OTs In Pelvic Health

Triggers, Frequency, and Freedom: Reclaiming Control from Urge Incontinence

• Lindsey Vestal • Season 1 • Episode 108

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(00:01):

New and seasoned OTs are finding their calling in pelvic health. After all, what's more a DL than sex peeing and poop? But here's the question. What does it take to become a successful, fulfilled, and thriving OT in pelvic health? How do you go from beginner to seasons and everything in between? Those are the questions, and this podcast will give you the answers. We are inspired OTs. We are out of the box OTs. We are pelvic health OTs. I'm your host, Lindsay Vestal, and welcome to the OTs and Pelvic Health Podcast. Let's dive into urge incontinence or overactive bladder. So I want to start by defining stress incontinence first because I would say stress incontinence is one of the most common types of incontinence that we see, and I would say urge incontinence is probably a close second, let's distinguish between stress and urge incontinence. Super quick stress is the type of leaking that occurs with activities, right?

(01:16):

So could be coughing, jumping, exercise, squatting, lifting, even laughing, stepping off of a curb, right? Basically, activities. Activities that put increased pressure on the bladder and it basically overpowers the sphincter muscles causing leakage. Of course, we can take into account what else could be overpowering these muscles such as breath holding or salva to accomplish the task that our clients are trying to do, and it really starts to make sense to investigate and uncover the layers of stress incontinence with the breath. So what about urge incontinence, right? Well, this type of leakage is really triggered by a strong uncontrollable urge to pee. So that's the differentiation, right? It's a trigger where you're just not even sure you can make it to the bathroom, and in fact, you don't, right? The leaking often occurs on the way to the bathroom. There could be a lot of triggers for this, right?

(02:22):

So our clients are going to mention the sound of water running. That's a super common one. The sheer act of just walking in your door, arriving home, putting the key in your door is very common. Cold weather, nervousness, mental stress, you name it, right? These tend to be sort of the regularly anticipated triggers, right? And your clients can almost immediately say what their triggers are. They know, and it's a big part of the education with this topic because we're helping them to distinguish the difference between an authentic urge and a non-authentic urge. What I mean by a non-authentic urge is one, based on those patterns or those regularly anticipated triggers, such as the sound of running water. Every time I put a key in the door versus the brain recognizing that the bladder has actually filled to a certain capacity and now it's time to go, that would be the authentic urge that is triggered by the spinal cord sending a message up to the brain that the stretch receptors in the bladder have filled.

(03:37):

And I actually use this terminology of authentic versus inauthentic with my clients because I want them to start to recognize that just because you think you have to pee doesn't always mean that you do need to pee, right? It's an inauthentic urge that's been brought on by patterning, by conditioning, by habits, roles and routines. And when you start educating your client about these things, a light bulb moment goes off and they're like, oh, I totally get it. Wait, you mean I have a say over this? I can actually tell my body. Hold off. You can actually be in control. And the answer is yes. And that's actually our work together. Our work together is going to train your body how to do just that, and it's actually incredibly satisfying how quickly we can change those patterns and it's illuminating and exciting, and our clients just feel so empowered.

(04:41):

So this idea of education brings me to a topic that I'm actually extremely passionate about, which is, although everyone pees, we get very little or no education about it, American sex ed classes don't cover bladder health. And don't get me started on sex ed. The abysmal nature of sex ed in schools is something I can go on a rant on, but I'll save that for another time. I think after potty training, no one really sits down to teach us about optimal pelvic floor function, right? There's not a dedicated time after potty training where we talk about peeing, pooping and what we can do to do it better. And I think you probably have all heard me say this before, the jobs of the pelvic floor happen behind closed doors, so they stay secretive, even shameful. And instead of sharing notes on optimal and healthy ways to perform these activities, we continue to do them the same way over and over, never really stopping to question their effect on our quality of life or how we could do them better.

(05:57):

So urge incontinence is both psychological and physiological. Physiological meaning the bladder has lost its ability to regulate urges, and the pelvic floor isn't really assisting to keep the urethra closed to prevent that leakage. It's psychological because when the brain sees or hears something that stimulates the need to go to the bathroom. And so these two processes work very closely together. Isn't this always the case? Right? Mind and body together, and it's why we love what we do. We never really look at pelvic health from a purely physical lens. We're always seeing the MINDBODY connection. Honestly, I think that's what makes our work so appealing, so interesting for us, and it's why clients come back and see us. They know it's not just one factor and we're taking the time to address all of the factors, and that's why they get better so much more quickly, so much more thoroughly.

(07:07):

And it's just so much more interesting from a clinician standpoint. So again, what causes urge incontinence? Sometimes the bladder sends messages to the brain too early before it's full. The bladder kind of overrides this hold on message from the brain causing your bladder to contract and release urine before you want to go because it does not fill up completely. You just may need to go to the toilet more. And this is where we start getting into frequency. So frequency and urge are really connected, and we have to listen carefully to our clients because they're going to probably tell you more about the one that bothers them the most, but they're often linked. And so that's why at that first evaluation, it's all about perfecting the art of asking a question. And we go into depth in this so much in OT pioneers, my flagship course for helping OTs become pelvic floor therapists.

