Let’s talk about your bladder! Turns out, the process of urination is a complicated one. There’s a lot going on! If something isn’t quite right with your urinary process, a pelvic floor physical therapist is oftentimes the right provider to help you figure out what’s wrong and how to fix it. Let’s start by talking about what normal urinary function involves, then we’ll go into what can go wrong and what we do about it.
Normal urinary function involves the complex interplay of various components in the urinary system, which is meant for the efficient removal of waste and excess fluids from the body. Here is a more detailed explanation of the key components and processes involved in normal urinary function:
Filtration: Blood flows into the kidneys, where it is filtered to remove waste products, excess salts, and water. This process forms a concentrated liquid called urine.
Regulation: The kidneys play a crucial role in regulating electrolyte balance, blood pressure, and maintaining the body's overall fluid balance.
Transport: Tubes that connect the kidneys to the bladder, allowing the flow of urine from the kidneys to the bladder through peristaltic contractions.
Storage: The bladder serves as a reservoir for urine. As urine accumulates, the bladder expands to accommodate the increasing volume.
Detrusor Muscle: The muscular wall of the bladder (detrusor muscle) contracts to expel urine during voiding.
Conduction: A tube that carries urine from the bladder to the outside of the body.
Sphincters: The urethra is equipped with internal and external sphincters that help control the release of urine.
Control: The central nervous system receives signals from the bladder and urethra, providing feedback on the need to void. Voluntary control allows individuals to decide when and where to urinate.
Great! Those are the components involved in urination. Now let’s talk about the process of urination including what can go wrong and how pelvic floor physical therapy deals with those breakdowns:
Filtration and Reabsorption:
Blood is filtered in the kidneys, and essential substances are reabsorbed back into the bloodstream while waste products form urine. If anything is going wrong here, this will be diagnosed and treated by a urologist or a urogynecologist. These are physicians who specialize in the medical diagnosis and treatment of urinary dysfunction, and it’s common for them to work with pelvic floor physical therapists. Sometimes patients see a physician first, sometimes they consult with pelvic floor physical therapy first. Either way is fine!
Of course, if you’re having ‘yellow flag’ symptoms such as blood in the urine, other discoloration of urine, or pain/burning with urination, make sure to check in with the physician to rule out any more serious causes of urinary dysfunction such as UTI or other infection.
Storage: The bladder stores urine until a sufficient volume is reached, triggering the sensation of needing to urinate.
As the bladder fills, it sends periodic signals through the nervous system up to the brain. These are quiet and infrequent at first, and as the bladder fills further (imagine a water balloon filling slowly), these signals become louder and more frequent. However, sometimes these signals are too loud and too frequent even when the bladder isn’t very full. This can lead to urinary urgency, frequency, and leakage.
In pelvic floor physical therapy, appropriate bladder signaling is often something we work on. If the bladder sensitivity is off - giving you the signal to urinate too early or too late - we want to retrain it. Bladder retraining is something that is done guided by a pelvic floor physical therapist to gradually retrain your bladder to hold the appropriate amount of urine and send signals to your brain indicating a full bladder at the right time.
When an individual decides to empty the bladder, the detrusor muscle that surrounds the bladder contracts to push urine out and sphincters relax, allowing urine to flow out through the urethra. This is a big one! Working on this part of the process in pelvic floor physical therapy is often one of our main focuses. If you have a pelvic floor that is too tight, that may cause urinary retention. This could involve difficulty initiating the stream of urine or difficulty completing the stream (spoiler alert: it’s the same thing for bowels!).
Tightness in the pelvic floor muscles and other mucsles of the pelvis can also cause urinary urgency. This is where someone needs to rush to the bathroom and may or may not leak urine along the way. This can also be associated with increased urinary frequency and pain/burning with urination! Turns out the pelvic floor is a pretty important group of muscles!
Now what happens when everything is going well with the process of urination, but your issue is actually keeping that urine inside you until you’re sitting on the toilet? Urinary leakage can be caused by weakness in the pelvic floor as well as a number of other conditions. Here’s a detour into learning more about the types urinary leakage:
Cause: Weakening of the pelvic floor muscles and/or the urethral sphincter, which can occur due to factors like pregnancy, childbirth, obesity, or aging.
Characteristics: Leakage of urine during activities that put pressure on the bladder, such as coughing, sneezing, laughing, or lifting heavy objects. We’ve been taught to accept that this is “normal.” That. Stops. Now! Leaking urine is not normal - it means that one (or more) part isn’t doing its job to control your bladder. Let’s regain that control over our bodies and our lives for good!
Cause: Overactivity or irritation of the detrusor muscle (bladder muscle), can be associated with conditions like bladder inflammation (cystitis) or neurological disorders. Also can be caused by tightness in pelvic floor or other pelvic muscles as well as irritation of the nerves in the pelvis.
Characteristics: Sudden and intense urge to urinate, with little warning, leading to involuntary urine loss. Individuals with urge incontinence may also experience frequent urination.
Cause: Inability to empty the bladder completely, resulting in constant dribbling of urine. Causes include an enlarged prostate (in men), urinary tract obstruction, or nerve damage.
Characteristics: A feeling of incomplete emptying of the bladder, frequent dribbling of urine, and difficulty starting or maintaining a steady stream.
Cause: Physical or cognitive impairments that prevent a person from reaching the toilet in time. This type is not due to a bladder or urinary system problem but is often associated with conditions such as mobility issues, dementia, or arthritis.
Characteristics: Inability to get to the bathroom in a timely manner, leading to accidental urine leakage.
Cause: Combination of more than one type of urinary incontinence, often stress and urge incontinence occurring together.
Characteristics: Symptoms of both stress and urge incontinence, with urine leakage occurring in response to pressure on the bladder and sudden urges to urinate.
Cause: Temporary factors such as urinary tract infections, medications, or acute illnesses that affect bladder function.
Characteristics: Sudden onset of urinary incontinence that resolves when the underlying cause is addressed.
Regardless of the cause, leaking urine is not normal! Our favorite saying is “common, not normal.” This lets us know that urinary incontinence (leakage) is common, yes, but it still is indicative of dysfunction. The cause may vary, but it’s still not something that should happen. In pelvic floor physical therapy, we figure out why and do something about it!
Now you know about the components involved in urination, the process of urination, and types of urinary dysfunction. But what actually is normal urinary function? Of course, everyone is different. How much fluid you eat and drink matters (even water content in food matters!), but we do have some general norms that most people fall under. Remember, the nervous system coordinates the signals between the bladder and the brain, allowing conscious control over the timing and frequency of urination.
Normal urinary function is characterized by:
Frequency: The typical range is 6-8 times per day, depending on fluid intake and individual variations.
Urgency: The ability to postpone urination until convenient without experiencing a strong, uncontrollable urge.
Nocturia: The ability to sleep through the night without waking up to urinate excessively. In general it is not normal to wake up at night to urinate. Some people consider it within normal to wake up one time per night to urinate. It all depends on what your normal is, though! Did you previously never wake up to urinate and now you do? That might be abnormal for you! Are you waking up two or more times per night to urinate? Then it’s time to see a pelvic floor physical therapist.
Volume: Normal urine production is approximately 0.5 to 2 liters per day. Of course, this will depend on how much fluid you intake through your diet.
What now?! If you learned today that you have urinary dysfunction, then it’s time to do something about it! Schedule an appointment at Sage Physical Therapy to take control of your bladder and your life.