Weak bladder, weak pelvic floor: the causes and remedies

Many women experience the infamous «trampoline moment» – even several years after their children are born. It’s when mum decides to have a bounce on the kids’ trampoline that it happens: the patter of droplets on the elastic matt below her feet, preceded by an uncontrollable rush of urine. Kinda embarrassing, given that bladder weakness is considered as something that only affects the elderly. People like the grey-haired lady from TV ads for incontinence pads.

Simply put, incontinence can affect anyone. Men usually get acquainted with it when an enlarged prostate presses on the bladder. Bladder weakness affects women earlier, say after pregnancy or during menopause – but it also impacts athletes. «In Austria, nearly a million people experience urinary incontinence. That’s near on 10 per cent of the population», says Vienna-based urologist Natalia Swietek. In Switzerland, it’s estimated to be about 500,000 people.

The bladder: a single player on a complex team

Before focusing on incontinence aka bladder weakness, it’s worth taking a look at a healthily functioning bladder. The bladder can hold a good half to three quarters of a litre, with the elastic hollow muscle of the bladder wall adapting to the volume. When your bladder is full, you’ve got to pee. Nothing new there.

In the background, however, there’s an elaborate system of nerves operating in the bladder wall, spinal cord and brain – a little like orchestra conductors. They’re responsible for the interaction between each part of the symphony: the bladder wall muscle with its involuntarily controlled inner sphincter and the outer bladder sphincter. The latter, which you control, forms part of the pelvic floor. The pelvic floor, by the way, is a three-layer system of musculature and connective tissue and serves, among other things, as a support for the bladder. But it also keeps the urethra closed, or relaxes when urine needs to be released.

As soon as urine flows into the bladder, the sphincters are closed. Tension receptors located in the bladder wall send an «it’s filling up» signal to the spinal cord. The brain isn’t clued in on this until the bladder is half full. Only then does the spinal cord pass the information on to the brain, causing us to feel the first urge to pee. If we don’t act on this urge, the bladder relaxes and stretches, while the internal and external bladder sphincters tense up. As soon as the bladder is nice and full, the spinal cord starts rapping at the brain’s door again, sending us in the direction of the loo. Our brain gives our muscles a conscious «please open» command, causing the sphincters to relax. The bladder wall muscles contract and the external sphincter opens. In the case of bladder weakness, this highly complex interaction is thrown out of kilter.

Two common forms of bladder weakness: Urge and stress incontinence

There are various forms of bladder weakness, but the most common are urge incontinence and stress incontinence. 90 per cent of those affected suffer from one of the two.

Urge incontinence is also called irritable bladder. Around 15 to 20 per cent of people in Europe experience it, mostly older men. Urge incontinence often develops as a result of benign prostate enlargement, but it can also result from nervous system disorders or hormonal changes. Stress, anger or anxiety can also be involved in the development of this kind of incontinence.

Irritable bladder is when the tension receptors on the bladder are overactive, probably due to an imbalance in bladder control. «Even small amounts of urine cause a lot of stimulation and an increased urge to urinate», says Swietek. When the brain receives word of an overly strong urge to urinate, the bladder is emptied reflexively. All before the person has made it to the toilet.

Stress incontinence, on the other hand, often affects women, especially pregnant women or young mothers and menopausal women. Hormonal changes «alter the connective tissue, musculature and nerves of the holding mechanism in the lesser pelvis», says Swietek. However, female athletes in high-intensity sports such as ballet, gymnastics, trampolining, weightlifting, or ball sports can be affected too (link in German). That said, it’s still not totally clear why these women experience incontinence.

Stress incontinence concerns the weakness of the pelvic floor muscles. Those affected release urine when sneezing, coughing, lifting heavy objects or doing activities such as trampolining, all of which cause a brief increase in pressure in the abdominal cavity. A weak pelvic floor isn’t able to take the pressure.

How does incontinence therapy work?

There are promising treatments out there for both forms of incontinence. «The remedy of choice for stress incontinence is pelvic floor training», says Swietek. The training is provided by physiotherapists, who work the muscles and fascia of patients affected by bladder weakness with their hands, and show them how to do the exercises. «This eliminates tension, sharpens awareness and trains movement sequences», says physiotherapist Franziska Malle. She frequently works with visualisations and associations: «We know from muscle physiology that more muscle activity is achieved when the patient can picture what they’re trying to tense up.» It’s why she shows her patients an anatomic model of the pelvic floor and its muscles as a first step. That way, they learn what the pelvic floor is, which organs it houses and how its three muscular layers interact with the bladder. In turn, they see how complex the system governing bladder function really is.

The exercises are combined with biofeedback, electrostimulation and vaginal cones (small weights for the vagina, similar to love eggs). In biofeedback, patients learn to perceive and influence unconscious processes in their own bodies – in this case, to actively control the pelvic floor muscles. With electrostimulation, the muscles can also be stimulated through electrical impulses.

When it comes to urge incontinence, the focus is placed on behavioural methods, such as reducing contact with substances that would irritate the bladder. Nicotine and caffeine are two prime examples. With so-called toilet training, people affected with bladder weakness learn to follow a loo schedule. Electrostimulation, biofeedback and pelvic floor exercises can also help with urge incontinence. «Medication is often prescribed in addition to this, namely anticholinergics, which prevent the bladder from contacting as much», says Swietek.

What else strengthens the pelvic floor?

The first person you should contact if you suspect you’re suffering from bladder weakness is your family doctor or gynaecologist. The fact is you won’t be able to strengthen your pelvic floor without getting any guidance from a qualified professional. However, there are, of course, simple at-home exercises that support physiotherapy training. These include:

• When going to the toilet, sit upright with your back arched slightly
• Release any leftover urine by tilting your pelvis several times – but don’t squeeze!
• When coughing or sneezing, cross your legs to support the sphincter. You can also: - Turning to the side to relieve pressure on the abdomen.
• Go to the toilet a maximum of eight times during the day and once at night. Keep in mind that the more often you empty your bladder, the more often you’ll feel the need to go. If the bladder never reaches its maximum volume, it shrinks, becoming less stretchy and signalling the urge to urinate prematurely (see irritable bladder). There should be a gap of three to four hours between toilet breaks.
• Nevertheless, you’ve got to drink enough! The body requires at least two litres of fluid per day.
• Don’t try to stop the stream of urine when you’re in full flow (so to speak): this knocks the system controlling the bladder out of whack, weakening the bladder’s ability to close.