How to Improve Bladder Health

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Fiona McMahon, DPT

The bladder, not super complex right? Just a tupperware for pee, holding your urine until an opportune time to go. The bladder is so much more than that, integrating information from the brain, muscles of the pelvic floor, and responding to stretch to efficiently serve its purpose. We never think of the bladder until something goes wrong with it.

In this blog, we will be exploring the anatomy of the bladder, what is normal for the bladder, what can go wrong with the bladder, and how to best take care of your precious and hard working bladder.

Bladder Anatomy/ Physiology

 

Male or female, we all have the same basic structure of the bladder, with a few exceptions. Here’s what everyone has in their lower urinary tract.

  • Detrusor Muscle: Forms the body of the bladder and is responsible for squeezing the bladder to empty its contents. It spends most of its time relaxed in order to allow for bladder filling.
  • Trigone Muscle: Forms the neck of the bladder, and is a powerful sensory organ. When the trigone stretches in response to the filling of the bladder, it sends a message to the brain that it’s time to pee.
  • Internal Urethral Sphincter: Smooth muscle (involuntary) which seals off the exit of the bladder and allows for continence.
  • External Urethral Sphincter: Striated or voluntary muscles which also seals the exit of the bladder.
  • Urethra: This is the tube that leads out of the bladder and is the pathway for urine into the outside world.

Sex differences:

People with male anatomy have a prostate. The prostate is a sex organ and is responsible for keeping the semen at the right pH to fertilize a waiting egg. It wraps around the urethra and lives just under the bladder. It also provides a mechanical buttress or support for the bladder, lessening the load on the pelvic floor.  Because of its proximity to the urethra, problems with the prostate can cause problems with the bladder.  An enlarged prostate, which can be a benign part of aging, cancer, or infection, will restrict the flow of urine out of the urethra, resulting in weak stream, painful, burning urination, and difficulty urinating (the same thing happens with tight pelvic floor muscles). A prostate that has been surgically removed, most often has occurred for treatment of prostate cancer can reduce support for the bladder and lead to leaking. For more information on prostate cancer click here  and for more info on prostatitis, click here!

Another important difference between people with female and male anatomy are the respective length of their urethras. Male urethras are a lot longer than female urethras. This is one of the reasons people with female anatomy are more prone to bladder infections. In a female, bacteria have a lot easier time making the trek to the bladder because of the shorter urethra.

Conditions of the Bladder

Incontinence

Incontinence is the involuntary leakage of urine. There are many causes of incontinence. It’s important to know why you are leaking in order to know how to appropriately remedy it. It is possible to have more than one type of incontinence, and when that occurs we call it mixed incontinence.  Let’s go through the types together.

  • Urge incontinence occurs when you leak urine  after a sudden urge to urinate. We call it, lock in key syndrome, because certain events like unlocking the door to your home can cause urge incontinence.  This is the type of incontinence, which should be treated first in cases of mixed urge/stress incontinence.
  • Stress incontinence is the result of pelvic floor weakness that prevents the closure of the external urethral sphincter with activities that increase the pressure on the bladder, like coughing, laughing, lifting or sneezing. Pelvic floor weakness can occur if the muscles and or connective tissues are too loose to create an efficient contraction and more commonly, especially with athletes, too tight or imbalanced, to fully close the external urethral sphincter. Read more about incontinence in athletes here.
  • Functional incontinence occurs when you physically can not get to the bathroom in time to urinate. This is common in the elderly or disabled, who may have trouble ambulating to the bathroom, removing clothing, or transferring from a chair into standing. It is imperative that this type of incontinence is treated aggressively by a physical therapist or occupational therapist as it increases the risk of potentially fatal or disabling falls.

Incomplete voiding

Incomplete voiding is when the bladder does not fully empty.

In a normally functioning patient, volitional effort should not be required to empty the bladder.  A pelvic floor that is unable to relax, will have a smaller opening for urine to pass through or the voluntary muscles involuntarily contract because of muscle spasming, resulting in hesitancy, or incomplete bladder emptying.

Bladder Pain

Pain is our body’s way of telling us there is something wrong. With a new onset of bladder pain, it is important to rule out infection or an organic condition. Often times musculoskeletal conditions or general bladder irritation can mimic bladder infections.  In our practice, we often see patients who had been convinced they had an infection only to find out all of their tests for infection, where in fact, negative and the source of their pain was a tight or shortened pelvic floor.

