Dysfunctional Voiding and Bladder Problems

Common Bladder Questions

If you have bladder problems and the doctor has told you that “nothing is wrong”, you may be dealing with dysfunctional voiding due to pelvic floor muscle dysfunction. You may ask yourself some of the following questions:

Why do I pee so much?

Why do I feel like I have to go all the time?

Why do I feel like I have to pee really bad and then not much comes out?

Dysfunctional voiding is the most common reason for voiding difficulties in women that are not of a neurogenic or structural cause. It can cause symptoms such as:

• Intermittent urine stream that starts and stops
• Having urinary frequency (> every 2 hours)
• Having urinary urgency (strong sensation to pee)
• Urinary retention where you cannot get all the pee out

Is Anything Wrong With the Bladder?

One of the things I do as a pelvic physical therapist is help people with their bladder problems. You know that saying, “If it looks like a duck, swims like a duck, and quacks like a duck, then it probably is a duck?” Well, this is not always the case with bladder problems.

It may seem like if you have urinary incontinence, urinary frequency, urinary urgency, or dysuria (pain with peeing), that you have a bladder problem. But when it comes to these symptoms, the problem isn’t always stemming just from the bladder. In fact, often times the problem is not the bladder.

This is why medical treatments (including medications like Myrbetriq, Oxybutynin, Detrol, or bladder instillations if you have IC or surgery) don’t work. Because these therapies are directed at healing the bladder and the symptoms are not coming from a problem in the actual bladder

3 Groups of People Who Pee All the Time

Okay, so what’s the problem then? Well, we will get there, but first I want to talk about 3 groups of people who pee all the time. Because there are some people for whom medical interventions are indicated.

You can classify people with bladder problems into the following 3 groups:

1. People who have a medical condition
2. People who have physical condition (dysfunctional voiding)
3. People who have both, so for instance you start off with a medical condition that makes you pee a lot and you then develop poor voiding habits and this leads to other issues.

The people who pee all the time because they have a medical condition can have a condition such as:

• Diabetes
  • Kidney disease
  • UTI
  • Pregnancy

In order to resolve the symptoms coming from the above conditions, you will likely need medical treatment. Or, as in the case of pregnancy, to give birth.

There are also groups of people who may have a condition that can benefit from both medical intervention and physical therapy, including:

• Interstitial Cystitis (85% have no ulcers in their bladder)
• Multiple Sclerosis

Dysfunctional Voiding

Now, let’s talk in more detail about the people who pee all the time because they have a physical problem. The physical problem I am talking about is called dysfunctional voiding. Just like people can have dysfunctional families, you can also have dysfunctional voiding patterns.

The definition of female dysfunctional voiding (FDV) according to Artibani and Cerruto is “an intermittent and/or fluctuating flow rate due to involuntary intermittent contractions of the periurethral striated or levator muscles during voiding in neurologically normal women.” A simpler way of saying this is to say that the muscle in the bladder that pushes the pee out, and the muscles that let the pee out (the pelvic floor muscles) aren’t communicating well with each other and there is no neurological pathology or disease that is causing this to happen.

What Happens Normally When You Pee

Normally, our bladder fills with urine and when it gets to a point, usually 300-400 mL, a signal goes off that lets us know it’s time to pee. Then, at the appropriate time, the detrusor (the muscle inside the bladder) contracts, and the muscles that keep us from leaking (in the urethral and the pelvic floor muscles) open.

What Shouldn’t Happen When You Pee

When peeing goes wrong, the muscles that should open to let the pee out don’t open and at other times they may open at the wrong time.

Have you ever met someone who, not to be rude, but someone who is a total “motor moron”? Like you tell them to lift their arm out front and they lift it out to the side and just can’t figure out? This can happen with the pelvic floor muscles and can be due to either an anatomical reason or a functional reason.

This is called dysfunctional voiding and is the most common reason for voiding difficulties in women that are not of a neurogenic or structural cause, meaning your nervous system is okay and your anatomy is okay.

Anatomical Reasons for Dysfunctional Voiding

Dysfunctional voiding can occur due to having an anatomical issue such as:

• Pelvic organ prolapse
• Anti-incontinence surgery
• Urethral stricture
• Urethral diverticulum
• Urethral tumors

Functional Reasons for Dysfunctional Voiding

Alternatively, dysfunctional voiding can occur due to having a functional issue. The functional issue, in this case, is pelvic floor muscle dysfunction. This means that muscles that control your pee have issues such as weakness, overactivity, shortening, or pain.

Some reasons why include:

• Overactive pelvic floor muscles, they don’t know how to let go (so I do tend to see this in a lot of ambitious, type A women)
  • Posture
    • Muscle holding and clenching patterns
    • Stress
    • Bladder habits (not taking enough time, drinking bladder irritants, always going just incase so your bladder never knows what if )

How Does Pelvic Floor Dysfunction Affect My Bladder

Having an issue with the muscles of the pelvic floor (which are different than the muscles of the bladder) can affect the bladder.

There are 3 reasons why:

1. If the body perceives something in the pelvic area as harmful (i.e. menstrual cramps, yeast infection, urinary tract infection, etc.) can trigger an inflammatory process in the bladder wall.
2. The viscero-somatic reflex: there is a reflex loop that connects the viscera (i.e. bladder) and the somatic (i.e. pelvic floor muscles) systems. So an irritation of the vagina (i.e. yeast infection) can cause the bladder to be irritated.
3. There can be neural cross-talk between the nerves that control the pelvic floor muscles and those that control the bladder. So if you are stressed and carrying stress in your pelvic floor muscles you can end up with bladder problems.

Q & A

Q: I have a cystocele and was told I needed surgery. Is this my only option?

A: No. First off, a cystocele can cause urinary urgency and frequency, but physical therapy has been shown to be just as effective as surgery in cystoceles grade 1 & 2 and can help grade 3. There are probably some other factors that are going on that caused that cystocele in the first place. So for instance abnormal voiding patterns, constipation, abnormal breathing patterns. And if you don’t correct those, you could end up potentially needing a second surgery.

Q: I am trying to go longer between voids and get myself on a voiding schedule. Is this effective as a means of treatment?

A: Possibly, but it’s kind of like if you want to lose weight and someone told you to eat less. You have to have rock-solid motivation, a thorough understanding of why this will help. So for instance, you need to address your voiding biomechanics (are you fully emptying your bladder), are there any dietary irritants that are causing you to urinate frequently? What is your pelvic floor doing? What is your fascia like? If you don’t address all of these factors first, getting on a schedule is not likely to be beneficial.

Q: I have always peed about every hour for as long as I can remember. Does this mean that I will never be able to go longer without having to pee?

A: Not necessarily. I do think it would be beneficial to have urodynamics study and see a urologist or a urogynecologist to see if you truly have a decreased bladder capacity or if this is a learned habit from childhood. Did your mom always tell you to go just in case?

References

Artibani W, Cerruto MA. Dysfunctional voiding. Curr Opin Urol 2014; 24(4):330-335.

Deindl FM, Vodusek DB, Bischoff CH, Hofmann R, Hartung R. Dysfunctional voiding in women: which muscles are responsible? Br J Urol 1998; 82:814-819.

Peters KM, Carrico DJ. Frequency, urgency, and pelvic pain: treating the pelvic floor versus the epithelium. Curr Urol Rep 2006; 7:450-455.

Do you have a bladder problem that you need help with? Contact me today for a free consultation.