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Urinary Urgency: How to Hold it Together When You’re Barely Able to Hold it In

October 16, 2021

Andrew Siegel MD 10/16/2021

Urinary urgency is the sudden and strong desire to urinate that causes an uncomfortable bladder sensation and pressure that demands immediate relief. It is a particularly annoying symptom because of its abrupt and unanticipated onset, the physical sensation it creates, and because of its inconvenience, often happening randomly and without access to a bathroom. With no bathroom accessible, the urgency can sometimes lead to an embarrassing episode of urinary leakage, appropriately called urgency incontinence. Those who suffer with urinary urgency often know the location of every bathroom in town and before an excursion outside their home take the time to think about and map out locations of available bathrooms. The constant need to use the bathroom makes one self-conscious and it is not uncommon to need to keep a bottle in one’s car or to have to empty one’s bladder in “improvised” places.

New York City is a particularly bad location to experience urinary urgency! Talk about lack of infrastructure. 8 million residents, yet less than 1200 public restrooms!

New York City. Image by Pexels from Pixabay

With the pandemic on the downslope and people flocking outside, lines at these restrooms are longer than ever. The largest providers of public restrooms are The Parks Department, MTA subway stations, city buildings (libraries, police stations), and public pools. The only 24/7 public restrooms are at Port Authority and Penn Station. Many restrooms are poorly labeled, poorly maintained, and frankly, filthy. Other countries, including Japan, Britain and Germany, have accessible and clean facilities. London even has a Great British Public Toilet Map. We can do better!

COMMON CAUSES OF URGENCY

Drinking Too Much Fluid or the Wrong Kinds of Fluids

Urinary urgency can occur with consumption of too much of any fluid, particularly caffeinated beverages and alcohol, both of which have a diuretic-like effect. In general, the greater the volume of urine in the bladder, the more intense the urgency. Furthermore, the faster the bladder fills up with urine, the more intense the sensation of urgency.

Far too many people have urgency simply on the basis of overzealous beverage intake. One of the biggest misconceptions is that humans needs to drink 8-12 glasses of water daily. This may be the case if you are running marathons in 90-degree weather, but certainly not under normal circumstances. Humans are extremely well-designed with sophisticated thirst mechanisms in play that safeguard one from dehydration. So, drink in accordance with your thirst as you eat in accordance with your hunger. I see way too many patients for unnecessary urology consults for urgency and frequency who do bladder diaries for me that show frequent full-volume voids do to over-drinking water. Please check out this terrific recent NY Times article: How Much Water Do You Actually Need?

Simple rule: He/she who drinks excessive volumes of water will pee excessively and will have urgency accompany the rapid bladder filling. The same goes for too much caffeine (coffee, tea, colas, energy drinks, chocolate) and alcohol.

Diuretic medications

These medications are intended to kick the kidneys into producing lots of urine and as a consequence urgency is likely and expected to occur.

Overactive bladder

A bladder that “squeezes without its owner’s permission” gives rise to acute onset of urinary urgency, often at inconvenient times. Many people whose urgency is based upon exposure to triggers (see below) have an overactive bladder; however, trigger exposure is not a requirement to induce an involuntary bladder contraction that may occur spontaneously without any provocation. Involuntary bladder contractions commonly occur with many neurological conditions including stroke, multiple sclerosis, Parkinson’s disease, etc. Please visit: 12 Ways to Overcome Overactive Bladder.

Psychological triggers

Many people develop conditioned responses to cues associated with the act of emptying one’s bladder. Any source of running water—the kitchen sink, bathroom fixture, shower, etc.—can elicit a conditioned response in which exposure to such a trigger causes urinary urgency. Parents often train their infant children to urinate on command by having them sit on the toilet and run the faucet, creating and reinforcing an association between running water and urinating. This is a helpful toilet training tool; however, this conditioned response can come back to haunt one later in life, when exposure to running water triggers an involuntary bladder contraction and hence urgency and perhaps even urgency incontinence!

Other common Pavlovian-type conditioned responses are placing the key in the door to one’s home, arising out of one’s car, getting closer to the bathroom, and anxiety. Any cue that reminds one of urinating is enough to trigger this response. Please visit: Triggers that Induce Urinary Urgency: You’re Not Crazy.

