When Your Bladder Starts Calling the Shots: Menopause, Leaks & Taking Back Control || Episode 26

Menopause Unscripted is a women’s health podcast hosted by Dr. Heidi, the creator of Hey Dr. Heidi. Each episode delivers expert insights, real-life stories, and evidence-based information to help women navigate perimenopause, menopause, and post-menopause with confidence.
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Transcript

SPEAKER_00 0:02

Thanks for joining me on Menopause Unscripted. Remember, the change is just another beginning. Welcome back to another week of Menopause Unscripted. I am Dr. Heidi Gaster and I am joined today by Dr. Emily Whaling. She is a good friend of mine and one of my mentors in pelvic health physical therapy. And we are back today for another episode to specifically talk about bladder-related issues, including incontinence, overactive bladder, and many more topics and what these things are, how we get there, what we can do right and wrong to help us manage these symptoms from a conservative manner. Thank you again for being here. Thank you so much for having me. I appreciate you coming back. Oh my gosh. My pleasure. Thank you. You're gonna help guide us with your wisdom as well. So you said you wanted to start with today. Yes, bladder norms. Yes.

SPEAKER_01 0:59

Bladder norms. Urgent or urinary urgency overact. Excuse me. Take a step real quick.

SPEAKER_00 1:05

We're both in our coffee phase. It's early.

SPEAKER_01 1:09

It's early in the morning. Um urinary urgency, overactive bladder, incontinence. These are all really common symptoms that patients come to see me with. And I always like to start with what is normal. Because how do you know if what you're experiencing is or isn't normal unless you know what kind of the key bladder norms are? So um when we are, let's talk about first how like the whole cycle of urination. Can we use the public?

SPEAKER_00 1:41

Just remember the vagina's broken. Be careful. Be gentle with I just always think it's so funny. It's like I should get it replaced, like I think it's apropos. It just comes off. Like the vagina is broken, so it just falls off.

SPEAKER_01 1:54

Look, my vagina's broken. Got it, got it. Okay, I'm gonna give it a little support here. Okay, so um this is the pelvis, and the bladder sits in the within the bowl in the front of the pelvis right here, and it's kind of like a balloon. And so the bladder sits here, and then what happens is we drink water, coffee, fluid all day long, right? And um the fluid goes into our stomach and then into our intestines and gets absorbed into our bloodstream and becomes part of our blood volume. There's no direct route from the mouth to the bladder. That's good. Tip number one. Um and so the fluid becomes part of our circulatory system, the kidneys start filtering um the blood and um and our blood volume and start to make the urine. And so the kidneys sit right here and are depositing urine into the balloon of the bladder at a constant rate all day long, about 15 drops a minute. Um, and so all day long the or the kidneys are making urine and the bladder starts to stretch and fill. Okay. At about halfway full, the bladder sends a moderate signal to the brain to say, hey, you might have to go to the bathroom soon. And at this point, we should ignore that signal and the bladder should continue to stretch and fill. Once the bladder is full, which is at about four to six hundred milliliters, which is quite a bit of fluid, the bladder is full, it sends another signal to the brain saying, like, hey, it's really time to go to the bathroom, and that's when we walk to the toilet and empty our bladder. Okay, so that cycle of the bladder filling and emptying should take about two to four hours. So normal bladder frequency is once every two to four hours. So if you're going to the bathroom and it's every hour, every hour and a half, consistently throughout the day, that's probably you're probably going too frequently.

SPEAKER_00 3:58

I'm nodding because I'm like I go way too much.

SPEAKER_01 4:00

Way too frequently. It's very common, and for a lot of people, it's not necessarily bothersome to them, um, but it can contribute to some of the um urinary incontinence and other things that we that can develop later on. So um it's good to get in the habit of extending. Extending and delaying, not too far. You don't want to go beyond the four hours. I do have some patients who are really good at delaying and they go over four hours consistently, and that also is not great. You don't want to overstretch the bladder, it can then become desensitized and not as good as not as um efficient at emptying. So you also don't want to go too far.

SPEAKER_00 4:40

I think of nurses, really good at holding their teachers.

SPEAKER_01 4:43

Nurses and teachers are brilliant at delaying, it's just by the nature of their job, a lot of times they can't get to the bathroom exactly when they need to, and then by the time they have the opportunity, it's like, oh, I don't really need to go and they're so busy, they just keep delaying the urge. So um, we'll talk about urge suppression in a little bit. But um yeah, so normal bladder frequency every two to four hours. Um, and it shouldn't be something that you're constantly thinking about. So we talk about toilet mapping. Some people know exactly where every toilet is on their daily errand route. Um, and we also shouldn't be doing what we call just in case voiding, which is going to the bathroom preemptively just in case, right? Like I might have to go. You're right. I'm about to leave the house and go for a 30-minute drive. I might need to go. I better go to the bathroom. And this, I think, really, excuse me, develops early on habitually in our lives as kids when we're being potty trained. And um, parents often will, you know, say, Oh, do you have to go to the bathroom? And they say, No, we'll go anyways. We're getting in the car. You better go to the bathroom and kind of force forcing kids to go to the bathroom before they get in the car just because um it kind of creates this lifetime habit of, oh, well, I'm leaving the house, I better empty my bladder first. And in general, we want to get away from that because emptying a bladder when it's not uh or trying to go to the bathroom when the bladder is relatively empty um causes some dysfunction within how the bladder muscle works and the passive emptying that we want to facilitate.

SPEAKER_00 6:26

Now, does that matter in gender? Like, does it matter if you are have a female genitalia versus male genitalia? Does it matter? Is it the same? No, it's the same. Yeah, bladder norms are the same for men and for women. You are a mom of a lot of boys. Yes. So as a palate floor PT and as a mom of multiple kids, what do you teach your kids?

