Bladder Boot Camp

“There are no shortcuts to any place worth going.”

- Beverly Sills

Your bladder is a muscular sack with two tasks – to hold, and eliminate, urine. In a normally functioning bladder, that process works like this: Urine descends into the bladder from the kidney via the ureters. The sphincter muscle at the bottom of the bladder keeps the urine from escaping. When the bladder is full, the muscular lining is stretched, giving the bladder the urge to contract. If your bladder functions normally, you can ignore the urge until it is more convenient, or at least until you get to the bathroom. If you wait too long, the urge will become unbearable and you will have to void.

What is too long? Nurses are notorious for making it through an 8 or 10 hour day before relieving themselves. Months or years of this behavior is bound to cause problems. People with overactive bladder symptom (OBS), or interstitial cystitis (IC) can sometimes last only minutes before the urge becomes too strong (sometimes painful) and they must void. If a person tries to hold urine “too long” they will either lose control (become incontinent), or they will experience pain and spasm, and possibly begin to retain urine. Neither one of these scenarios is desirable.

A normal bladder habit is one in which the person voids 4-6x/day and 0-2x/night. This means in a 24 hour day, if you are awake for 16 hours, you should be going to the bathroom every 3 ½ to 4 hours. If you are one of those 8 to 10 hour people – do yourself a favor and take a lunch break - go to the bathroom, your bladder will thank you. For those of you that are going to the bathroom more often, things are a little more difficult.

There are many reasons that a person may have a small bladder capacity. The muscle may be tight (like a shortened hamstring that needs to be stretched) or prone to spasm. The smaller capacity may be habitual. For instance, if you are pregnant, you get very used to making bathroom runs “just in case” every where you are, by the end of the last trimester, chances are you don’t go past a bathroom without stopping in. After the baby is born, going to the bathroom very often has become a habit, and eventually your bladder thinks that it is normal to go every hour or half hour.

If the problem is not painful, and the bladder does not seem to spasm (which is typically painful), then bladder training may be very beneficial for you. There are several different ways to re-train your bladder. I like to start with the bladder diary, and assess the voiding patterns.

Sometimes the diary will show that someone is only having problems when they consume things that irritate the bladder. I have had people completely “cured” simply by eliminating certain things from their diet. Things to look out for:

· Anything with caffeine – coffee, tea, chocolate

· Alcohol, particularly red-wines

· Citrus – juice or fruit

· Tomatoes (even spaghetti or pizza sauce)

· Anything carbonated

· Hot, spicy things

· Vinegar

Ok – that’s the short list, but most of the “biggies” are on it. Look carefully and be sure that you understand the relationship between what goes in and how quickly things come out. As a side note, water will help to keep your urine dilute, so the urine is not as concentrated, and not as likely to irritate the bladder, so drinking water (a few sips every 10 minutes or so) is highly recommended.

Before I go into the actual training part, remember that if having a full bladder is painful, then bladder training is probably not appropriate for you. Interstitial Cystitis patients particularly, if the lining of your bladder is compromised (Hunner’s ulcers), please question anyone that asks you to start a retraining program to explain their rationale. Be very clear that they understand what the lining of your bladder looks like, and what they hope to accomplish by stretching it.

When I feel it is safe to start someone on a training program, I look at the bladder diary. If you are going on the average 20x/day, that is voiding approximately every ½hour to 45 minutes. I try to take the conservative view, and assume that you can probably make it on a 30-minute schedule. You start with the first void of the morning, then every 30 minutes you stop what you are doing, and go take a comfortable trip to the bathroom. If you have to go at 20 minutes, take a big breathe, find a diversion, and try to ignore it for the next 10. Sometimes if you contract and relax the pelvic floor muscles two or three times (quick flick Kegels), it will help to control the urge. If you do not void at 30 minute, wait until the next scheduled void before you try again. If you absolutely cannot wait until the scheduled void, note the time that you went, and time subsequent voids based on the new time.

This first phase gets you in control of your bladder. You may actually be going more frequently than you would normally, but it is controlled by your brain, not your bladder. If this schedule is managed within a few days, we change the void schedule to 45 minutes. Again, beginning with the first void in the morning, and attempting to void every 45 minutes. After this we add 15 minutes about once a week. Sometimes we have to play with it a little, sometimes 15 minutes is too much to add; sometimes it takes longer than a week to master the new schedule.

Patients with pelvic floor dysfunction have to be extremely cautious when starting a training schedule. The “quick flick” method of controlling urge can have devastating effects on your ability to relax those muscles. “Holding” for too long can cause spasm in the pelvic floor, increased pain, and potential problems with retention. Although many medical practitioners are perfectly capable of establishing and following a bladder training program; for patients with pelvic floor problems I think that it is vital that you are being followed by a trained physical therapist with experience in treating the pelvic floor.

It is very important to pay attention to when it is difficult, and what is going on in your head when you have more frequency. Do you have a work bladder and a home bladder? Which one is easier to play with? Do you need to bring your home bladder to work with you? Stress can play a huge role in bladder activity, and you need to be able to find that place in you where you feel most relaxed, even if the environment is difficult.

Good luck, and safe training!