It is important to understand the character of your bladder pain. Does your bladder hurt as it fills with urine and then feels better only shortly after voiding? If your answer is yes, you may have bladder irritation from urine that isn’t dilute enough (you are not drinking enough water), or you are consuming something irritating like spicy food, caffeine or alcohol. You may also have a condition known as painful bladder syndrome/interstitial cystitis which is contributing to your symptoms. It is important to get a handle on bladder filling pain right away, because it is the first step in treating other conditions such as frequency, urgency, incomplete emptying and retention.

If you have pain and burning during urination with no infection, it is likely the pelvic floor muscles and tissues cannot relax enough to allow urine to flow out without burning, (the pelvic floor also plays a role in bladder filling pain as well). Burning with urination that is not caused by an infection, is treatable with pelvic floor PT.

Frequency:

Everytime I hear someone say “I have a small bladder”, I have the uncontrollable urge to say, “No, you have a sensitive bladder, which can be trained to be better”. Saying you have a small bladder is 95% of the time fatalistic and just untrue. Most bladders, with few exceptions can hold 400-600 mL. Holding capacity can be diminished in cases of constipation, pregnancy and some neurological conditions, but most everyone is working with similarly sized equipment (the exception, being growing children).

Average intervoid interval, aka times between pees, is 2-3 hours, unless you chug a liter of fluid or cups of caffeine in one sitting. An example is being able to make it through James Cameron’s, Titanic, without having to excuse yourself. The trick with the bladder is it’s antsy. It informs you with the first urge to urinate when it is approximately 40% full. Over time, if you listen at that first urge, the bladder will begin to inform you earlier and earlier until you are going once every 20 minutes. Training your bladder to hold more is achieved with ignoring the urge or practicing various behavioral strategies, like deep diaphragmatic breathing with pelvic floor drops, to allow for longer intervals until your bladder capacity is within normal limits. This can be a longer process for those with a more sensitive bladder.

Bladder training is complicated by pain. Pain usually must be treated simultaneously in order to truly get the most benefit from bladder retraining. It is also important to realize that substances like caffeine and alcohol increase urgency and make bladder training more difficult.

How to Manage Bladder Issues:

Fortunately, there is a lot you can do, RIGHT now to manage your bladder symptoms. I find that in my practice and everyday life, there is a certain fatalism about bladder conditions. I can’t count how many times I’ve heard phrases like, “ I just have a small bladder”, “People my age after babies just leak”, “I am older so I pee more at night” and “it’s always been like this”. The bladder is a trainable organ and the muscles influencing it can be stretched and strengthened like any other muscle in the body. The best part is there is so much you can do for yourself at home. It’s totally worth trying and in many cases is a life changer.

Diet and fluid intake:

It may sound counter intuitive, but drinking plenty of water is good for almost all bladder conditions. Yes I am talking about leaking, urgency, incomplete emptying and frequency. Drinking lots of water keeps your urine nice and dilute, minimizing the irritation of the bladder wall as well as the reactive spasm of the detrusor muscle. You should drink approximately half your bodyweight in ounces of water a day. For example: a 150 lbs person should consume 75 ounces of water a day. You should increase this amount if you are exercising, or experience a lot of sweating or drink a lot of caffeine and or alcohol, which are both dehydrating. It is also important to be mindful of bladder irritants which can worsen bladder issues. Big irritant culprits are alcohol, caffeine, citrus, and spicy food. In children, dairy milk is a common bladder irritant.  Keep in mind that one person’s bladder irritant may not be your bladder irritant. It’s easy to look at lists of bladder irritants and get overwhelmed. Try eliminating a suspected offender for two to three days. If you feel better when you aren’t consuming that item and worse when you add it back in, consider eliminating that item from your diet.  It is also important to eat in a way that prevents constipation, as this worsens bladder symptoms and puts extra pressure on the bladder.

Posture

If you are having problems fully emptying your bladder or you have post void leakage (dribbles following going to the bathroom) consider your toileting posture. People with bladder issues should sit on the toilet ( even dudes), to allow the pelvic floor muscles to relax and allow the bladder to fully empty.