SPEAKER_01 6:47

So in let outside of the acute potty training phase, like when I'm actually taking them from diapers, you know, they're two years old and we're going from diapers to going in the toilet. At that point, totally fine to be like, you need to sit on the toilet to go, because you are actually teaching them to recognize their urge to go to the bathroom and they don't know at that point, right? Um, but beyond that, my boys are now older. My youngest is eight. I don't ask any of them really to go to the bathroom before road trip. I really don't ask them ever. I mean, before road trip, I will just say, do you need to go to the bathroom? And if they say no, that's it. We don't I don't force them to go to the toilet ever. Um, but I will remind them because boys are busy and kids forget. And they also don't know how long we're gonna sit in the car. If we're going on a road trip, like you said, for hours, I'll I'll definitely ask them, hey, do you have to go? Yeah. And if they say no, great. I just say we're gonna be in the car for a while. Are you okay with that? Oh yeah, that's fine. I also tell people the very worst thing that happens when it, you know, to get past the just in for people who are struggling with the getting over the just in case voiding habit. Um, what is the worst that happens? The worst thing that happens is you have an urge to go to the bathroom when you're in the car and you pull over and use the toilet. Right. Like there are McDonald's, Starbucks, there's a plethora of places, it might be inconvenient, sure, but it's not the worst thing in the world. Sometimes people act like, well, what am I gonna do? How you know, and pull over. You pull over. If it's now been two hours since you've last gone and you really have to go, pull over, or hopefully you can, you know, delay 15-20 minutes to get to where you're going and then use the toilet calmly.

SPEAKER_00 8:38

So when you mentioned earlier that you can desensitize a bladder by holding it too long. So the just in case peeing, does that oversensitize the bladder? Because people will tell me all the time, my bladder is really small. I'm like, no, your bladder is not really small. That's not a thing.

SPEAKER_01 8:55

Yes, I would agree with that. I mean, oversensitize, I'm not sure if that's clinically accurate, but when you get used to yeah, emptying on a small bladder, the nerve endings within the lining of the bladder start to get, I guess, overly sensitive to like that stretch. Exactly. So um, that signal getting sent to the brain of I really have to go to the bathroom is heightened in somebody who's going to the bathroom all the time because the bladder isn't used to that stretching sensation. And that's really a key for people with overactive bladder and urinary urgency, is they have a they definitely do have this oversensitivity of the bladder stretch, and um it's really uncomfortable and they get very anxious and they are going to the bathroom all the time to try to mitigate that, but it becomes a catch-22. So, okay, so let's talk about nocturia. So that is referring to um waking up at night to have to use the toilet. So normal um is being able to sleep eight hours or your normal sleep cycle six to eight hours, waking zero to one time. So we shouldn't be waking up excessively at night to use the toilet. If consistently you're going, waking up one, two, three, I've had someone go five, six times in a night, that's not healthy. You're not getting the good REM sleep that you need. Sleep is so restorative and important for our health. Um, so one time is considered normal, but um really we want you to be able to sleep throughout the night without constantly being awakened by um the need to go to the bathroom.

SPEAKER_00 10:34

So I feel like that leads us right into like overactive bladder. So can you define that for us?

SPEAKER_01 10:39

Yeah, so overactive bladder, I already talked about how the normal frequency is once every two to four hours. So if you're going less than that, you're gonna be hitting a total 24-hour um time frame of over eight times a day. Okay. So overactive bladder is going to the bathroom more than eight times a day. If you were to take a diary, which I do have my patients do, and keep track of exactly how many times you are going to the bathroom to empty your bladder, whether that's for just in case voiding or that's because you actually have a strong urge, or whatever the reason is, if you are sitting on the toilet more than eight times a day, that's a higher frequency than is considered normal.

SPEAKER_00 11:20

Okay. And what are the different types of incontinence?

SPEAKER_01 11:23

So when with incontinence, we're talking about overactive bladder. The type of incontinence that's most often associated with overactive bladder is urinary urge incontinence. And incontinence is any leakage of urine that is unwanted, but is not sitting on the toilet. Doesn't matter any volume is so incontinence. Any volume, if it's a small few drops, if it feels like it's your whole bladder, any leakage of urine beyond when you're sitting on the toilet is considered incontinence. So there are many different types. The one associated with overactive bladder is often the urge incontinence. And so this is somebody who probably is feeling the urge and going to the bathroom more than eight times a day. And with that strong unwanted urge, they are also experiencing a leakage of urine, usually a few drops to a medium amount. And oftentimes they say, Oh, it happens en route to the bathroom. Sure. They feel the urge and then they then are like rushing to get to the toilet, and in the process of getting to the toilet, sometimes even just while they're pulling down their pants or opening the door to the bathroom, um, they'll get some leakage of urine.

SPEAKER_00 12:31

Okay. And would you is that still urge incontinence, or does that lead us into stress incontinence? That's still urge incontinence, yes.

SPEAKER_01 12:38

So even though they're moving and there's an activity involved, the key um finding is that they are it's when they're experiencing the urge. The urge is contributing to the loss of urine.

SPEAKER_00 12:51

And then so what is stress incontinence then?

SPEAKER_01 12:54

So stress incontinence is leakage of urine with any movement activity like a cough or a sneeze is the most common. Say, um, you know, every time I sneeze, I have a little leakage of urine or laughing really hard, um, or even just a little bit, you know, depending on the severity. Um, it can be getting up from a chair. Oftentimes we'll say, When I stand up, um, I get a little leakage of urine, or getting in and out of the car. Um, the key is that there's this is in the absence of an urge. It's not when they are experiencing an urge to go to the bathroom. Um, you know, uh getting on a trampoline is kind of the classic running, maybe. Running, absolutely. So running, exercise, picking up the baby out of the crib or lifting your child um, you know, out of their car seat or out of the shopping cart, um, any sort of movement activity um associated with urinary leakage is can considered stress incontinence.