Language Barrier

“Incomprehensible jargon is the hallmark of a profession.” –
Kingman Brewster

We, in the medical field, use a lot of specific medical terms. This allows precision in professional communication, and helps us avoid confusion. For instance – when you tell your doctor or physical therapist that your shoulder hurts, we really don’t know what you are talking about. For you, “shoulder” can mean the area between your neck and your shoulder, the upper part of your arm, the muscles around your shoulder blade, or the ball and socket joint that moves your arm; for me, it’s the joint, and the structures that act on the joint. When you say “shoulder,” I ask you to point. This is the only way for me to be sure we are talking about the same thing.

Sometimes confusion happens when medical people try to use your terminology to explain things, thinking that they are helping you, then you go see a new health professional, full of everything your doctor said, and the explanation you give doesn’t fit into our language.

It gets worse. Sometimes we use terms in one branch of medicine that have completely different meanings to someone in another specialty. Sometimes a new term will pop-up to explain a phenomenon that is getting more attention. Whole specialty areas can be established around this “new” health concern, and the term can be used by medical professionals for years before it is fully defined. Often, by the time a standard definition is established, the professionals that have been using the term are either so used to it having the meaning they assign (which may be very specific in their head, but have little to do with what other professionals understand that term to mean); or, they are unaware that there has been a standardization of the term.

This has happened with the term “Pelvic Floor Dysfunction.” There is a specific definition, and I am just as guilty as others about using my own version of the term.

Here is the real definition, as established by the International Continence Society, and published in the Journal of Neurology and Urodynamics in 2002:

• "Pelvic Floor Muscle Dysfunction can be qualitatively defined by the tone at rest and the strength of voluntary or reflex contraction as strong, weak or absent or by a validated grading system. A pelvic muscle contraction may be assessed by visual inspection, by palpation, electromyography, or perinometry. Factors to be assessed include strength, duration, displacement and repeatability."

OK – I said medical terms are specific, I didn’t say they were clear. Pelvic floor muscle dysfunction (PFD) is any abnormal quality in the muscle that affects:

• resting tone (spasm, or low-tone)


• strength (weak muscles that indicate stress incontinence are symptoms of PFD)


• duration of contraction (how long can you hold it?)


• displacement (does the pelvic floor lift, bulge, or stay in the same position with contraction?)


• repeatability (after contraction, can you relax it? Can you contract it again to the same level?).

I tend to use the phrase to indicate spasming muscles, or muscles that can’t relax properly. I am aware that weakness and low tone are forms of PFD, but I lean towards labeling the problem differently when these are the factors.

What is my point?
When your doctor or therapist tells you that you do, or do not, have PFD, ask her to be specific in her definition. Pain in the pelvic floor is often, but not always, and indicator of muscle spasm. Trigger points are active in muscle that are tight or spasmed, so if you have trigger points in the pelvic floor muscles, regardless of where they refer, you have PFD. If your muscles are weak, you have PFD. If the muscles are in spasm, you have PFD. If you contract, and the pelvic floor does not lift, you have PFD. If you can't hold the contraction, you have PFD. If you can't relax after contraction, you have PFD. If you can't repeat the contraction, you have PFD. It’s a big list.

As a physical therapist, I think that everyone with PFD, regardless of their symptoms, can benefit from pelvic floor therapy. It is a muscular dysfunction, and that’s what PT’s do. Your doctor may have different ideas, and may feel that different drugs or therapies are indicated for different PFD presentations. You certainly wouldn’t want him to give you a muscle relaxor for PFD if your presentation is weak, low tone muscles, would you? So – ask questions, and be aware that while you may both be speaking English, it is a different dialect, and patience (on both sides) is important.

Exercise and IC

I was recently asked for guidelines on exercises for someone with Interstitial Cystitis. I feel it extremely important that people stay as active as possible, even when their condition limits the amount of time and energy they can commit to an exercise program. Here are key points that I go over with my patients. If you suffer from IC, and are thinking of starting an exercise program, please discuss it with your doctor or physical therapist first.

Exercise and IC

• Posture: This is absolutely key. Good posture increases blood and nutrient supply to the pelvic organs, and reduces stress on skeletal muscles, ligaments and joints. Be wary of sitting on hard surfaces (like work-out benches), many people have no problems with these, but for some, it can irritate symptoms
• Aerobic Conditioning: This is always beneficial. Especially important with IC: REMAIN HYDRATED! Toxins build up in the tissues with exercise unless you flush them out. These toxins are bladder irritants, and need to be diluted. Avoid high impact activities that will jar the bladder and encourage tightening of the pelvic floor.
  Bicycling may irritate the pelvic floor, depending on the seat.
• Core Stability: These exercises are especially beneficial, if not too strenuous, and attention is paid to the increase of inter abdominal pressure. Pilates is rarely a good idea for pelvic floor patients, unless they are in absolutely excellent condition with minimal symptoms.
  Ball activities are great. Sitting on the ball reduces tone in excessively tight PFM muscles, and increases tone in weak muscles.
• Stretching: Very important, but pay close attention to postural alignment, and be gentle.

Avoid Vigorous activity: (Stretching and strengthening), especially if it involves the muscles of the groin, abdominals, buttock, inner thigh or piriformis. Microtrauma to these muscles from over strenuous activity may cause trigger point or activation of latent trigger points that refer into the bladder or pelvic floor region. Don’t avoid working these areas, just be cautious.

Most IC patients know more about their bodies and their condition than any of the health professionals working with them. Listen to your body and pay attention to the signals. There may be increased symptoms if you overdo it at first, but keep working at it until you find a balance that allows you to improve your overall condition without irritating your IC.