Bladder Training

If you have bladder frequency or leakage  now is the time to try and train your bladder to hold more urine. Keep in mind you should start treatment to address pain with physical therapy and in certain cases, with medication, to allow you to be successful with bladder training. I always tell my patients to start their bladder retraining at home, where a bathroom is available to take the stress out of possible leaks or not being able to find a bathroom. Start by simply waiting to go to the bathroom 5-10 minutes past your first urge to urinate. Use behavioral strategies, such as deep breathing and pelvic floor drops, mindfulness, distraction and others.  If you don’t have to go after 5-10 minutes, Great! If you do, go to the bathroom. As waiting 10 minutes becomes easy, stretch your time to 20 minutes and so on until you are able to go 2-3 hours in between urination.

Physical Therapy

Physical therapy is considered a mainstay and top treatment for musculoskeletal causes of bladder disorders and bladder pain.  Expert pelvic floor physical therapists are clinicians who can find the cause of your bladder issues and provide you with a customized plan that will provide you with the best results possible. PT’s can work to relax spasmed muscles, treat constipation contributing to bladder issues, improve your toilet posture, reduce tightness around the bladder, abdominal and thigh region that can contribute to bladder dysfunction, as well as strengthen weak muscles. If you are experiencing bladder issues, please come see us.  There is so much we can do to help!

Sources:

Berghmans L, Hendriks H, Van Waalwijk, et al. Conservative treatment of urge urinary incontinence in women: a systematic review of randomized clinical trials. BJU Int. 2000; 85: 254-63

Chancellor, M, Yoshimura N. Neurophysiology of stress incontinence. Rev Urol. 2004; 6(Suppl3)S19-S28

Chang H, Lynm C, Glass R, et al. Urinary incontinence in older women. JAMA, 2010; 303(21): 2208

FitzGerald M, Brensinger C, Brubaker L, et al. What is the pain of interstitial cystitis like?. International Urogynecology Journal Including Pelvic Floor Dysfunction. 2005

Shafik A, Shafik I. Overactive bladder inhibition in response to pelvic floor muscle exercises. World J Urol. 2003 May; 20(6):347-7. Epib. Apr 4

Continuing our Education: Treating Pain in Individuals with Male Anatomy

Fiona McMahon PT, DPT

One of the requirements for maintaining your license as a physical therapist, is to take continuing education classes. The amount of classes you are required to take will vary from state to state. Many physical therapists take the option to do the bare minimum required to maintain their license. This is not the case with the PTs at Beyond Basics Physical Therapy, whom also do a ton of in house training, in-services, case studies, and journal clubs in addition to formal classes. Many of our physical therapists exhaust their continuing education days and continuing education budget and chose to attend continuing ed on their own time and dollar, because they love it so much. Even though, they are well beyond satisfying their requirements for licensure. It is something that makes the physical therapists at Beyond Basics really special and in the top of their field.

As practicing pelvic floor physical therapists, we have extensive experience, but the truth of the matter is we can always know more. For many of us, before we arrived at Beyond Basics, we learned to treat pelvic pain on individuals with male anatomy by avoiding the penis all together. To be honest, we can get a lot of patient’s better by treating the muscles of the pelvic floor internally, but as a group, we were eager to be able to learn and treat issues of the penis directly. We just wanted to be able to get patients with issues like Peyronie’s disease (a bend in the penis, due to dysfunction in the fascia), erectile dysfunction and incomplete bladder emptying better on a much quicker time scale.

We were lucky to have Sara Sauder, PT, DPT and Kelli Wilson, PT, DPT, FAAOPPT, OCS come up to visit us in NYC one cold Saturday in January to help us expand our physical therapy tool boxes for individuals suffering from the following conditions, amongst others:

  • Erectile Dysfunction
  • Post Vasectomy Pain Syndrome
  • Prostatitis
  • Urinary Pain
  • Urinary incontinence
  • Pain following Hernia Surgery
  • Circumcision Scarring

In the class we covered a broad range of factors influencing the health and function of male reproductive anatomy, including the interplay of hormones, scar tissue from old surgery, restrictions in the fascia of the penis or scrotum, and hernia. We learned hands on techniques to improve the movement of tissues around and blood flow to the penis and scrotum.

Speaking for all of us, I would say, that Sara and Kelli helped us to better treat our male patients. It is clear as physical therapists, we continue to grow and learn long after physical therapy school. We at Beyond Basics Physical Therapy hold our continuing education close to our hearts and truly believe it is what sets us apart from other physical therapy clinics.

If you are interested in learning more about what we can do for pelvic floor conditions of the male anatomy, check out our other articles here!