SPEAKER_00 13:57

And then when do we get mixed incontinence?

SPEAKER_01 13:59

Is that the combination of the two? Yeah, exactly. So mixed incontinence is going to be experiencing both of those at different, they don't usually happen exactly at the same time. So um I leak when I cough and I sneeze, and I also am leaking when I have a strong urge to go to the bathroom. And so sometimes one is weighed heavier than the other. Some patients will say, Oh yeah, I I leak maybe 10% of the time when I cough or sneeze, but I'm leaking every time I get a strong urge to go to the bathroom. So our treatment is more focused, maybe more on the urge than the stress, um, and vice versa. So um there can be, you know, it's not always like an equal amount. It's not sure the severity doesn't go. Sometimes it does, but usually it's kind of one or the other is the priority.

SPEAKER_00 14:47

So I want to say focus on bladder septicity. I do think it's important to mention other types of incontinence, especially things that could be also impacting maybe male partners, things that they don't think of as incontinence, and women do get it also, or you know, female people get it also, but I think that's important to note some of the other types of incontinence as well. Sure.

SPEAKER_01 15:09

Well, so male patients or patients with male genitalia can um also experience stress and urge incontinence, so those are not exclusive to um female anatomy. Um and honestly, all genders experience the same types of incontinence. So the other types of incontinence are functional incontinence. This is more seen in um functional incontinence refers to the leakage of urine because of other reasons for not being able to make it to the toilet in time. So a good example of this is someone who maybe had a hip replacement recently or a knee replacement, and all of a sudden now they're using a walker and they're slower than they were two days before. And in that process of getting to the toilet, they physically cannot get there in time because of more other mobility issues or a dexterity issue with like undoing their belt and their pants. You know, it could be somebody had a stroke or some other neurological or they broke their arm or something. And so because of that other functional limitation, they now are struggling to make it to the toilet in time.

SPEAKER_00 16:15

I think of this especially being like our you know, folks who are getting up in the middle of the night because they have a macterrhea, but then they functionally can't get from their bathroom to the, you know, from their bed to the bathroom in the middle of the night.

SPEAKER_01 16:26

Absolutely.

SPEAKER_00 16:26

So sometimes it's a combination of things, absolutely. I think about like the falls risk, because I see that so often when I have someone come in because of an orthopedic issue, it fell and broke something, but the impetus to the fall was the bladder issue. Yeah. Absolutely.

SPEAKER_01 16:43

Fall risk is and the and getting up in the middle of the night is a huge problem. So it's another reason. Not only is nocturia not good for your bladder health, not good for your sleep quality, but it also puts you at a higher risk of falling in the middle of the night and severely injuring yourself. So lots of reasons to reasons.

SPEAKER_00 17:02

And then other types of incontinence that we haven't mentioned.

SPEAKER_01 17:04

There's also overflow incontinence, which um is less common, but is um referring to either there's some sort of an outlet of obstruction, so an injury, an illness, possibly um malignancy or something that's obstructing the urethra. Um, and so the bladder can't empty properly, and then the bladder just gets so full that it just gives up, and that pressure of the detruser, the muscle lining within the bladder just contracts. And this is generally um presents as like a large volume of urine loss without an awareness of. Usually with stress and urge incontinence, patients kind of like feel that it's coming or they know they're gonna cough or sneeze and leak, or the urge is their overflow, it there's not really an awareness of it all the time. So it just kind of happens. Um, and that's not something that physical therapy often is addressing for. Right. What about things with like feet uh feces or with gas? Oh, okay, so fecal incontinence, yeah. So um fecal incontinence or gas incontinence um are under the umbrella of anal incontinence. Um, absolutely, those are things that can be related to urinary issues as well. If someone's having urinary issues, they are more predisposed to some of the anal incontinence. If the cause is pelvic floor weakness or there's been an injury or a surgery, um, so that's absolutely something we screen for. There are different types of fecal and anal incontinence. The first you mentioned gas incontinence. Um fecal incontinence is going to be actual physical stool um leakage, and that can be related to um so there's fecal seepage incontinence, which is just like seepage of fecal matter without the you don't feel like an urge to dedicate right, exactly. And so this often is related to incomplete bowel emptying or um constipation. Interesting to have constipation and leakage, I know, but there can actually be when there's impacted stool higher up within the colon, there can be overflow of loose stool.

SPEAKER_00 19:16

So let's get let's now kind of go back to different strategies that people can be doing in order to help to manage these different things. So we can kind of start back at the beginning and talk through like what are conservative measures people could be doing. Absolutely.