Learned maladaptive habit

If one is hyper-focused on their sensations arising from the bladder, they may start responding to the initial hint of low-level urgency by running to the bathroom (as opposed to most adults, who ignore the urgency until it gets beyond a certain threshold). This hyper-focus and response ultimately become an ingrained habit and the hyper-focus exacerbates the urgency.

Incomplete bladder emptying

A bladder that does not empty starts off on a bias; because it remains partially filled after voiding, it takes less time to fill to capacity. This can be caused by prostate enlargement, scar tissue in the urethra, bladder prolapse, under-active bladder, and neurologic issues affecting bladder function, etc.

Low capacity bladder

Aside from overactive bladder, a reduced “functional” bladder capacity may be caused by bacterial cystitis, bladder stones, bladder cancer, radiation cystitis, interstitial cystitis, pelvic floor muscle tension myalgia, and prostate enlargement. A reduced “anatomical” bladder capacity may be cause by bladder scarring, radiation, prostate enlargement, etc.

Peripheral edema (fluid accumulation within tissues of legs)

Swelling of the ankles and legs may be caused by heart, kidney, or liver impairment, nephrotic syndrome, malnutrition and venous stasis. When lying down to sleep, because of the influence of gravity the accumulated fluid is mobilized and released from the kidneys as urine, causing nocturnal urinary urgency.

Obstructive sleep apnea This is a common cause of nocturnal urinary urgency and an entire topic in and of itself. Please visit: Snoring Your Way to Frequent Nighttime Urinating.

Diabetes Poorly controlled diabetes causes the presence of sugar in the urine that acts as a diuretic. Certain diabetic medications that lower blood sugar by excreting it in urine have the same effect. Please visit: Diabetes and Urological Health.

Extrinsic compression on bladder

Pregnancy, uterine fibroids, constipation and pelvic masses and even gas in the colon can put pressure on the bladder and induce urgency.

Lower ureteral stone

The terminal portion of the ureter traverses the bladder wall and a stone at this location can irritate the urinary bladder causing intense urgency to urinate.

LESS COMMON CAUSES OF URGENCY

Diabetes insipidus

This affects the kidneys’ ability to concentrate urine and gives rise to massive volumes of urine production and hence urinary urgency.

Kidney disease with loss of kidney concentrating ability and high volumes of urine production and hence urinary urgency.

Primary polydipsia due to a dysfunctional thirst mechanism from brain trauma, radiation, surgery, etc. The disturbance in the thirst mechanism causes one to drink constantly with resulting high volumes of urine production and hence urinary urgency.

MANAGEMENT OF URINARY URGENCY: USE YOUR PELVIC FLOOR MUSCLES TO COMMUNICATE WITH AND CALM THE BLADDER

Aside from the obvious solution of cutting back on fluid, caffeine, and alcohol intake and taking care of any medical or urological issues that may be contributing to the urgency, there is a nifty trick that can be employed to help suppress one’s urgency, tapping into a reflex that can effectively calm down the over-contracting bladder.

What can be done when the urge to urinate strikes? If one’s bladder is truly filled to capacity, nothing will help short of emptying it. However, if one’s bladders is not full, but is simply contracting involuntarily– either spontaneously or in response to a trigger–there is a simple and effective means of countering it. Deploying one’s pelvic floor muscles will counteract/prevent the involuntary bladder contraction. When the pelvic muscles are voluntarily squeezed, a reflex relaxation of the bladder can make the urgency disappear.

Whether female or male, by doing simple and well-time rhythmic contractions of the pelvic floor muscles (Kegel contractions), the involuntary bladder contraction can be terminated/obviated. If the urgency is in response to a trigger, the pelvic contractions can be done immediately after the urgency to counteract the involuntary bladder contraction, but preferably before exposure to the trigger to prevent the involuntary bladder contraction from initiating. If the urgency occurs spontaneously (without triggers), the pelvic floor contractions should be done at the first hint of urgency.

The bottom line is to not drink excessively with the best guide being your thirst and to know your triggers, anticipate urgency, and Kegel on demand or preemptively to send your bladder a message to calm down. This is not about strengthening and conditioning your pelvic floor muscles, but about tapping into the reflex relaxation of the bladder that occurs with pelvic floor muscle contractions. Try it, it truly works! Please visit: The Reflex to Overcome Urinary Urgency.

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. He is a urologist at New Jersey Urology, the largest urology practice in the United States. He is the co-founder of PelvicRx and Private Gym. His latest book is Prostate Cancer 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families.