’t wait too long to use the bathroom…..
- Just since my surgery….
- Getting up 2-4 times a night for the bathroom is to be expected at my age (actually 0-1 is normal)…..
These are common explanations used by a lot of people. But common does not mean normal! The internet is loaded with misinformation and opinions that minimize this problem – sometimes from reputable sources and educated people. Even such a distinguished source as NIH (National Institute of Health), while to be commended for putting out their 15 Tips for Keeping the Bladder Healthy, misses (in my opinion) the mark with their recommendations. Then there’s this favorite of mine from the 2013 CrossFit regional competition. The interviewer went around and asked attendees if they peed during their workout – in other words had episodes of urinary incontinence. Most admitted they did, which is pretty sad from this young, seemingly fit crowd. It got even sadder when they found a gynecologist in the audience who informed everyone listening that, in her professional opinion, it was OK to pee during double-unders (a jump rope maneuver). Sigh. For what it’s worth in my professional opinion it’s very not OK. At the end there is a nauseating video of a young woman who lost her bladder control and urinated all over the floor while performing her competition segment. The narrative from the commentators passed it off as just part of the routine that happens to everyone – a sign that you are giving your all, a rite of passage of sorts. Kind of sick.
One of the most popular theories explaining BP is weakness of the pelvic floor muscles, which are thought to no longer be adequately supporting the bladder. Along these lines, in 1948 American gynecologist Dr. Arnold Kegel (pronounced Kee-gull) first introduced his revolutionary exercise of contracting the pelvic floor and claimed remarkable changes in UI and pelvic organ prolapse, although his results have not been reproduced in more structured studies. Yet throughout the years Kegels remain touted as the go-to exercise for most pelvic floor and bladder issues including UI. Unfortunately there is little research validating how many Kegels need to be done, how long, how often, etc. If you go to Wikipedia and look up Kegel you will see that they are still begging for research citations to quantify. Even the Mayo clinic website still upholds Kegels as a front-line intervention. While many still recommend this exercise (see internet) the staggering statistics I shared earlier would suggest that Kegels aren’t quite curing the problem.
More sophisticated forms of targeted pelvic floor therapy have evolved and are used by many practitioners. While helpful for some patients, these interventions are not successful for everyone. The literature supports that much of what is being done in practice leaves a lot to be desired (you can access some research articles here). Like Dr. Kegel, initially the focus of most BP regimens was on strengthening the pelvic floor. However, perhaps owing to failure of this approach to rectify all BP, the pendulum has swung in the opposite direction to propose that a tense/tight pelvic floor may be the problem for others. For this population strengthening is contraindicated, and instead relaxation and sometimes stretching of the pelvic floor are thought to be needed. Either approach (strengthen or relax/stretch) has been shown to be of some benefit for some people sometimes. But in my experience there are multiple problems with relying entirely on either of these premises:
- They often depend on the ongoing performance of exercise or other techniques which people eventually abandon, only to have their problems return.
- They often require multiple visits with a clinician/provider.
- They can take an extended time period to yield results.
- They often require internal pelvic examination and treatment techniques, which many people would prefer to avoid if at all possible.
- There are many people who don’t respond satisfactorily to the strengthening, relaxing/stretching, or internal approaches.
I’ve brought up internal pelvic examination and treatment, also known as pelvic floor therapy, so let’s talk more about it. I’ll go out on a limb here and share my opinion that I believe the pelvic floor (PF) is overemphasized in the treatment of BP, as well as many other pelvic problems. The PF is certainly a necessary and amazing part of the body related to multiple functions. But I compare a targeted focus on this structure for treating pelvic problems, like BP, to focusing on the quadriceps (quads) for treating knee pain. Healthy function and movement involving any muscle group requires that the nervous system elements (muscle spindle and golgi tendon organ) be embedded in a flexible, adaptable fascial matrix. This applies to the PF as well as the quads. Considering that anatomically this fascial matrix is continuous from head to toe, one should then be open to the possibility that dysfunction outside of the quads and the PF can exert an impact on the knee or the internal organs. This study showed such a relationship between movement at the pelvis and also at the gastrocnemius – a calf muscle. Perhaps a lack of appreciation for the global, connected nature of the fascia and connective tissues is why the targeted focus on strengthening or relaxing the PF does not yield optimal results for many people. Certainly there are cases where PF emphasis and internal work is warranted. But in my experience the greater majority of patients I see accomplish positive change without “going in there.” It’s why I prefer to be called a pelvic therapist and not a pelvic floor therapist.
