Author: Lisa Cheek, PT, DPT, CLT-LANA
Let’s face it: going to the bathroom is a big part of our lives. We do it many times throughout the day, and yet it’s not something we talk about very much. As a result, many of us don’t have a great sense of what’s normal and what’s not when it comes to bladder habits. We learn our habits early on, and we carry our habits into our adult life. Unfortunately, many of these habits are not healthy and may even lead to bladder problems like urgency (a strong, uncomfortable need to empty the bladder), frequency (having to go the the bathroom too often), nocturia (going to the bathroom at night), and even urinary incontinence (leaking urine any time you don’t mean to). Before we talk about bad habits, let’s learn about normal bladder function so that we can better identify what’s not normal.
The bladder can hold about 400-600 ml of fluid– about 2 cups worth.1 It usually fills at a rate of about 1 ml per minute, faster in times of increased fluid intake. At this rate, we should be emptying our bladder between four and eight times per day, and zero to 1 time per night.2-3 When the bladder hits about 40% of its capacity (160-200 mL), we feel the first urge to empty the bladder.4 In other words, the bladder starts to tell us that we might want to think about heading to the restroom. If we don’t heed the call, the urge will plateau then eventually go away. Once the bladder hits about 90% of its capacity, we start to feel an uncomfortable urge to go. Once we get the the restroom and sit down, our brain gets the signal that the time is right. It then tells the pelvic floor muscles to relax at the same time as the detrusor or bladder muscle contracts. It should take about eight to twelve seconds to empty the bladder. This whole process involves a very complicated set of reflexes that occur in the brain and brainstem, the bladder, and the pelvic floor. If we aren’t practicing good bladder habits, this series of reflexes can get disorganized and we can end up with bladder problems. Signs of bladder dysfunction include:
- Emptying the bladder more than eight times per day.
- Getting up to use the bathroom more than once per night.
- Leaking urine (incontinence). It’s never normal to leak!
- Slow or fast stream.
- Trouble emptying the bladder- straining, pushing, having to “double void” or try multiple times.
Habits play a big role in bladder function. Without realizing it, we might be setting ourselves up for bladder issues through our everyday actions. Lets talk about small ways that we can change our habits and make our bladders happy!
1) Going to the bathroom “just in case”.
This is something we learn in childhood. We all remember our parents telling us to go to the bathroom before a long car ride. As adults, we might empty our bladder before we go for a run or before a plane ride, even if we don’t really have to go. We’d rather get our trip to the restroom out of the way to save ourselves the inconvenience later. Good idea, right?
Let’s think back to what we just learned about normal bladder function. The bladder can hold a lot of liquid. It also has a set of well regulated mechanisms that let us know when it’s time to go. If we get in the habit of emptying the bladder when it isn’t full, it learns that it isn’t important to fill all the way. Once the bladder learns this, it takes advantage. It starts giving us the signal that it needs to empty, even if it isn’t anywhere near capacity. This can lead to urinary urgency and frequency over time. Think about it– having to go to the bathroom all the time is much more disruptive than having to pull the car over every now and then during a road trip, right? That time we think we saved by taking that pre-emptive trip to the restroom is really not worth it in the long run.
Try this instead: Wait to go to the bathroom until you actually need to go. Typically, this should be about 3-ish hours after the last time you went, unless you are chugging water. Try not to go if you don’t feel any urge. It’s just not worth it.
2) Hovering over the toilet seat.
Let’s face it: sometimes toilet seats are icky. Many of us have the fear of placing our bare derrieres on the cold, hard plastic of a public toilet. As a society, we tend to have a fear of germs and we want to keep our environments as sterile as possible. For many of us, this means avoiding contact with surfaces that are known (or perceived) to harbor bacteria. We channel our inner body builder and squat over the seat while we go. We empty our bladder and save ourselves from contracting some mega-virus at the same time. Smart, right?
Poor toileting posture.
First of all, literally every surface of the restroom is covered in bacteria.5 Many would argue that it is far less sanitary to touch the handle of the toilet with your bare hands, since your hands are much more likely to come in contact with you mouth, nose, eyes, and all those lovely ports of entry for bacteria. It’s highly unlikely that bacteria will be introduced through the skin of your rear end—it just doesn’t work that way. The far more pressing matter is the effect that hovering has on your pelvic floor.
Remember that emptying your bladder is a reflex, and it depends on the ability of the pelvic floor to relax while the detrusor muscle is contracting and emptying.6 When squatting, we are using a number of different muscles to support our body weight, namely our glutes, adductors, and core. When these muscles are active, it is virtually impossible for the pelvic floor to relax. This can lead to incomplete bladder emptying, and can also interrupt the normal reflex. If we get into the habit of not relaxing the pelvic floor at the right time, our bladder loses its normal rhythm. This can set us up for issues of urgency, frequency, and even urge incontinence –leaking urine when you get the urge to go. These consequences are very real— as opposed to the theoretic risk of contracting some bug from sitting on a toilet seat.