SPEAKER_01 19:30

Okay, so let's start with like overactive bladder and urinary frequency. So there's a few things. The first is doing a bladder diary to really get some objective information of where you're at. People, some patients will often think they know how often they're going or think they are in a certain realm, and then when they actually are diligent at marking everything down, they're a little surprised at actually how frequently it is, or different habits and patterns. So the first is kind of taking an objective screen with a bladder diary, keeping track of fluid intake, every trip to the bathroom, any episode of leakage, and if there wasn't strong urge or not. Um, and so once we look at that, um, we the first thing I look at is fluid intake, because obviously, if we're drinking too much or drinking too little, that can affect how often you're going to the bathroom. Now I know at the beginning we said kidneys are constantly making urine at a constant rate and there's no direct route from the mouth to the bladder, but how much we drink does affect our bladder health. So we our total fluid intake throughout the day, we want it to be about half our body weight in ounces. That's a good way to kind of know what is normal for you. Um, and so if a patient is not drinking enough water, say somebody weighs 120 pounds and they are drinking 20 ounces of water a day, that is not enough. They are dehydrated. And sometimes these patients will say, Well, I don't want to have to go to the bathroom. So they're water restricting. They're water restricting. They're saying, I don't want to, you know, I have to go to the bathroom all the time, anyways. Why would I drink more water? Well, when we're dehydrated, our urine is more concentrated. And um, that irritates the bladder lining and makes us feel like we want to go to the bathroom when we don't need to, when we don't have a full bladder. So drinking more water can actually hydrate our urine and make it less irritative, irritative to irritating to the bladder lining, which can help. Um, so sometimes it's about getting people just to drink a little more water and be a little more aware of what the norms are. On the flip side, I also have some patients who drink way too much water. Um, they are drinking one to two hundred ounces of water a day when they weigh 120 pounds, so drinking twice, three times as much as they should for different reasons. Some people are just in the habit of it. We're told by you know, every magazine you pick up. You know, drink water for skincare, for constipation, for all these things. And yes, we want to stay hydrated, but there is a balance. You don't want to be just chugging water all day long. It does overload the sub the system. Um, I've had some patients say they drink water to try to fill up because they're trying to diet and lose weight, and so they are drinking a whole lot of water to try to satiate and not, you know, feel like they need to eat. So having a balance with it, sometimes I'm telling my patients actually to cut back. I always preface that with let thirst be your guide. If you're thirsty, obviously you need to drink water because it's a cue, right? If you're taking medications or have another medical issue that your doctor has told you you need to be drinking that level of that volume of water, sure. Um, but outside that sticking to half your body weight in ounces is a really good goal.

SPEAKER_00 22:51

And with that, I run into a lot of people that were trying to up their water intake. Yeah. But they get to say 6 p.m. and they realize like I haven't had enough, and then they're like, yeah, I tried to drink the rest of it at that time, and they overload themselves and then they can't lid it, or now I'm actually having more issues. So I try to get people to pace themselves throughout the day versus Absolutely.

SPEAKER_01 23:15

That's such a good tip. Absolutely, because if you're drinking the majority of your fluid intake in the second half of the day, that is gonna predispose you to waking up at night as well. And that's one of the management techniques we use for Nocturia is asking patients to drink the bulk of their fluid um in the first half of the day so that their body has time to um accommodate that fluid and it's not overloading their system at night.

SPEAKER_00 23:40

Do you give people kind of a cutoff time for fluids before bedtime? I usually tell people like whatever your bedtime is, try to stop like two hours before. Do you do the same? I do.

SPEAKER_01 23:49

I usually say even three to four hours and then just sips of water if they're thirsty. Sure. Yeah.

SPEAKER_00 23:54

I always tell people to gargle too. It's like just swish and spit. Sure. It's like, I mean, if your mouth is dry, it's like you don't want to like be doing that or no.

SPEAKER_01 24:02

And again, if someone's thirsty, I want them to drink water. Thirst is a sign that our body is dehydrated and that we need to be drinking water. So I would never tell someone not to drink if they're thirsty. It's the patients who are chugging water and really good at guzzling like a huge bottle of water. So they've conditioned themselves to like, you know, they've they get like a gold star for the hydration. 100%.

SPEAKER_00 24:24

Any day gold star is like I can't not hit my two leaves.

SPEAKER_01 24:27

Yes, exactly. It's funny what a spectrum there is, because then I have I do have patients drinking maybe 20 ounces a day, they hardly drink any water, and it's really hard to get them to even half of what they should be drinking. So fluid is a big um, you know, consideration for overactive bladder. So making sure you're kind of in the norms for fluid. Um, and then when it comes to um delaying and learning how to teach your bladder how to store longer, we utilize something called urge suppression. So looking at the bladder diary and seeing if there are times during the day that you are not hitting that two-hour mark, if you're going every single hour, um, how do we extend that to two hours? And so I use a rule of 15 minutes. So if somebody frequently throughout or consistently throughout the day is going every single hour, um, I'll ask them to try to delay it by 15 minutes. And we use a timer. Okay. So I say pull out your phone or on your watch, set a timer. Every time you go to the bathroom, you go to the toilet, you sit, you empty, and you are gonna set a timer for an hour and 15 minutes. Now, if you get the urge to go to the bathroom before that timer goes off, you're gonna sit down. This is where pelvic floor PT comes in because we need to know they have a good enough engagement of pelvic floor to utilize this. But sitting with your feet flat on the floor, taking a few deep calming breaths to calm the nervous system because the bladder is so entwined with our visceral nervous system and our autonomic nervous system that just taking a few deep breaths to kind of calm everything, that alone can help the bladder relax a little bit. And then doing a few pelvic floor contractions, so squeezing, tightening, and then letting go, releasing, because tightening our pelvic floor activates an inhibition reflex arc to the bladder to allow that muscle to calm down and relax so that it's not sending that message to the brain that you've got to go. So it it dampens that urge. Okay. And then relaxing and distracting yourself. So reading a book, checking an email, calling a friend, whatever you need to do to distract yourself, hopefully the volume on that urge goes down. Um, and then you just allow the bladder to continue to stretch and fill either until the next urge comes on, where you repeat that again if needed, um, or the timer goes off. Now, when the timer goes off, you don't rush to the bathroom. You wait for the next normal urge because you may have just suppressed the urge at, you know, let's say 60 minutes and now it's an hour and 15 minutes. You probably maybe don't have to go to the bathroom. So you're kind of gaining this awareness of what it feels like to have a moderately full bladder and say, okay, do I really is it bothersome? Do I have to go or do I not? And if you don't, you just wait for the next natural urge to come along, which might be five minutes later, it might be 30 minutes later. When that urge comes along, then you go to the toilet. We don't delay a second time after that first hour and 15 minutes. Um, and then we repeat that and we stick with that for at least a week and then gradually bump up by 15 minutes a week when it's successful.