(08:12):

Because when we stay curious and help our clients to become detectives of their own body asking with curiosity, it's what makes their goals meaningful, the conversation meaningful, and it's what makes them want to work on what is targeted, triaging their concerns on what's happening and how we can help them get through it. So contributing factors are probably, I would say primarily behavioral in nature with urge incontinence. I'm thinking about a parent who gets up two or three times a night to feed their baby and they just kind of get used to peeing right before starting the feed to avoid that uncomfortable feeling in the middle of the feed of needing to pee, right? So now fast forward in time. Now maybe baby is sleeping through the night, but the parent is still getting up two or three times a night to pee. This is just one example.

(09:16):

The brain is part of a reflex that causes you to urinate. So even just thinking about it, thinking about peeing can really bring on that urge for us. And as I mentioned, frequency and urgency often go hand in hand together. So the client who pees before leaving their house every time out of concern for not wanting to use a public restroom, that one came up a lot in New York City where my private practice was. Clients would often do that because they may not know where bathroom was, but even if they did, they probably didn't want to use it in New York City. And in terms of this, it's called just in casing, just in case P, you're going out of convenience. I share with clients that we're looking for patterns, right? Patterns are what makes a difference. It's months and years of doing this that really changes the brain to bladder connection.

(10:09):

And it's amazing how adaptable our bodies are, how much the brain has our back in these situations. And that's what it is. I tell my clients, your body's trying to listen to your cues and it is listening to your cues. You went more and more frequently, and so your brain thinks it needs to tell you to go more and more frequently, but now we're going to give it different cues. Now we're going to give it different input to help you get back to a better quality of life where you're peeing less frequently. Another scenario of that anticipatory response is when I think about employees who don't have time at their disposal freely. So I'm thinking about teachers, I'm thinking about nurses, I'm thinking about pilots who basically can't go to the bathroom whenever they need to. And so what happens is they're actually kind of doing the opposite.

(11:07):

They're not listening to their body, they can't listen to their body. And so the bladder actually gets a little bit more stretched out and it's less sensitive to the feeling of urge. It's less sensitive because you didn't listen to the cues. And so now maybe it's not sending the cues as frequently. So it's kind of an opposite scenario. But you can see how patterns and habits and either preempting the urge or not listening to the urge can cause problems. And it happens slowly over time. You don't just wake up and it's the situation. It evolves over time. And that's why I love things like the pelvic health questionnaire, any pelvic health questionnaire. It gives us a chance to take inventory of our normal behaviors and habits that we could stand back from and go, wait, this is my new normal. I didn't realize there was a time when I didn't pee every 30 minutes.

(12:11):

So it gives us a chance to stop and take inventory because habits can be sneaky and subtle when they start to accumulate. And so I just love the idea of checking in with our bodies and kind of recognizing what our new normal has become. So when our clients come to us and are recognizing that they do have a problem, they do have a scenario where, wait, I don't want to pee every 45 minutes. Can this be different? This is a beautiful opportunity to really educate on how it can be different. One of my mentors shared with me that the poop drives the pee. I'll say that again. The poop drives the pee, and it's true. What do I mean by this? It means that often we can have a longstanding issue with our bowels. Constipation comes to mind. A lot of people just kind of put up with constipation, don't realize that it can be different, and then the urination issue comes along.

(13:10):

So now all of a sudden they've got stress incontinence or urge incontinence, but actually we may need to triage the bowel issues first before the urination because sometimes the bowel issues are causing the urinary issues. And so taking the time to ask questions of our clients, looking over their questionnaires and recognizing what's the newer symptom, what's the older symptom, can make a huge difference in getting our client more quickly to their goal. And the thing is, bowel movements and the topic of constipation or even loose stools can be a really stressful conversation. I remember a client who told me that every time she got into the subway in New York City, she had a very intense urge to have a bowel movement. It actually kind of freaked her out. She's like, what is this? I had a bowel movement this morning. Why 45 minutes later when I'm in the subway, do I have to go?

(14:11):

Right? And we talked about pattern recognition. We talked about how it's probably not an authentic urge. She recalled a story where there was a fire on the tracks due to trash, which actually happens pretty often in New York City. This particular time though, my client was stalled for, I don't know, I think an hour, hour and a half, and she was really stressed. That was going to happen. Again, linking, okay, what if I'm in this situation again? And I do have that urge. And so I think many of our clients fast forward to the worst case scenario, and they're playing that scenario out, which just fuels the anxiety and the stress, and honestly just really ramps up the nervous system. It really ramps up the nervous system. And so talking about it and recognizing it can help our clients kind of get out of that thought looping.

