It depends…are you an urgent pee-er, or do you have a lazy bladder?
By Dr. Aldene Zeno
When patients ask me about holding their urine, they usually fall into one of two groups: urgent pee-ers or over-stretched bladders. As I mention below, how often one goes to the bathroom is not an issue until it starts to affect quality of life. There is, however, a happy medium when it comes to how long to wait to urinate.
The problem: going to the bathroom at the first sign of bladder urge
If you are unable to suppress the urge to go to the bathroom, this, by definition, is urinary urgency. In some women, this manifests as the feeling that you have to run to the bathroom as soon as you feel the need to go. Other women will experience bladder leaks with these urges if they do not go in time, which is known as urinary urge incontinence. Often times, women with urinary urgency will go to the bathroom frequently to avoid bladder discomfort or leaking on themselves. Imagine having to take a trip to the bathroom every 15 minutes — the condition is very disrupting.
Anyone with a normal bladder gets an “urge,” or some sort of sensation as the bladder becomes full. However, the bladder is supposed to be like a balloon and stretch as it fills, so that even as it is filling the relative pressure in the bladder stays the same. Because of that, a normal bladder can actually hold a lot of urine — I’ve unfortunately seen some cases where women who could not feel bladder urges unknowingly had over 1 liter of urine in their bladder (think half of your standard, large soda bottle!).
There are several reasons why someone can’t hold a shot-glass of urine in their bladder for more than 15 minutes, and others can hold one-half of a large soda bottle of urine for several hours. Many experts believe there may be a miscommunication between the brain and the bladder, where either the bladder is very sensitive and tells the brain to pee even though it’s not very full, or the bladder may leave the brain out of the conversation entirely and cause bladder contractions through automatic reflexes. There’s other factors to consider, such as underlying medical conditions, medications, and a woman’s hormonal status (urinary urgency is more common in menopause), but many interventions to treat bladder urge focus on either relaxing the bladder or improving the way the brain and bladder communicate (called neuromodulation).
The problem: holding your urine all day
This is sometimes known as “lazy bladder” or “teacher’s bladder,” however I often see this in women with jobs where they ignore urges to pee for several hours. When I say several hours, I mean 6 hours or longer, sometimes only peeing once at the beginning of their workday, plus-or-minus during their break, and then at home after work. Over time, usually years or decades, this can cause bladder muscles to become weak. Along with excessive urine holding, many of these women have other unhealthy bathroom behaviors like hovering over the toilet to pee or bearing down while peeing. Normally, urination should be a passive event — relaxing your pelvic muscles on the toilet should help your brain get the signal to squeeze your bladder automatically. However, holding your pee for excessively long combined with not relaxing your pelvic floor while hovering or bearing down leads to problems down the road.
Eventually, the bladder becomes overly-stretched and cannot contract enough to squeeze out urine. On top of that, the pelvic floor that normally helps hold in urine sort of “forgets” how to relax, worsening the normal communication from our brains to contract the bladder. Over time the bladder becomes a floppy balloon, or what experts call “hypotonic bladder.” This floppy balloon can even contract so poorly that women will leak before they get the urge to go to the bathroom. On the other hand, they may only get bladder urges when the bladder is excessively full, making it seem that they have urge incontinence when in fact they have a lazy bladder. This type of leaking is called overflow incontinence.
The solution: bladder training
Like other muscles, you can train the bladder. I liken this to potty-training, but for adults. The solution to urinary urgency and hypotonic bladder begins with self-awareness. If you see a specialist, they will often begin your treatment by giving you a bladder diary to understand your symptoms. Once you understand your symptoms, then you can begin to work toward increasing time between voids if you’re an urgent pee-er, or going to the bathroom more frequently if you have a lazy bladder. This handout from the International Urogynecological Association (IUGA) explains bladder training for urinary urgency. For women with hypotonic bladder or overflow incontinence, they may need to start going more frequently on a schedule, even if they do not have the urge to pee.
Another reason to understand your symptoms before starting treatment is because pelvic floor exercise, or Kegels, may benefit urinary urgency patients, but be counter-productive in patients with overflow incontinence. Remember, patients with overflow incontinence tend to have lazy bladders coupled with pelvic muscles that are not relaxing at the right time. Exercising the pelvic floor in this situation may contribute to already overly-tight muscles.
There are many other treatment options for urinary urge and hypotonic bladder, ranging from non-surgical to procedural and, if necessary, surgery. An experienced specialist in these conditions should offer several treatment options that are tailored to an individual’s bladder needs.