SPEAKER_00 27:46

And you're trying to get them to approximately two hours? Yes.

SPEAKER_01 27:49

So more than two hours. Okay. And I say more than two hours consistently and um without bother. So if at if you're getting to two hours 100% of the time, but at an hour and 45 minutes every time you're like, oh my gosh, doing the urge suppression and really anxious about it and feeling like it's difficult, that's not normal. We want you going every two to four hours without much thought to it. It should start to become something that's very natural and that you're not thinking about it all the time, that you're not thinking how long has it been. Instead, you get a strong urge and you might look at the clock and oh yeah, it was it was two and a half hours ago.

SPEAKER_00 28:26

Great, I'm gonna go to the bathroom because that's listening to that then, that urge feeling, but in a more not our more normal like range of time. Exactly.

SPEAKER_01 28:35

Yeah, it just normally versus like always thinking about it. No more toilet mapping, no more just in case voiding. A little less anxiety, less anxiety, that's the other thing. Right, no one should ever be rushing to the bathroom. Um, and so that's something I do encourage my patients to do as well. Even when it's time to go to the bathroom, if you're leaking urine en route to the toilet, I ask patients to do a little urge suppression and calming before they stand up to go to the bathroom. So if they're sitting on the couch and they know they've been watching TV for two hours and they know they're gonna stand up and have to go before they even stand up. Same thing, a few deep breaths, a few strong pelvic floor contractions just to prep the bladder that, okay, we're gonna go to the toilet, but we're not gonna have this urge that's gonna cause some leakage. Sometimes it's even um oftentimes this happens, people get home from wherever they've been, work errands, and they know that the minute they they call this the key in the door symptom that they're gonna have that urge. I'll have them do this in their car before they even get out to unload groceries or go into the even if they are gonna walk into the house to use the toilet, let's calm the bladder first and then calmly walk to the toilet. Because when you start rushing, the nervous system engages the bladder and is counterintuitive. So we just want to calmly walk to the toilet.

SPEAKER_00 30:00

I feel like a lot of those people are holding their breath at that point, and then they're actually mechanically pushing down as well. So I need you to breathe as you're running the toilet. Try not to physically hold your breath and then bear down because they don't know they're doing that, and it's like then you're pushing it as well. Absolutely. I'm so guilty of this. It's like Pavlov's dogs, right? I'm fine. My whole drive home and I drive get in the driveway, and it's like the minute I sense that toilet, instantly, I didn't have to go, but now it's like I really have to go. So I've been working really hard at breaking for myself that pattern because it's like the bell ringing and I start salivating. It's like that door is there, and my bladder is like, you gotta go right now. And it's it's been a hard thing to break, but I've been trying it, it's getting better.

SPEAKER_01 30:45

Oh, good, it does work. That's one of the nice things is when you do take the time to make some small changes and have the awareness of what's normal to empower yourself to take control over these things, they really do work. The bladder accommodates really well. Um, and I also tell patients if they're in this severe overactive bladder and for many years have been going less than two hours, they probably do have, you know, a really sensitive bladder or what they would describe as a small bladder. Um, I always tell them it's not gonna be comfortable for the first few weeks. It's gonna take a few weeks and it won't feel good, but it's normal. I think some people, there's a myth, I should I guess I shouldn't say myth, if someone's really overstoring urine, that is not a good thing, but that they're gonna get a UTI if they don't go to the bathroom. Going to the waiting two to four hours, you're not gonna get a UTI. So go to, you know, it's okay to store urine longer, but it might not feel good, right? At first it's gonna feel really uncomfortable, it's gonna feel like you really have to go. Um, and you do have to have a little mind over matter with that. I say, like, be your bat be the boss of your bladder. Your brain controls the bladder, the bladder doesn't control the brain. So be your bladder boss, be the boss of your bladder, and tell it no, it's not time to go just yet. And also have the now knowledge and awareness that you're not harming yourself by delaying going to the bathroom.

SPEAKER_00 32:15

So and I think that's really important because people do say that all the time. Well, I'm gonna get a UTI. No, no, no. No, but I like that I'm seeing it. Boss of your bladder.

SPEAKER_01 32:23

Be the boss of your bladder. You tell that to our pediatric patients, you know, you are the boss of your bladder. I have a bladder boss sticker chart for my kids that I see. That's cute. And yeah, be the boss of your bladder, take control of it. It really makes a difference. People will be amazed. People are amazed. I have patients so surprised that it actually works for them, just bladder retraining on its own. I love that.

SPEAKER_00 32:44

So we just wrapped up talking about being the boss of your bladder. So can we circle back to fluids and the types of fluids and talk about like how those dietetic things might matter?

SPEAKER_01 32:54

Yeah, absolutely. So um, water is the gold standard. We want to be drinking water all day, but obviously, you and me included, we we don't just drink water. So things like caffeine, coffee, um, iced tea, tea in general, caffeinated tea, those can be irritants to the bladder. And so everything in moderation. It's not to say not to use it, but um, if you are only drinking coffee and only drinking carbonated, caffeinated beverages throughout the day, that can also be contributing to the irritation of the bladder lining. So carbonated water, right? Even carbonated water, some patients can be very sensitive to that. And so um there are lots of things that are listed as bladder irritants. It doesn't mean for every individual that it's true. Um, I find that individuals process different foods differently. So for some people, a sip of coffee will make them feel like they have to go, you know, more, where other people coffee doesn't really affect them, but iced tea really affects them. Um, same with like spicy foods and acidic foods. Some patients are really sensitive to tomato sauce, even or a spicy meal can irritate the bladder and even the GI tract as well, of course. Um, but it's very patient-dependent. So if you're experiencing these symptoms and you do your bladder diary and you look at the fluids that you're drinking, and you're drinking a whole lot of coffee and a whole lot of carbonated water, say, cutting back on that and alternating with sips of water can be a good way to try to um improve those and limit those bladder irritants.