Urodynamic testing is sometimes utilized to help arrive at a diagnosis. While many people feel more comfortable having a title for their problem, for me the bigger issue is not what to call it but how to change it. There are multiple BP medications aggressively advertised to us, a reflection of the fact that the US and New Zealand have the most permissive pharmaceutical advertising in the world. While pharmaceuticals can help with suppressing symptoms, they do not change the underlying problem, and also always have side effects. Herbals and supplements are popular and seem to entail fewer side effects, but still require ongoing use to accomplish minimal change. Devices such as electrical stimulation, pessaries, vaginal weights, pelvic wands, and dilators are also low risk interventions that can often be used at home. But they are also somewhat of a hassle to deal with, can be costly, and yield mixed and often disappointing results – as do all these interventions.
Specialty equipment such as biofeedback and abdominal ultrasound (US) are often used in conjunction with pelvic floor exercises. These are typically performed only in a clinic with a trained practitioner. Biofeedback is utilized to promote pelvic floor muscle contraction or relaxation, depending on which is being proposed as the problem. US can visualize the position and movement of the bladder, and sometimes show that the bladder neck is not in an ideal position, thought to contribute to UI. As mentioned earlier, a popular culprit to blame for this is a weak pelvic floor.
Of course there’s always surgery, which is certainly the most drastic measure and always carries multiple inherent risks including permanent alteration of the anatomy. Bladder surgeries are typically focus on lifting and supporting the bladder to compensate for a presumed weak and dysfunctional pelvic floor. While surgery can be helpful, the improvement garnered is often temporary and typically leads to further surgeries. I would suggest that the temporary improvement associated with many of these interventions stems from a lack of attention to the root cause of the problem.
This brings us to the question: what is the root cause of BP? Certainly if there is an infection it needs to be dealt with straight up. But I will say that recurrent, unresponsive problems in the absence of clear pathology signal that the cause driving the BP is not being rectified. My training and experience, as well as the research support that it’s typically not exclusively the pelvic floor nor the organ (bladder, ureter, urethra, kidneys) that’s at fault but the fascial environment in which these structures are trying to function. That’s why tests studying the organ/bladder are often negative or inconclusive. They are looking at the organ itself, which is typically not the problem. In contrast, the fascial environment refers to the fascia enveloping and going into the organ (investing fascia) and the fascia that attaches the organs to the trunk walls (insertional fascia). For a better understanding of this you can see my earlier posts on Fascial Manipulation for Internal Dysfunction, which explains more about the fascia of the internal organs.
Recall that a healthy fascial environment consists of tissue layers that are elastic, adaptable, and free to slide on each other. This is especially true in the trunk, which shelters organs, some of them hollow with constantly changing volumes – like the bladder. If the fascia looses this adaptability through the development of fascial densifications, then symptoms may arise that seem to be stemming from the organ. In the case of the bladder problems (BP), it may be urinary daytime/nighttime frequency, urgency, incontinence, pain/burning with urination, bladder/kidney stones, and much more. Often tests focused on the bladder are negative because the problem is the fascial environment surrounding the organ – not the organ itself.
Equally important to remember is that it’s not just the fascia of the trunk that relates to the organs, but also the fascia of the upper and lower limbs. In the case of BP the lower limb is much more impactful since the bladder is housed in the lower half of the body within the segment of the pelvis. The fact that we walk on two legs forges a very strong biomechanical alliance between the lumbo-pelvic region and the lower limbs. Fascial dysfunction in the lower limbs can cause problems up the kinetic chain and into the trunk. A commonly occurring example of this is an old ankle sprain which eventually heals and no longer causes symptoms. Damaged connective tissues may heal, but often without restoration of slide in the tissue layers. This in turn can exert abnormal tension up the kinetic chain that may negatively impact the bladder – even if the ankle sprain is no longer symptomatic, and even if it happened many, many years ago. Conversely, fascial dysfunction in the trunk can impact not only the bladder, but also create tension from above to below that may manifest as knee pain, hammer toes, or bunions just to name a few possibilities. So considering both the trunk and lower extremities is essential.
