Andrew Siegel MD 6/9/2018
Many suffer with urinary urgency and frequency, requiring repeated trips to the bathroom. Although not serious or life-threatening, it is annoying and inconvenient. After happening repeatedly, it can be become an ingrained habit that is difficult to break. Concerns surface about sitting in traffic, traveling, seeing a Broadway show, getting the right seat on an airplane, etc.
If you are dealing with an urgency/frequency issue, you may benefit from “bladder retraining.” It is relatively simple, requires neither medication nor surgery, and can help you control when you urinate, how often you urinate and allow you to delay urinating.
What happens under normal circumstances
As the bladder gradually fills, most people ignore the initial sense of urgency, continuing to go about their life and carrying on with their activities. As the bladder continues to fill, they continue to tune out the sense of urgency until the point that it becomes compelling enough so that they are motivated to leave their activity and go to the bathroom to empty their bladder.
What happens to the frequent urinator
For one reason or another, the frequent urinator often becomes “hyper-vigilant” about their sense of urinary urgency. For him or her, the bladder is “front burner” and not “back burner.” This may be based on a previous physical bladder problem that gave rise to the hyper-focus, commonly a urinary infection. The frequent urinator often responds to the initial sense of urgency by acting upon it and heading to the bathroom to empty their bladder. When this behavior is habitually repeated, it becomes a dysfunctional ingrained habit—the “new normal,” and again, a habit that is tough to break. The bottom line is that when there is excessive focus on the sensations arising from the bladder (or for that matter, any part of the body), one will be hyper-acutely aware of sensations that they normally are not cognizant of.
As another example of this, if you focus on the weight of your watch on your wrist or your ring on your finger, within a matter of minutes, their presence will start annoying you. No good comes of when background becomes foreground!
A 24-hour bladder diary (log of urination recording time of urinating and the volume of each urination) is a simple but helpful tool in sorting out the different causes of urgency/frequency. Since normal bladder capacity is about 12 ounces, if the diary shows frequent voids of full volumes, the problem is most likely related to excessive fluid intake (or rarely a kidney or hormonal problem that can cause excessive urinary production). However, if the diary shows frequent voids of small volumes (e.g., 4 ounces), the problem can often be improved with bladder retraining. If the diary shows frequent voids of small volumes during the day, but full volume voids while sleeping or no voids while sleeping, it points to frequency on a psychological basis and also can often be improved with bladder retraining. It is important to know that frequent voiding of smaller volumes is not always a dysfunctional habit and may be on the basis of prostate or bladder issues that might require the services of your friendly urologist. However, no harm can come from an initial attempt at bladder retraining.
Fixing it
The goal of bladder retraining is to break the dysfunctional habit and restore normal—or at least better—bladder functioning. Bladder retraining can be challenging, yet rewarding, and requires a positive attitude and being willing, informed and engaged.
- FLUID AND CAFFEINE IN MODERATION
Urgency will often not occur until a “critical” urinary volume is reached, and by limiting fluid intake, it will take a longer time to achieve this volume. Try to sensibly restrict your fluid intake (without causing dehydration) in order to decrease the volume of urinary output. Caffeine (present in tea, coffee, colas, some energy drinks and chocolate) can increase urinary output and is a urinary irritant, so it is best to limit intake of these beverages/foods. Additionally, many foods—particularly fruits and vegetables—have hidden water content, so moderation applies here as well. It is important to try to consume most of your fluid intake before 7:00 PM to improve nighttime frequency.
- ASSESS MEDICATIONS
Diuretic medications (water pills) can contribute to frequency by design. If you are on a diuretic, it may be worthwhile to check with your medical doctor to see if it is possible to change to an alternative, non-diuretic medication. This will not always be feasible, but if it is, may substantially improve your frequency.
- AVOID BLADDER IRRITANTS
Irritants of the urinary bladder may be responsible for worsening your symptoms. Consider eliminating or reducing one or more of the following irritants and then assessing whether your frequency improves:
Tobacco
Alcoholic beverages
Caffeinated beverages: coffee, tea, colas and other sodas and certain sport and energy drinks
Chocolate
Carbonated beverages
Tomatoes and tomato products
Citrus and citrus products: lemons, limes, oranges, grapefruits
Spicy foods
Sugar and artificial sweeteners
Vinegar
Acidic fruits: cantaloupe, cranberries, grapes, guava, peaches, pineapple, plums, strawberries
Dairy products
- URGENCY INHIBITION
The act of reacting to the first sense of urgency by running to the bathroom needs to be modified. Stop in your tracks, sit, relax and breathe deeply. Pulse your pelvic floor muscles rhythmically to deploy your own natural reflex to resist and suppress urinary urgency (more about this below).