SPEAKER_00 34:35

So is that part of the bladder diary is keeping track of like the type of things you're drinking, the type of thing that you're drinking?

SPEAKER_01 34:40

Yes, exactly. Your total fluid volume, what you're drinking, and how much of it, what the volume is. So for someone who loves their coffee in the morning, most people, myself included, um, I don't recommend getting rid of the coffee. Instead, I will say have your coffee and then have a glass of water next to your coffee or a bottle of water if you're taking it to go. And for every sip of coffee, take a sip of water, just alternate back and forth so that you start hydrating on top of the bladder irritant that maybe you're experiencing.

SPEAKER_00 35:13

That makes sense. Yeah. Tell me about cranberry juice. We hear all the time about cranberry juice, cranberry extract, kind of helping to soothe the bladder. Is there truth to that?

SPEAKER_01 35:24

You know, I am I would need to go back and look at the current research. I know historically that has been helpful, and there have been um I know I don't think cranberry juice itself has enough of the um kind of protective value. Exactly. There are cranberry pills um that can be protective. Usually that's more in helping the bladder lining in terms of for patients with maybe chronic UTIs. I think it helps to prevent the bacteria from sticking to the lining. Um, but I'm actually not sure what the current research is, so I'm the wrong person to ask for that, or I would need to look it up to give solid advice on that.

SPEAKER_00 36:04

It's just one of those things you hear kind of all the time, just like woman to woman, you hear cranberry juice.

SPEAKER_01 36:08

Yeah, I don't think for general bladder health, it's like, oh, everyone should be drinking cranberry juice, maybe cranberry pills if you're having chronic UTIs, but I would have you ask your doctor for that.

SPEAKER_00 36:20

So aside from dietary factors, what are other and making changes, what are the conservative measures that patients can take, including what we might do in pelvic fluor PT? Um, for ovarectal bladder specifically, or kind of the whole spectrum of bladder issues, overactive bladder, and then with like the different types of incontinence. What are things that people can be doing conservatively to help manage?

SPEAKER_01 36:43

Um again, it kind of depends on what you're most bothered with. If you're having stress incontinence but not having any urinary frequency issues, um, you want to likely strengthen your pelvic floor and also work on the timing and coordination of your pelvic floor. And this is where pelvic floor PT is so important in getting an assessment by a trained professional to look at each individual and say, you know, you you have this level strength and um this type of coordination and working on your individual clinical impairments and functional problems like the leakage. But um, so all to preface this to say not everybody needs to be doing kegel exercises, but in general, pelvic floor strengthening can help to close the outlets and to help manage um the pressure with that occurs with urinary incontinence. So with stress incontinence, we said how it's there's a movement, there's some sort of activity related to the loss of urine, and that is because with the activity there's pressure on top of the bladder. So let's go back to our elder model. I've got it. So the bladder again sits here in the front, and when there is a cough or a sneeze or a jump on a trampoline, there is pressure from the abdominal cavity on top of the bladder that is contributing to the stress. Again, that's why it's called stress incontinence, at the lower urethra, at the sphincters, and the sphincters can't manage. So the pressure inside the bladder is greater than the pressure managed at the sphincter, and it's a physics issue. There's just loss of urine because of um, you know, that poor pressure management and the poor strength at the sphincter. So strengthening the pelvic floor to manage that sphincteric closure, and then also to help kind of hug the bladder. The pelvic floor, it's closing off the sphincters, but the deeper pelvic floor muscles are also kind of lifting and I would like to say like giving the bladder a hug so that with that pressure it's not as um it's not displaced as much. There's not as much movement and the pressure is better managed.

SPEAKER_00 38:59

I think that that's a great point, is that the pressure's normal, right? The increase in pressure, but when it's managed poorly and overrides with the pelvic floor can hold, then that's when we get the exact so um breath holding is a really big is a common habit that we see that contributes to stress incontinence.

SPEAKER_01 39:17

Um holding breath with say lifting a heavy bag of groceries or weightlifting or um whatever it may be puts increased pressure downwards without um you know being able to manage that. If you exhale, you dampen that pressure from above so there's not as much pressure on the bladder to lead to incontinence. So some one conservative management technique is just being aware of if you're holding your breath when you s sit to stand or again picking up the baby off the floor or whatever it may be.

SPEAKER_00 39:50

I think that's a good, really good point. And what you're kind of saying is that these patients need to be assessed and not guessing what the problem is. Absolutely, yeah.

SPEAKER_01 39:58

Um, in general, strengthening is a good thing for most patients, but there are, as you know, many patients who experience pelvic pain and also which is a whole other topic podcast, but there are times that we need to be able to both generate strength and be able to relax and lengthen our muscles. So we want to have a balance between between them. So I hesitate to say, oh, everyone should just be, you know, strengthen your pelvic floor if you're having urinary issues, because that's not always the right thing for everybody.

SPEAKER_00 40:29

And that's good because so many people did that's what they hear over and over is that you need to strengthen those pelvic floor muscles, but maybe you're totally too much tension.

SPEAKER_01 40:36

Right. So for some of our urgency patients, they have too much pelvic floor tone, um, and they actually need to learn how to relax their pelvic floor to let go and to help manage their urgency as well. So yeah, it's not a one-size-fits-all prescription, unfortunately.

