Tissue Talk: The most estrogen-dependent tissue in the body

You might be thinking the uterus, ovaries, or mammary glands. But no, we're talking the urethra. Yes, that's right, the urethra. It is the most estrogen-dependent tissue in the body for both men and women.

The urethra depends upon sufficient estrogen levels to maintain proper lubrication, which is essential for normal functioning, especially in women. Women lack an internal urinary sphincter. Instead, the urethra must compensate through an adequate bladder neck angle (also called a urethral angle) and a process called coaptation. The urethral angle refers to the angle the urethra exits your bladder. Too small an angle may contribute to diminished flow. More common, too great an angle may contribute to incontinence. Coaptation means that the tissue must open and close in response to external (to that tissue, not to your body) stimuli. In order to do that, it requires sufficient lubrication provided by the mother of lubrication--estrogen.

Several of my menopausal and post-menopausal patients have found that a topical cream has been part of the solution to their incontinence. The cream does not carry the risks associated with oral hormone replacement therapy. You may benefit from the topical if you have low, or borderline, estrogen levels, have bladder issues and especially if your stream is affected (diminished, increased, spurting, etc).

The weighted bladder

Research shows that bladder dysfunction is affected by changes in body weight. Even a five pound increase in weight can adversely affect a bladder already experiencing symptoms. The good news? A five pound decrease in weight can lessen the stress on the organ and, hence, mitigate the experience of bladder symptoms.

Tissue Talk: The importance of being hydrated

I always tout drinking more fluids, especially water, in order to work the bladder as a muscle, keeping it strong. The other side to this coin is the benefits of hydration. All tissues function better if appropriately hydrated.

While there has never been research to indicate just how much we should drink and there are varied ideas about how to compute amounts to drink, I tell my patients to use their bladder as their gauge. If you are exercising regularly and have gained control of your bladder issue, you know you are drinking enough if your symptoms subside and you are dehydrated if your symptoms relapse. You can also use your time on the toilet as a gauge. Women should urinate for 10 to 12 seconds and men should urinate for 12 to 15 seconds. If you don't make that mark, you need more fluids.

People tend to think more about hydration in warmer weather, when they're more active. But these Minnesota winters are so dry that it is important to think about hydration year round.

But I have a small bladder.....

I'm amazed at how often I hear this and that this myth has survived in such an educated society. You never hear anyone say, "I can't do aerobic exercise because I have a small heart." It sounds ridiculous, right? But somehow when people say they have a small bladder, it goes unchallenged.

All species are born with organs of appropriate size for their bodies. My 8# Papillons have very small bladders. But when there has been occasion that I wasn't able to get home for 10 hours, they held it. They are continent through the night. Size is irrelevant; condition is everything.

It is true that the bladder, being a muscle, can atrophy, just like a heart can degenerate into unhealthy condition. The heart degenerated from not exercising and the only way to get it back in shape is to do aerobic exercise. The bladder atrophied from not drinking enough fluids and from urinating too frequently and the only way to get it back in shape is to drink more fluids and to urinate less frequently.

Next time someone laments that they have a small bladder, let them know that there is help for them and direct them here.

Popular myths surrounding incontinence or urinary leaking

The three things that most people do when they find that they are suffering from any sort of incontinence or urinary leaking are to decrease their fluids, increase their frequency of urination and to stop exercising.

They figure that if they're leaking fluid that they must be taking in too much or that decreasing intake will somehow make it less likely to leak out. They figure that if they have been urinating every three or four hours and leaking in between, then maybe they can stave off that leaking by going more frequently. They figure that if they have been leaking on impact when exercising, then maybe they should stop exercising. All of these are rational; all of them are wrong and set up the bladder for more incontinence.

If a bladder is already compromised, it may be that there are false signals relayed to the nervous system indicating an urge to urinate when the bladder is not full. Often this is from irritation within the bladder or from dyscoordinated neuromuscular activity of the bladder with other surrounding structures. In any case, the strategies of drinking less and urinating more are strategies of dehydration. This is never healthy systemically and actually makes the bladder worse off as it atrophies over time. The bladder has a muscular layer, the detrusor, and like any muscle, needs to be worked to stay healthy. Unlike other muscles, the detrusor is only worked when filled and stretched. The detrusor is stretched by the bladder filling up to functional capacity, by drinking fluids and urinating infrequently.

There are studies that show that any exercise done regularly, even if it doesn't address the pelvic floor itself, will improve the condition of the pelvic floor over time. If there is leaking on impact, the leaking is not caused by the impact; it is caused by the neuromuscular dyscoordination. One might consider switching to a low-impact exercise or wearing pads while continuing the higher-impact exercise.

So, counter-intuitive as it may seem, the best course of action when one starts leaking or experiencing any sort of incontinence is to drink more fluids, urinate less frequently and keep exercising (or exercise more). Work that bladder!

You might want to check out the List of Bladder Irritants in my Treasure Trove (tab in navigation bar).

Neurology & the pelvic floor

I'm always stressing the central role of the nervous system in the functioning of our bladders and pelvic floors.

Eric Franklin, PT:  "In the opening stages of training, the building up of strength is almost wholly neurogenic. An actual change in muscle substance is called a myogenic change, and this only happens after a relatively long period of training."

Janet Hulme, PT:  "Even muscles you are not aware of being able to control, like the bladder, are affected when you change muscles you can control."

Diane Lee, PT:  "Exercises for PFM are not intended to improve strength! Coordination and endurance is key!!!"

Dumoulin & Hay-Smith (2010) found in randomized trials "support for the widespread recommendation that PFMT be included in first-line conservative management programmes for women with stress, urge, or mixed, urinary incontinence." as compared to no treatment, sham treatment and placebo.

Neuromuscular coordination is the goal of pelvic floor or pelvi core rehabilitation.

Urology as a subspecialty of neurology, a case study

"It's all about neuro-muscular coordination."

If you've taken my Bladder & Pelvic Floor Health class (whether for patients or for practitioners) you've heard me say this umpteen times. It's one of the major take-aways from the class. You've also heard me joke that "Your bladder doesn't pee, your brain does."  While this is not completely accurate, it serves to underscore an important theme: Your bladder is part of a very complicated neurological system and it operates within that system, not as an adjunct.

I have a patient whose story is an excellent representation. She had an existing bladder issue from a previous trauma when she came to my Bladder & Pelvic Floor Health class. Over time, she was healing herself with the exercises that I taught. However, she recently had a fall that caused a moderate head trauma. She didn't drive for four weeks and she was off of work for seven weeks. She found that her body prioritized the new trauma; her bladder issue, with the new stressors her body was going through, worsened. The concussion left her balance and proprioception compromised. She experiences dizzy spells. These are common neurological symptoms with trauma, and especially with head trauma.

At my Pelvic Floor & Core Workout Series she has shared with us how, in doing the slow movements and really paying attention and feeling her body, it fatigues her mind and body. She's noticed that she gets emotional with the movement and with her impatience in feeling fatigued, and that the emotion and fatigue are both signals for her to take a rest. But she's seeing improvement with these slow, intentional movements that challenge the core, coordinate proprioception and improve balance. Remember, these all contribute to and mirror the condition of each other because they are all neurologically based.

It truly is all about neuro-muscular coordination.