All About Testicles

Prostatitis What it is and What to do About it

Also for more information on how manual physical therapy can help pain conditions of the male anatomy, check out this article:

Anderson R, Wise D, Sawyer T, et al. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005; 174(1): 155-60

 

You can read the full abstract here

Prostatitis What it is and What to do About it

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Fiona McMahon DPT

Introduction

Prostatitis is a common diagnosis we see at Beyond Basics Physical Therapy. If I have a new evaluation on my schedule, who is male and between the ages of 18-40, we can place a pretty good bet that they are coming to see me for issues pertaining to non-bacterial prostatitis. It is estimated that 35-50% of men are reported to have prostatitis symptoms  in their lifetime (Rees). Prostatitis can be classified into different types based on their causes and response to treatment. Prostatitis is a vexing condition for many patients. In cases of non-bacterial prostatitis, which makes up 95% of all prostatitis, it’s often very difficult to determine what brought it on, and often times our patients have been bouncing from practitioner to practitioner trying to find answers and effective treatment. Let’s dive into the causes, symptoms, and treatment in order to help shed light on this condition.

 

Prostatitis Symptoms,

Although there are different types of prostatitis, the symptoms of prostatitis are mostly the same between types. That isn’t to suggest that every man with prostatitis experiences the same symptoms, quite on the contrary. Men with prostatitis may experience almost all of the symptoms listed below or they may only notice one or two. This melange of symptom possibilities can add to the confusion of having prostatitis and getting down to an effective cure.

 

Symptoms:

  • The sensation of having a golf ball stuck in the rectum
  • Hesitant urinary stream (having trouble getting the urine to start flowing)
  • Post void dribble (spotting of urine on underwear following voiding)
  • Pain that radiates into the abdomen (this is one of the differences from symptoms of benign prostatic hyperplasia)
  • Erectile dysfunction and decreased libido
  • Painful ejaculation
  • Painful or burning urination
  • Genital pain: penile, testicular, groin and perineal pain

 

Types of prostatitis:

Here’s where it gets a little more complicated. There isn’t one type of prostatitis. There are four. Each type of prostatitis is a little different in terms of etiology (how it developed) and how it’s treated.

Type 1: Acute bacterial prostatitis

This type of prostatitis is caused by an infection by a microbe. It is relatively rare. In addition to the symptoms above, a person with this type of prostatitis will feel the symptoms of an ongoing infection, including pain in the body, fever, and chills. This type of prostatitis generally response well to antibiotic treatment.

Type 2: Chronic bacterial prostatitis

Chronic bacterial prostatitis can occur after multiple infection or when there is an ongoing low grade infection. The symptoms, particularly those of infection are dampened in this form of prostatitis than those of type 1. Type 2 is often more tricky to treat and may require multiple courses of antibiotics

Type 3: Chronic Prostatitis/ Chronic pelvic pain syndrome (the most common making up 90-95% of all prostatitis and WHAT WE TREAT!)

This type of prostatitis occurs with no evident infectious cause and makes up the majority of cases. This is the classification that is one of the more frustrating for patients to deal with because the causal agent is much harder to ascertain; however the majority have musculoskeletal dysfunction, which we now know can be treated effectively through expert pelvic floor physical therapy.  Type III prostatitis can be further categorized based on the presence or absence of white blood cells in the urine or prostatic fluid, inflammatory and noninflammatory respectively.

Type 4: Asymptomatic inflammatory prostatitis

As the name implies, this type of prostatitis is usually not noticed unless semen or urine analysis is being performed to diagnose another condition. Typically this type is left untreated.

 

Causes

Here’s one of the universal questions that patients with prostatitis have: “why do I have this?”  Sometimes patients may find themselves blaming their prostatitis on something they have done in the past, like masturbating or poor hygiene habits as children. The fact is, prostatitis can occur for a multitude of reasons, and it’s usually something one has no control over like a fall on the bottom or an infection. It’s unfortunately something that happens, and as noted in the introduction of this blog, it is quite common. Here are some possible causes:

 

  • In chronic nonbacterial prostatitis/ chronic pelvic pain syndrome 90-95% of cases- no definitive cause ( or very difficult to ascertain); however pelvic floor dysfunction is a prevalent contributor.  
  • Bacterial infection, which can have good results with antibiotics
  • Chronic bacterial prostatitis, recurrent infection
  • Inflammation to the pelvic area
  • Central and peripheral sensitization- meaning a past injury in the area caused your pelvic nerves to perceive non painful stimuli as painful
  • Trigger points (irritable points of muscle) in the pelvic floor and abdomen

 

Treatment

Treatment is evolving in prostatitis. Increasing evidence supports a multimodal approach to treating prostatitis and its symptoms, meaning that not only is medical intervention used, but psychological, nutritional, and physical therapy.