SPEAKER_00 40:52

Question with the holding tone. Some people who have a difficult, difficult time fully voiding, or they have like an incomplete void, or they have to double void. Is that part of that problem?

SPEAKER_01 41:02

Yeah, it could be, absolutely. If someone has a really tight pelvic floor, they're not used to letting go of those muscles, it could be actually obstructing the ability of the bladder to fully empty. Um, so and that if your bladder is not fully empty, you're gonna feel like you have to go sooner, right? That's something we didn't touch on earlier with the urgency and frequency. If you're not fully emptying your bladder, you're gonna be going all the time because the bladder actually is full, you're just not letting all the urine out. So sometimes we need to teach patients how to lengthen these muscles, let go of that tension when they're sitting on the toilet. So when you're on the toilet, the pelvic floor muscles, you want to be fully relaxed, which we talked about, we were gonna talk about toileting tips.

SPEAKER_00 41:47

So maybe perfect transition to that. Perfect transition to that stuff.

SPEAKER_01 41:51

Um, toilet posture matters. How you sit on the toilet helps to empty your bladder and your bowels um properly because it helps to facilitate pelvic floor lengthening. Um so when you're on the toilet, you want to sit with your feet flat and you want to take a few deep breaths. And the bladder, like we mentioned before, has the detruser muscle muscle, which is um involuntary. We don't have control over the bladder muscle. It's passive, it's automatic, it's part of our autonomic nervous system. So when we are sitting on the toilet with a full bladder, what should happen is the pelvic floor muscles should let go and lengthen, and the detruser should contract to physically push the urine out. We ourselves should not be pushing or straining. There should be no breath holding, there should be no pushing, straining. You should not have to do anything except let go of your pelvic floor muscles to fully empty the bladder. And I know some people are speed peers, they try to like get it all out really fast, they're in a hurry. They want to just sit on the toilet and um let you know, get it out as fast as possible and move on. That is highly dysfunctional and can create many problems in the future. Um, so you want to avoid straining. The other thing on this same topic is um I said you sit on the toilet, which sounds so obvious, but there are so many women and men probably well, maybe men usually just stand, but you never know some men who sit. Um hovering. So hovering over a toilet, especially in public restrooms. Okay. That is a big no. Um, public restrooms, I get it. I come from a long line of OCD germaphobes in my family, and um, I totally understand public restrooms not wanting to sit on a toilet, but put down the paper, put down toilet paper, whatever, you know, a cover, whatever it is you need to do to get it covered, you need to sit on the toilet a hundred percent of the time. If you are hovering over a toilet, put this back here so you can holder. If you're hovering over a toilet, you are physically using hip muscles, core muscles to engage. To stay in this position, right? When you engage those muscles, it makes it nearly impossible for the pelvic floor to fully relax. And if your pelvic floor isn't fully relaxed, you are not fully emptying your bladder. So if one, two, three times a day you are in a public restroom running errands, maybe at work, whatever it may be, if you are hovering over those toilets, you are not fully emptying your bladder. And I would put money on it that most of those people who hover frequently are also straining because it's harder to go to the bathrooms. They have to push a little bit to get it all out. So we want to be sitting, we want to fully relax. It's really important for our pelvic floor muscles to let go, let the detruser muscle do its job, and then stand up and be on your way. Two related things. Yeah. One, squatty potties. Oh, squatty potties. Yeah, absolutely. So squatty potties are fantastic. They are a tool. It's just a step stool to put. This is already a really low chair. But um, when for having a bowel movement, and this can be true for urinating as well, if someone's having a hard time relaxing their pelvic floor, you can use this as well. But putting a step stool under your feet to bring your knees higher than your hips helps to relax the deep pelvic floor muscles to further allow um emptying. So if someone has issues with constipation and incomplete bowel emptying, a squatty potty, or it doesn't have to be a squatty potty, just anything step stool that brings your knees higher than your hips is really crucial to help get the muscles to fully relax and have that optimal positioning to get a complete bowel emptying. Awesome. Yeah.

SPEAKER_00 45:36

What about standing in the shower?

SPEAKER_01 45:38

So that's kind of yeah. Um, you know, I know that's habitual for some people that they feel the water and they're in the shower and you know, they might pee in the shower. Um it's kind of along the same lines of squatting, right? If you are standing, you have muscle activity, you can't fully empty your bladder. So if you are experiencing these symptoms, I would avoid peeing in the shower for sure. If it's just habitual and you also and you don't have any of these symptoms, it doesn't bother me as much as the hovering god frequently does.

SPEAKER_00 46:10

Let's talk about some other toileting tips. Yeah. Oh, anything else besides hovering and like that in like we talked about hovering or not hovering, we talked about not pushing. Anything else that you really recommend?

SPEAKER_01 46:21

No, nothing I can really think of off the top of my head that kind of I think that covers it.

SPEAKER_00 46:26

All right. Yeah. Anything else that is really just kind of not home remedies, isn't it? Or just kind of conservative, non-invasive things that you recommend for people to try?

