Calling my “Small Bladder” Friends.

Dr. Amanda Welter — January 28th, 2024

Do you struggle with a “small bladder” or feel like you have to pee all the time? Are you getting a sudden urge to pee without much warning? Does this urgency come with anxiety or perhaps even some leakage on the way to the toilet? Do you pee more frequently than every 2 hours?

Urinary Urgency/Frequency and Urge Incontinence

These symptoms are associated with a pelvic health condition called urinary urgency/frequency or urge incontinence. It can also be referred to as overactive bladder. This is a condition where your nervous system tells your bladder to empty more frequently than it needs to. Urinary urgency is the signal from your brain to your bladder and if you experience leakage associated with this signal, it’s considered urge incontinence. Whether or not you experience leakage, this is an “unhealthy” bladder response that can worsen over time. Unfortunately, I’ve worked with far too many women that have stopped doing the things they love to do because they’re always having to pee.

Bladder Habits

Urinary urgency/frequency is often a conditioned response to bladder habits like "going just in case" or going pee when you don't actually have the urge. Additionally, your body can learn to associate certain environments or activities with peeing; sending the urge to go when you encounter things like:

• putting your key in the door

• pulling into the driveway

• walking into the bathroom

• seeing or hearing running water

• waking up in the morning

• standing up for your desk, etc.

Pelvic Floor Tension

Oftentimes, tight pelvic floor muscles can also contribute to urinary urgency/frequency. The tension or trigger points in your pelvic floor can push on your bladder and urethra, feeding the urgency. You can have both tight and weak muscles, but you want to address the tightness first. Imagine you were walking around all day with your bicep flexed. After a while, this would get uncomfortable and tiring. The bicep wouldn't function like it should and it could create other problems. We would first want to relax the bicep before we do anything else. The pelvic floor works the same way.

Dehydration

While this sounds counterintuitive, chronic dehydration can also contribute to urinary urgency/frequency. If your urine is more concentrated, this will be more irritating to the bladder wall and can increase symptoms. I often see patient’s who purposefully decrease their water intake to avoid having to pee, but this can backfire and is not a good solution for the long term. 

Bladder Irritants

Lastly, there are several beverages and foods that can contribute to urinary urgency/frequency known as “bladder irritants”. Some, you may be familiar with like coffee and alcohol. Others are more unsuspecting, like citrus fruits and seltzer water. Some are diuretics which can make you urinate more often which is not helpful if you already have a cranky bladder. Some are more acidic which can irritate your bladder lining. Most people won’t be sensitive to all the bladder irritants listed, so the first step is to be mindful of what you are consuming on a regular basis and take note of your bladder response after consuming. If you are noticing an increase in symptoms with some of these, you may not need to completely eliminate them but it is helpful to cut back. Additionally, it’s helpful to consume a glass of water before whatever bladder irritant you are about to consume because the water coats the bladder lining and helps protect your bladder from the irritant. 

• Coffee (decaf or regular)

• Caffeinated tea (although herbal teas may be irritating for some)

• Carbonated drinks (seltzer, soda)

• Artificial sweeteners (Spelnda, Sweet ‘N Low, or anything that includes aspartame, acesulfame potassium, sucralose or saccharin)

• Foods with artificial coloring

• Citrus fruits and juices (lemons, oranges, grapefruits)

• High doses of vitamin c supplement

• Tomatoes

• Spicy foods

• Vinegar

• Chocolate

• Dairy products

Treatment

As you can see there are many factors that can contribute to your urinary urgency/frequency. Therefore it’s best to treat it with a comprehensive approach. Below I break down the common treatment strategies I give my patients:

1. Avoid “going just in case”. Only go pee when you actually feel the need to go. This is a tough habit to break but one of the most fundamental steps. Times where you want to make this exception: peeing after sex and peeing before bed.

2. Implement “urge suppression” which is a technique that is very helpful for quieting the urge to pee and can help retrain your bladder to respond with less urgency over time. Typically, when we get the urge to pee our instinct is to rush to the bathroom - but rushing will only increase the urgency and increase your likelihood of leaking. Instead, you want to:

1. Stop where you are: Sit if you can but standing works too. This brings your nervous system out of the fight or flight response and into the rest and digest response.

2. Do 5 quick kegels: Aka tighten pelvic floor muscles 5 times, quickly 

3. Do 3 diaphragm breaths: Aka breathe in deeply through your nose so your belly fills with air

4. Distract yourself: You may start with telling yourself “this is a false alarm” then try to focus on another task or count backwards from 100

5. If needing more support you can:

1.  Cross your legs or sit at the edge of your chair and tilt pelvis forward, applying pressure to your vagina 

2. Do 5 heel raises or walk to the bathroom on your tiptoes (contracting the muscles in your feet and calves will help contract your pelvic floor muscles)

3. A healthy voiding window is to pee every 2-4 hours. If you are peeing more often than this, you want to work on gradually increasing time between bathroom trips. You can start increasing this window by using the urge suppression steps anytime you get the sudden urge or it’s been less than 2 hours since your last trip. The key is to stay consistent with your urge suppression. Sometimes it will completely suppress your urge and you may be able to put off the bathroom trip for another 20+ minutes. Other times, you will still feel the need to go after the urge suppression - but this is not a failure. Anytime you replace rushing to the bathroom with your urge suppression steps, you are building a new pattern in your brain that will strengthen overtime and eventually resolve the urgency. 

4. Add in pelvic floor relaxation exercises and hip stretching. Ask your pelvic floor PT for specific exercises or self-massage techniques. 

5. Increase your hydration. You want to get at least half your body weight in fluid ounces of water per day (most of my patients aren’t doing this). If you are far off from this goal, increase gradually. Your body will likely take some time to adjust and you may see a temporary increase in urination as a result. It’s also best to sip water throughout the day as opposed to drinking a bunch at once. Sipping rather than chugging will help your cells more easily absorb the water and avoid flooding your bladder, which can also lead to more urgency/frequency. 

6. Limit bladder irritants, specifically the ones that you are sensitive to. 

Your brain doesn’t learn these patterns overnight, therefore it can take some time to retrain. The good news: you will start noticing improvements in symptoms shortly after implementing the strategies listed above. Full brain-bladder retraining (AKA achieving a “healthy” bladder response) generally happens over the timespan of 3-6 months.
Note: when making lifestyle changes it’s best to start with one to two realistic changes at a time. This will help with consistency and retention. Then, you can add on more, as these habits become semi-automatic.

It is best to work with a pelvic floor physical therapist as they can help you prioritize which treatment strategies to start with and provide you with customized exercises and support so you can overcome your urinary urgency and frequency. And most importantly, so you won’t miss out on any of the things you love to do!