So with BP, like any other problem, we begin with getting a history paying particular attention to co-existing or past problems (old is gold) especially in the lower limbs. Ankle sprains are sooooo common and sooooo underestimated in their impact, even years later. My chapter in this book dealt with post-partum UI in a 33 year old runner who had a history of ankle sprains dating back to high school! Equally overlooked are past fractures, surgeries, plantar fasciitis, and pain in the hips, knees, and heels. Sometimes people don’t remember these things because they were long ago and seemed to resolve. Yet a lack of pain or other symptom does not signal full healing with restoration of vital slide between the tissue layers.
This can happen anywhere in our body where the tissues are overloaded – and we overload ourselves all the time. But the FM® method suggests that if such a loss of tissue slide occurs at specific points that are more important for movement and organ motility, then the impact will be greater. These points are based on movement, force vectors, muscle and fascia physiology, and meticulous anatomical dissections. So we are looking for a loss of slide in tissue layers, and paying particular attention to the segment of the pelvis since it houses the bladder, as well as the lower limb. The FM® approach gives us a road-map of sorts to follow.
Many clinicians like to utilize a bowel and bladder diary in the management of BP. Some find this helpful in identifying problems as well as tracking changes in response to treatment. It basically consists of a log for fluid and foot intake and output, as well as activities and issues. That said, I typically do not use these as I find I can track status other ways. It’s also been my experience that patients find them a bit annoying, especially when asked to measure amounts of urine. I find counting the number of trips to the bathroom at night is an easy parameter (remember, 0-1 is ideal). Daytime frequency can also be tracked, with bathroom trips less than 10 or being able to go two hours without needing a bathroom is normal. Certainly there is some variability under circumstances where fluid intake is higher. If someone is using incontinence pads then I like to note the size and how many are used in a day/night. The number of episodes of unintentional loss of urine can also be tracked, and sometimes the number of times clothes need to be changed due to episodes. I had one very motivated patient who even weighed the used pads and compared it to the dry weight – very precise for tracking change! Improving tolerance to activity (running, jumping) without having unintentional urine loss is also another parameter to track.
Being aware of bladder irritants is also important. Some clinicians caution their patients that they should avoid these items perpetually as part of their management strategy. But that’s not how I approach it. I believe a healthy bladder should be able to tolerate these substances without issue. It’s been my experience that once the environment related to the bladder is made as normal as possible, most people can tolerate these items, certainly with moderation and in reasonable amounts. From my perspective, telling a person with BP to avoid these items is like telling a person with knee pain to avoid stairs and squatting. That approach is not dealing with the problem: it’s just avoiding it. I think we can do better for BP and knee pain. But I do think it’s fair to consider temporarily curtailing these while working on BP. It’s also a good strategy to limit their intake before a particularly taxing activity such as travel or jogging. Once the BP is improved then these measures may not be necessary.
- Coffee, tea and carbonated drinks, even without caffeine
- Certain acidic fruits — oranges, grapefruits, lemons and limes — and fruit juices
- Spicy foods
- Tomato-based products
- Carbonated drinks
As with most issues, there are potentially multiple influential factors and addressing them comprehensively will yield optimal results. I do a LOT of educating with patients (the inspiration for this site) to address the pervasive gaps there are in quality information (Dr. Google and Dr. Oz are not my favorites…). Maybe there are a few key exercises (not Kegels or sit-ups) that will help to support the changes made with FM® treatment. Maybe some lifestyle modifications would help (breaking up sitting, eating less salt, wearing supportive shoes, etc). Perhaps getting a tool (percussion/vibration, 3TOOL) for self-treatment at home will help. Everyone has different needs warranting a different approach. But ultimately EVERYONE needs a self-care maintenance strategy!
I hope you can see that drugs, surgery, and living with BP are not the only options. And please appreciate that the sooner these problems are addressed the easier they are to resolve. BP are typically not something that get better with time.
Wishing you health and joy,