SPEAKER_01 46:35

Yeah, absolutely. Um, so there are a few modalities that can help with things like your overactive bladder, urinary frequency. One that actually has some really great evidence um for being um successful at managing that bladder urge is something called posterior tibial nerve stimulation. Um if you've ever used a tens unit, possibly for pain, it's like the little electrodes in the little battery pack. The little E stem box. The little, yeah, it's the um the little um nerve stem box. Um you can put, you would just use one channel and you use two pads, one right at the um, like just medial to your ankle bone on the inside of your leg, and one about five centimeters above, so a few inches higher. Um, and then there are, I'd have to look it up. I forget off the top of my head what the frequency is. Um I can we'll look it up so you can put it on here. Um, is you want to be able to adjust the tens unit. So getting a tens unit that is adjustable. There are some out there that only like the acupuncture and they're like preset for right back pain. You don't want that, you want one that you can actually adjust. Um, but you set it to a certain frequency and then just turn it on and you it's passive, you just let it ride for about 30 minutes. The protocol is twice a week. Okay. And it is successful at modulating that um urgency. The way it works is it's working as what we call an afferent, which is where the body takes nerve, it takes information from a stimulus and brings it up towards the brain in the spinal cord. Um, and so it is taking that stimulus as an afferent to the same sacral nerve roots that affect the bladder. And that mode and frequency is proven to help get the detruser to relax to not be sending that unwanted signal to the brain. So it's a great way, it's a great adjunct to the bladder retraining and learning how to be your bladder boss. It just kind of helps to calm the bladder and um help patients be a little more successful with that.

SPEAKER_00 48:37

And it used to be that we had to have the acupuncture uh needles in it. Yes, but then now we know that we can use it to be.

SPEAKER_01 48:43

I love the data, the resource that's come out in the last few years. It's so great because yes, exactly. They've been using this for the last, I think, 20 years with acupuncture needles in the in the Eurogyne office with nursing using these acupuncture needles and um and STEM. And then in I think it was 2021, there was an um a really great research article that came out and compared the acupuncture needles to the use with just the STEM units with the pads, um, and they found the same results. So there's been repeated studies to confirm that as well. So you no longer need to go to the office in person to get it done and sit there, and you know, it's way easier just to have the little$30, I think they run about$30 on Amazon. Yeah, very reasonable, and then you just have it and you do it at home. It's very easy. So I definitely think increases compliance because you have to go somewhere. So exactly. Yeah, I love that. So it's an easy thing for patients to use. And the I don't think that I haven't seen research for this yet, but I feel like it's coming is also using that for pain management, painful bladder syndrome and um interstitial cystitis and those types of things.

SPEAKER_00 49:51

So I can imagine that from the sacral area, but that might definitely have some implications. Yeah. Oh cool. Any last tips you want to tell us about all of this bladder stuff we should have? I don't know. I don't think so.

SPEAKER_01 50:02

I feel like we covered a lot. Um, I just, you know, would encourage anybody to reach out to a specialist if they are experiencing these issues because again, it's really helpful to be able to know two people are exactly the same. We talked about a lot of generalities and hopefully the norms help people. Sometimes just knowing the norms are enough to get you to where you want to be, to just delaying on your own or whatnot. But if that doesn't work, definitely get in and see somebody for individualized help because that's why we're here.

SPEAKER_00 50:30

Yeah. We like to be assessed on guests. Yes, exactly. I love when people know about a bladder diary and they bring that in into their first visit. Oh, yeah. So, like we'll put one of those in the the show notes for everybody. But I think that's so great because it's just like kind of like coming in labs. Yes. Absolutely.

SPEAKER_01 50:47

There's even some apps now that are really great at for bladder diaries. There's one called the Healthy Bladder app, and it's so interesting. They created uh somehow with technology um an interface where you allow it access to your microphone and you bring your phone with you into the toilet. Okay, and you turn it on, and it measures how much you have urinated just by listening to you empty into the toilet. It's actually accurate.

SPEAKER_00 51:16

I was saying, not totally sure of how I feel about that. Yeah. For someone who agrees. I know a terrible counter, yes.

SPEAKER_01 51:21

I can see your very useful. It's just getting a little more accurate data in terms of how much you're emptying your bladder. Like, who is listening to that to create the data for us? I know, I know, I know. It's such a funny thing, but you know, we have these great devices, and that's one way that it can be really helpful to people. That's why it's helping with our health. Yeah, exactly. I like that.

SPEAKER_00 51:43

Thank you so much for being here.

SPEAKER_01 51:44

Oh my gosh, I always love seeing you.

SPEAKER_00 51:45

Thank you for having me. As I say, I think the pain is gonna be the next thing that we need to get rid of. So we'll come back. I will, absolutely. Thanks for having me. Thank you. And thank you all for being here for another week of Metaplaus and Scripted. Please like, follow, and subscribe everywhere you get your podcasts. We'll put where you can find Dr. Emily Rayland in the show notes, as well as all these different different resources we talked about today. And with that, could I ask you one final question? Of course. Okay, I'm putting it on the spot. Okay. What is your one daily health non-negotiable for what you do for yourself? First thing that comes to mind. That's a really good question. I don't know. I was gonna say, this isn't something that you don't need to do.

SPEAKER_01 52:29

I know, it isn't. No, I need to work on myself. Honestly, I'm trying to um like get my steps in every day and um having a little bit more renewed effort to be working out more than I should, than I know I need to be, that I just don't. I mean, life is busy, it's really hard. So three kids and work and things, I feel like it goes by the wayside. So, no, I don't feel like I have a good non-negotiable. Let me think for one second. I mean, my husband makes green juice almost every other day, and so just drinking green juice and trying to be more mindful with what I'm putting into my body has definitely become a non-negotiable. There you go. Um, but yeah, I don't have a good answer, so that means I need to work on things.

SPEAKER_00 53:14

Sorry to put you on the spot. No, I love it.

SPEAKER_01 53:16

We'll call your daily green juice.

SPEAKER_00 53:17

My daily green juice. Thank you for having me at home. Yes. Thank you again for being here. Oh my gosh, thank you. Now I have to end with the boring stuff. While I am a doctor, I am not your doctor. This podcast is for entertainment and educational purposes only. If something in today's episode resonated with you, please bring this to your own healthcare team and self-advocate. We always are promoting that. I cannot wait for you to join me on next week's episode of Metapods Unscripted for another hot topic.