Let’s Talk About Leakage
World Continence Week is here! Which gives me the perfect opportunity to delve into the topic of urinary incontinence, something that is often overlooked and undermanaged within the medical field.
Recent studies have shown that 1 in 4 Australians are affected by incontinence, and it is the leading reason that people are admitted to aged care facilities.
But don’t be fooled by that last statistic - incontinence affects both men (10%) and women (38%) at any age, regardless of background or physical ability. There are factors that increase your risk for developing incontinence, which include:
Pregnancy (both pre- and post-natal)
Menopause
Obesity
Recurrent UTIs and bladder infections
Constipation
Prostatectomy or hysterectomy
Poor mobility affecting how quickly you can get to the bathroom
Health conditions such as arthritis, prostate problems, cardiovascular problems, stoke and multiple sclerosis
Some medications
However, 70% of individuals do not seek help. The reasons can range from feelings of awkwardness, choosing to take the ‘wait and see’ approach or people simply not knowing that something can be done.
Normal Bladder Habits
Every person is different, so it’s good to know your usual bladder habits so that, if something does go wrong, you are able to tell the difference between ‘normal’ and ‘not normal’. A healthy bladder will:
Empty between 4-6 times per day
Hold between 400-600mL of urine
Give you a signal at half-full and completely full, while still leaving you time to find a bathroom
Completely empty every time you pass urine
Wake you up once per night (or twice if you are over the age of 65years)
Not leak
What is Urinary Incontinence?
Urinary incontinence (UI) refers to the involuntary loss of urine. Symptoms can range from a small leak to a complete loss of bladder contents, and as such can be very upsetting and impactful of people’s self-confidence, stress levels and ability to complete their normal day-to-day activities. It is important to remember that, while common, any amount of leakage is not normal.
When talking about UI, we usually break it into 4 different categories:
1. Stress Incontinence
Stress UI is the loss of urine with activities such as lifting something heavy, sneezing, coughing or laughing. It can also occur when taking part in high-intensity exercise, such as weightlifting or CrossFit.
I want you to imagine an unopened can of soft drink. Have you ever noticed how the base of the can is thicker and rounded upwards into the can? This is how I explain the pelvic floor. Your pelvic floor sits at the base of your pelvis, and acts as the floor of your core support system. It contracts upwards into the abdominal cavity to help support your pelvic organs and help you hold onto your urine when you feel the urge to pee.
Now, imagine you squeeze the sides of the can. Because the can’s base is reinforced, no liquid escapes. But let’s imagine for a second if the base of the can wasn’t reinforced, or if it has a hole in it. If you were to squeeze it now, it would probably leak. Welcome to stress UI - leakage caused by a weak, damaged or not properly functioning pelvic floor that is unable to fully hold against an increase in abdominal pressure.
2. Urge Incontinence
Normally, our bladder will give us signals (‘urges’) when our bladder is half-full as when completely full. This mechanism allows us time to plan out our course to get to the bathroom, or hold off depending on our situation. Our bladder is stretchable and can hold up to 600mL, so most people use the bathroom anywhere between 4-6 times per day. Our pelvic floor works with our urinary system to contract to close off the urethra so that no urine can escape, allowing you time to make your way to the bathroom. It also lifts to provide support to the bladder, and reduce the stretch placed on the bladder when filling. If your bladder is not full, this offloading can reduce the urge signal sent to your brain and help you put off the need to go to the bathroom.
Urge UI is the loss of urine due to an inability to hold their bladder in time to get to the bathroom. This occurs when the urge signal to our brain fires off prematurely, or fires off more strongly than it should. This makes it hard to differentiate which urges need to be followed and which can be put off. We end up interpreting every signal as a strong urge to go to the bathroom and, in our panic to reach a bathroom on time, can experience leakage. You may also feel as if you need to pass urine more frequently, as the urge signals being sent off can sensitize the body to feel like it needs to pee even when the bladder hasn’t completely filled.
These symptoms are more common as we age, and can be made worse by stress, or by drinks that stimulate the bladder (such as coffee, tea, alcohol or fizzy drinks). Poor bladder and bowel habits, such as taking “just in case” visits to the bathroom before the bladder is full, can also impact urge UI.
3. Mixed Incontinence
Mixed UI is a combination of both stress and urge symptoms, and can make it harder for you to figure out patterns in your activities or aspects of your diet that may be provoking your leakage symptoms.
4. Bladder dysfunction
We talked before about how the bladder sends urge signals to the brain when its filling and full. However, impairment of the bladder to be able to send this signal at the correct time or to send the signal strongly enough to trigger bladder emptying this can result in either an overactive bladder, painful urination, incomplete emptying or urinary retention.
What Can We Do?
It is important to get the correct diagnosis your incontinence, as treatment varies significantly between the different dysfunction types. Assessment and diagnosis by a trained incontinence physiotherapist or doctor is essential, but all forms of incontinence can be treated with specific pelvic floor muscle retraining and modification of your bladder and bowel habits. Physiotherapy is actually the best line of treatment available for incontinence! While talking about these problems can be awkward for some people, your pelvic health physio can confidently help with diagnosis and prescription of a pelvic floor program specific to your symptoms, allowing you to return to normal leak-free living!
Some Tips for Healthy Bladder and Bowel Habits
Keep up the fluids!
It sounds counterintuitive but in fact keeps providing feedback for normal bladder filling. Drinking less water will concentrate your urine and make things worse. Aim between 2-2.5L per day (or as directed by your healthcare professional).
Eat well
Make sure to incorporate enough fibre into your diet daily - around 25 grams should help to keep you regular and will assist in water absorption into the stool rather than being filtered through to your bladder. Fibre can be found in fruits (such as prunes, kiwi fruit, avocados), vegetables, wholegrains, nuts and seeds and legumes.
Regular exercise
This aids in gut motility and reduces your BMI, which directly reduces your incontinence risk.
Keep a bladder diary!
As physios, we give these out regularly to our clients to hone in on what’s happening with your fluid intake, bathroom visits, urges and leakage. It helps to know what’s normal or, if you are struggling with incontinence issues, helps give us a picture of what’s happening.
Go to the bathroom when you have an urge, not “just in case”.
Toilet position
Set yourself up for success! Sit forwards, elbows supported onto knees and (if you need it) your feet elevated onto a step. Lift up through the chest and let your tummy relax FULLY. This will allow your pelvic floor and sphincters to completely relax. When finished, firmly draw in your back passage.
Don’t strain on the toilet!
This one is huge - straining causes our abdominal pressure to bear down onto the pelvic floor, which will make things worse. If you don’t feel as if you’ve completely emptied; take your time, move around or even stand up and sit back down (we call it a “double void”). This will help move your bladder around so that any remaining urine will siphon down to the base and hopefully pass.
If you would like further information, the Continence Foundation of Australia is a wealth of knowledge that you can review in your own time, or you can call the National Continence Helpline at 1800 33 00 66. For specific help, you can also book in for an in-depth pelvic health consultation with one of our MVP continence physios.