From a medical perspective the first line of treatment for prostatitis is the “3 A’s”, antibiotics (especially the quinolone class), anti-inflammatories, and alpha blockers. Antibiotics obviously clear up any infection that might be causing your symptoms, anti-inflammatories to bring down the pain and discomfort, and alpha blockers to improve urine flow. Sometimes this is just what the doctor ordered (literally), especially in individuals with type 1 prostatitis and they are on their way with no further treatment needed. Since the vast majority of people with chronic prostatitis fall outside of the type one category and into more difficult to treat types, their recovery may require a more involved intervention to effectively treat their symptoms and the 3 A’s may not be the answer, or the complete answer for these patients.

 

Physical Therapy: Anderson and his colleagues described the relationship between the presence of myofascial trigger points and symptomatic prostatitis. They also showed that physical therapy intervention, including manual release of these trigger points was effective in reducing symptoms of prostatitis. The benefit of physical therapy was shown again to be more effective than placebo in a 2011 paper by Nickel. In addition to treating the trigger points themselves, PT’s work to determine what lead up to the formation of the trigger points in the first place, whether that be poor habitual posture, poor strength, or tight muscles in other parts of the body. They also teach patients how to avoid clenching their pelvic floor to prevent exacerbating symptoms.  This type of therapeutic approach was found to be effective in reducing pain in 72% of participants in a study conducted by Anderson and colleagues in 2005. The therapists at Beyond Basics Physical Therapy work to go beyond simple treatment of the trigger points themselves.  We develop plans and treatments to prevent their recurrence in the future.   Some other effective physical therapy techniques that we use include but are not limited to, joint mobilization to assist proper structural alignment, therapeutic exercise, postural and neuromuscular re-education and a detailed and individualized home exercise program.

 

Dietary Modifications:

Avoiding irritants to the bladder and gastrointestinal system is another simple and effective place to start. In some men, avoiding spicy foods, alcohol and caffeine can work wonders in making symptoms more manageable.   

 

Phytotherapy:

Preliminary data shows that there is evidence to support the use of saw palmetto, quercetin and bee pollen extract in reducing the pain of prostatitis. If supplementation interests you, consult with your general practitioner or urologist.

 

Stress Reduction

As clinicians who have seen a lot of cases of prostatitis, high stress is a contributor that we see with the vast majority of our patients. Studies have shown that high levels of stress are correlated with higher pain and disability scores in individuals with prostatitis. Stress can also perpetuate unhealthy holding or clenching in the pelvic floor, which causes or contributes to trigger points discussed earlier in this section. Stress reduction is a key component to expediting your recovery and is something we recommend to nearly all of our patients.

 

Final Thoughts

  • Prostatitis is a common and aggravating condition to be living with, and the fact is, every case of prostatitis is different. You may fall into the category were a course of antibiotics does the trick or you may fall into the category where you require physical therapy alongside medical intervention which can be much more slow going. Regardless of where you fall, be patient, there usually is a lot that can be done to help the more complex cases of prostatitis clear up. If you are suffering with this condition, make an appointment with an expert pelvic floor physical therapist today. There is so much we can do.

 

Sources

Anderson R, Sawyer T, Wise D. Painful myofascial trigger points and pain site in men with chronic prostatitis/ Chronic Pelvic Pain Syndrome. J Urol. 2009;182(6): 2753-8

Anderson R, Wise D, Sawyer T. Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. J Urol. 2005;174(1):155-60

Chronic nonbacterial prostatitis (chronic pelvic pain syndrome). Harvard Health Publications. Harvard Medical School. 2007. http://www.health.harvard.edu/newsletter_article/chronic-nonbacterial-prostatitis-chronic-pelvic-pain-syndrome. Accessed December 11, 2016

Duclos A, Lee C, Shoskes D. Current treatment options in the management of chronic prostatitis. Ther Clin Risk Manag. 2007; 3(4):507-12

 

Rees J, Abrahams M, Doble A et al. Diagnosis and treatment of chronic bacterial prostatitis and chronic prostatitis/chronic pelvic pain syndrome: a consensus guideline. BJU Int. 2015; 116(4):509-25

 

Nickel J. Prostatitis. Can Urol Assoc J. 2011; 5(5): 306-15