(15:10):

And this is an opportunity to demonstrate that symptoms can really get exacerbated when we get into that stressful state. So it can start to empower our clients when we kind of talk about the relationship of the nervous system and how that nervous system is connected to our physical being. And potentially we need to work on nervous system function, nervous system regularity first. And this is where I always say when we work with the pelvic floor, we're working with the nervous system. So yes, working on the physical symptoms, but also checking in with any kind of thought, looping, they're having any kind of assumptions that they're making that could be interfering with some of their progress. So remember when I said poop drives the pee, right? Again, this can be because the system can be so backed up from a constipation standpoint, and there's just not a lot of room.

(16:11):

Think about the size of the pelvis, think about the organs that are in there. We have, for someone identifying as female, we have a bladder, a rectum, and a uterus. And so in this case, if we're backed up and constipate it, the pressure that it puts on the bladder could actually be the source of the symptom. So addressing the constipation actually may help resolve the bladder issues. The bladder is such a trainable organ, and the thing about bladder training is that it can take time and determination. A cure doesn't happen overnight, but the work is so successful, and the goal with bladder training is simple. Decrease the number of times that we go to the toilet and increase the amount of urine we pass each time. And this is done gradually by increasing the length of time between your trips to the toilet. This is called bladder retraining, and it can be difficult at first, but becomes easier, really easier as the bladder adjusts and recalibrates to holding more urine.

(17:15):

Now for our clients that maybe their bladder is overstretched, right? The pilot, the nurse, this is where we actually put them on a schedule of going, right? We're asking them to go once every four hours at first, then every three, then every, whatever the goal would be because we're teaching their bladder to pick up on the perception of filling, right? So in one case, we're drawing it out. In one case, we're increasing their frequency. I definitely encourage you all to get that bladder diary and intake before a client's first visit and have them send it in. This is really pivotal because it's going to help you save time. It's going to help you get buy-in from your clients so much faster, and you are going to increase the chance of them rebooking because you are getting to the heart of their matter so much more quickly.

(18:11):

Let's take a brief moment to talk about the people who stop drinking water because they don't want to pee or have that urge. It is such a misconception that if we don't drink water, we won't have to pee. It's actually quite the opposite, right? It's quite the opposite, because what happens is the bladder is a little bit like a toddler having a tantrum. When it gets more dehydrated, it actually gets more irritable, it gets more twitchy, and it actually sends more signals more quickly. So I tell them actually, even the sheer idea of you drinking enough water will not only benefit every system in your body, but it just may be the thing to take the edge off that urgency off that intensity. So education, education, education, it's definitely one of my favorite parts of being a public health therapist. It is so empowering to know for our clients, for them to know that they have a choice.

(19:16):

So sharing with things, sharing things with our clients, like what optimal habits are. Peeing once every two to four hours is what's ideal. There should be no effort to start or stop the stream sharing with our clients. The bladder can actually hold 16 ounces. I have this beautiful picture that I share with my clients. Actually, one of my clients took the picture. She was a photographer and she offered to do it, which was so sweet of her basically showing that our 16 ounces is between 400 and 600 milliliters. So within that, if the bladder can hold 400 to 600 milliliters, when do we get that first urge to urinate? Many people really start to feel it when their bladder is about 150 to 200 milliliters full. A stronger sensation comes along around 300 to 400 milliliters. This is really when people start to go, okay, I need to go.

(20:13):

I need to find a bathroom. And at 500 to 600 mils, the bladder is fully stretched. And so showing illustrating what this could look like is also really powerful because most people, when they see a bottle that's filled 400 mils, even 200 mils, they're like, oh, wow, that's actually a lot of urine. And then we can tie that back to the number of seconds that it takes them to pee. So typically, we tell clients, we ask them to count how long their P is lasting to get a back of the envelope calculation to ballpark the amount of urine they're producing, right? So like a five to seven second P would be about 50 to 140 milliliters, a 10 to 15 second P would be about a hundred to 300 milliliters, right? And flow rate is different for anatomy and what our gender is and all of that. But roughly speaking, it's a great way to help our clients kind of track how much urine is coming out, authentic urge versus inauthentic, urge, hydration, all of that stuff that again, we're not talking about and we're just not having the chance to check in and find out what's optimal. So we put up with suboptimal, which just can exacerbate over time.

(21:42):

This was such a fun episode to record. I hope you all are having an amazing day. Thank you so much for listening to the podcast. If you could please rate and review the podcast, it really does make a difference with helping people find it, and it would mean the world to me if you could rate it and leave a comment. Alright, I will talk to you guys next time. Thanks for listening to another episode of OTs and Pelvic Health. If you haven't already, hop onto Facebook and join my group OTs for Pelvic Health, where we have thousands of OTs at all stages of their pelvic health career journey. This is such an incredibly supportive community where I go live each and every week. If you love this episode, please take a screenshot of this episode on your phone and post it to ig, Facebook, wherever you post your stuff. And be sure to tag me and let me know why you like this episode. This will help me to create in the future what you want to hear more of. Thanks again for listening to the OTs and Pelvic Health Podcast.

 

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Lindsey Vestal

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