Managing Bladder Urgency
Beth Safarian, MScPT, PT
Registered Physiotherapist – Pelvic Health
Bladder urgency is an extremely common concern that we treat at our clinic. It is defined as a sudden, intense desire to urinate that is difficult to ignore. It is a key symptom of overactive bladder (OAB), and can occur with or without incontinence. Urgency is distinct from simply needing to urinate—it involves a strong, uncomfortable sensation that creates a need to find a washroom immediately. This feeling is typically out of proportion to the actual amount of urine in the bladder and for some people, this urgency can become so strong that they lose bladder control. This is called urge urinary incontinence. While it is common among older clients, it is very frequently seen in younger populations as well. The mechanisms that may be contributing to urgency can include inappropriate tightening of the bladder muscle when filling, increased sensory nerve activity in the bladder lining and/or central nervous system dysfunction. Because the mechanisms of urgency are very different than stress urinary incontinence (leaking with cough/sneeze/laugh), the treatment and management are quite different as well.
Education and Behaviour Modification
The first step to managing bladder urgency is education and behaviour modification. We explain to our clients the different mechanisms that lead to urgency, as well as identifying specific triggers. The majority of people experiencing urgency will notice particular situations that initiate the sense of urge. Some of these triggers include approaching their front door, putting the key in the door, being in an elevator, running water (eg. brushing teeth, doing dishes, showering), or standing up from a sitting position. By identifying a client’s specific trigger, it can allow them to prepare and make appropriate adjustments in their behaviour prior being exposed to the trigger. We also discuss the role of fluid intake and diet on bladder function. You may think that reducing water intake is a good idea if you deal with frequency; however, it can actually have the opposite effect. Dehydration causes our urine to become more concentrated, and therefore more acidic. The acidity can irritate the bladder lining, increasing the sensory nerve activity in the bladder. This can causes inaccurate signalling to the brain that the bladder is more full than it actually is. If you are experiencing OAB symptoms, while it may seem counter intuitive, make sure you are well hydrated! Many clients also find it helpful to reduce bladder irritants like coffee and alcohol.
Strategies to Help Diminish Bladder Urgency
Once triggers have been identified, then we can start implementing strategies to use before and after a client has been exposed to the trigger. The most effective and simplest strategy that we start with is down regulation of the nervous system. In other words, staying calm and relaxing the body. I know this seems counterintuitive, but it really does work and here’s why. As mentioned earlier, bladder urgency can be caused by premature or excessive contractions of the bladder muscle (also known as the detrusor muscle). The detrusor is a smooth muscle that lines the walls of the bladder. Because it is a smooth muscle, we do not have voluntary control over it (versus a skeletal muscle which we can control). Smooth muscle is impacted by our central nervous system; therefore in order to relax smooth muscle, we want to activate the parasympathetic nervous system. The parasympathetic nervous system is activated via relaxation techniques like deep breathing, slow movements and positive self talk. The majority of our clients will be skeptical when we first discuss these techniques, but they usually will notice improvements very quickly with this shift in their approach.
After implementing relaxation, distraction and visualization techniques, many clients will be doing much better with their urge management. However, these techniques are not always sufficient for everyone. So let’s talk about kegels... when used correctly, they can be effective at relaxing the detrusor muscle. When the pelvic floor contracts, it creates a signalling loop to the brain and back to the bladder which causes the detrusor muscle to relax. Common types of kegels we may work on could be a 5 second gentle hold, followed by a slow and controlled release. We may also try some gentle quick contractions with a 1 second contraction, followed by a slow relaxation. While kegels can be effective, they can also make urgency worse if not executed appropriately. Where clients go wrong is when they try to squeeze as hard as they can to “hold it in”, and maintain that pelvic floor contraction as long as they can until they make it to the washroom. The issue with this approach is that clenching constantly to an intense degree can actually make the detrusor spasm more to the more point where it overpowers the pelvic floor, resulting in bladder leakage.
Transcutaneous Tibial Nerve Stimulation (TTNS)
If a client is not responding to these strategies discussed above, we may suggest transcutaneous tibial nerve stimulation (TTNS). TTNS is a non-invasive neuromodulation technique that involves the application of electrical impulses to the tibial nerve, typically via electrodes placed near the ankle where the tibial nerve is best accessed. The tibial nerve shares common nerve roots (S2–S4) with the nerves that control bladder function, so stimulating it can modulate neural pathways involved in bladder storage and voiding reflexes. By regularly stimulating this nerve, TTNS can help inhibit involuntary bladder contractions, reduce urinary urgency and frequency, and improve overall bladder control. There is a wide range of frequency recommendations from the research; so we typically suggest anywhere from daily to weekly for 12 weeks.
Medication and Further Medical Management
If all of the above techniques fail or result in minimal improvements, we may suggest talking to your doctor for a referral to a urologist or uro-gynecologist. They can perform more specific testing, as well as discuss pharmacological treatment options, such as Mirabegron. This works by activating B3-adrenergic receptors in the detrusor muscle of the bladder wall. Activation of these receptors causes the detrusor muscle to relax when the bladder is filling, which increases bladder capacity and reduces the sensation of urgency.