- INTERVAL TRAINING
Imposing a gradually increasing interval between urinations will help establish a more normal pattern of urination. If you are urinating small volumes on a frequent basis, your own sense of urgency is not providing you with accurate information about the status of your bladder fullness. Urinating by the “clock” and not by your own sense of urgency will keep your voided volumes more appropriate. Voiding on a two-hour basis is usually effective as a starting point, although the specific timetable has to be tailored, based upon the bladder diary. A gradual and progressive increase in the interval between voiding can be achieved by consciously delaying urinating. A goal of an increase in the voiding interval by 15-30 minutes per week is desirable. Eventually, a return to more acceptable voiding intervals is possible. The urgency inhibiting techniques mentioned above are helpful with this process.
- BOWEL REGULARITY
A rectum full of gas or fecal material can contribute to urinary difficulties. Because of the proximity of the rectum and bladder, a full rectum can put internal pressure on the bladder, resulting in worsening of urgency and frequency.
- PELVIC FLOOR MUSCLE TRAINING (PFMT)
The pelvic floor muscles (PFM) play a VITAL role in inhibiting urgency and frequency. Voluntary rhythmic pulsing of the PFM can inhibit urgency and frequency and PFMT hones the inhibitory reflexes between the pelvic floor muscles and the bladder.
Initially, one must develop an awareness of the presence, location, and nature of the PFM and then train these muscles to increase their strength and tone. These are not the muscles of the abdominal wall, thighs or buttocks. A simple means of recognizing the PFM for a female is to insert a finger inside her vagina and squeeze the PFM until the vagina tightens around her finger. Another means of identifying the PFM for either gender is to start urinating and when about half completed, to abruptly stop the stream. It is the PFM that allows one to do so. When feeling the urge to urinate, rhythmic pulsing of the PFM–“snapping” the PFM several times—can diminish the urgency and delay a trip to the bathroom.
- LIFESTYLE MEASURES: HEALTHY WEIGHT, EXERCISE, TOBACCO CESSATION
The burden of excess pounds can worsen frequency by putting pressure on the urinary bladder, similar to the effect that excessive weight has on your knees. Even a modest weight loss may improve the situation. Pursuing physical activities can help maintain general fitness and improve frequency. Lower impact exercises–yoga, Pilates, cycling, swimming, etc.–can best help alleviate pressure on the urinary bladder by boosting core muscle strength and tone and improving posture and alignment. The chemical constituents of tobacco constrict blood vessels, impair blood flow, decrease tissue oxygenation and promote inflammation, compromising the bladder, urethra and pelvic muscles. By eliminating tobacco, symptoms can be improved.
Bottom Line: Bladder retraining can be an effective means of whipping your bladder (and your mind) into shape to help convert dysfunctional habits into more normal and appropriate voiding patterns. This has the potential of helping many people. However, if the aforementioned strategies fail to improve your situation, you should have a basic urological evaluation, including a urinalysis (dipstick exam of the urine), a urine culture (test for urinary infection) if indicated, and determination of how much urine remains in your bladder immediately after emptying. At times, tests such as cystoscopy (a visual inspection of the urethra and bladder with a narrow, flexible instrument) and urodynamics (sophisticated tests of bladder function) will need to be done as well. Urologists have the wherewithal to improve this situation and your quality of life.
Wishing you the best of health,
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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery. He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community.
Dr. Siegel has authored the following books that are available on Amazon, iBooks, Nook and Kobo:
MALE PELVIC FITNESS: Optimizing Sexual & Urinary Health
THE KEGEL FIX: Recharging Female Pelvic, Sexual and Urinary Health
PROMISCUOUS EATING: Understanding and Ending Our Self-Destructive Relationship with Food
These books are written for educated and discerning men and women who care about health, well-being, fitness and nutrition and enjoy feeling confident and strong.
Dr. Siegel is co-creator of the male pelvic floor exercise instructional DVD: PelvicRx
Female version in the works: Female PelvicRx
Tags: Andrew Siegel MD, bladder, bladder retraining, overactive bladder, pelvic floor exercises, pelvic floor training, urinary frequency, urinary urgency, urologist, urology
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