Here’s what to try instead: This is going to sound harsh, but it’s the truth: learn to deal with it and SIT DOWN. The toilet seat is not a gross as you think. Bring an antiseptic wipe if you are that concerned. Wash your hands often and use alcohol based hand sanitizer if you are worried about getting sick. I promise you’ll survive.
3) Not drinking enough water to avoid having to go (or to avoid leaking).
It’s a pretty reasonable assumption that many of us make: more water in equals more water out. Maybe we are trying to cut down on our trips to the restroom, or maybe we already have a problem with urinary leakage that we want to fix. It would stand to reason that less water in would equal less water out, right?
Sorry, not the case.
While it is true that decreased fluid intake will slow down bladder filling, it can also lead to concentrated urine in sitting in the bladder. We know urine is concentrated when it comes out looking dark yellow, cloudy, and in small amounts. This concentrated urine can actually act as a bladder irritant6, meaning that it can upset the lining of the bladder. When bladder irritants are present, the bladder will actually try to empty more in order to clear it out. So you see, less water in can actually equal more water out in the case! Moreover, one study7 showed that in people with bladder control problems, there is no effect on urinary frequency or incontinence when fluid intake is increased, as long as other bladder irritants are cut down (more on than below). What is known is that fluid intake of less than 50 oz daily is associated with increase urinary incontinence.8 If you want to decrease urgency or leakage, drinking less water is clearly not the answer.
Try this instead: Stay hydrated! Try to drink at least half your body weight in ounces every day.9 Good hydration will keep your bladder happy and will help it to function normally. Also, try to cut back on known bladder irritants if you want to decrease frequency. These might include: caffeine, alcohol, artificial sweeteners, acidic foods, processed foods, and carbonated beverages.6 Cutting back on these foods and drinks can encourage normal bladder function, and is generally a good idea for your overall health.
4) Waiting too long to go.
So far, we’ve mostly talked about going to the bathroom too often. However, there are also times when we just don’t go enough. We’ve all been there– we are working really hard, in the zone, taking care of business, and then it hits us. We can’t remember the last time we went to the bathroom. We remember going in the morning, yet here we are eight hours later and haven’t had time to stop all day. Good for us, right? After all, we know it’s a problem to go too often, so we must be doing really good!
Not so fast.
Let’s remember that a healthy bladder should need to empty itself every three to four hours. It can hold a lot of fluid, but it has its limits. If it is filling beyond its normal capacity, it can cause the detrusor muscle in the bladder to stretch out.6 This might mean that the bladder can hold more fluid, but it also means that the detrusor muscle becomes overstretched and weak. The detrusor muscle needs to contract in order to empty. If the muscle fibers get stretched out, they can’t contract effectively. This can lead to incomplete bladder emptying, which might in turn lead to increased urinary frequency as the bladder tries its best to empty.
Try this instead: Go to the bathroom when you need to go. Be mindful of what you’re putting into your bladder and what is coming out. If you have the urge to go to the restroom and you think you’ve put at least two cups of liquid into your system, it’s probably time to go. If you have the urge to go to the restroom and it has been at least three hours since your last trip, it’s probably time to go. Don’t go just because you think you should, but really learn to listen to your body. It’s very smart, and it will tell you what it needs if you are treating it right.
The bottom line
Know what is normal and what is abnormal. Give your body what it needs, and cut back on things that it doesn’t need. Listen to your body’s signals, and try not to interfere with its natural rhythm. Most importantly, if you think that your bladder habits might be abnormal and you aren’t quite sure how to get on track, get in touch with an expert who can help you cultivate healthy habits.
- Haylen BT et al. An International Urogyencological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogyn J. 2010; 1:5-26
- Carriere B, Markel Feldt C. Storage and Emptying Disorders of the bladder. The Pelvic Floor. Stuttgart Germany: Georg Thieme Verlag; 2006
- van Kerrebroeck P, Abrams P, Chaikin D, Donovan J, Fonda D, et al. (2002) The standardisation of terminology in nocturia: report from the Standardisation Sub-committee of the International Continence Society. Neurourol Urodyn 21: 179-183.
- Fowler CJ, Griffiths D, de Groat WC. The Neural Control of Micturition. Nat Rev Neurosci. Jun 2008: 9(6):453-466
- Flores GE, Bates ST, Knights D, Lauber CL, Stombaugh J, et al. (2011) Microbial Biogeography of Public Restroom Surfaces. PLoS ONE 6(11): e28132. doi:10.1371/journal.pone.0028132
- Siracusa C et al. Pelvic Health Physical Therapy Level 1 Course Manual. American Physical Therapy Association Section on Women’s Health. 2015.
- Pearson BD, Larson J. Improving elders’ continence state. Clin Nurs Res. 1992; 1:430-439
- Meinders AJ, Meinders AE. How much water do we really need to drink? Ned Tijdschr Geneeskd (Dutch). 20120; 154:A1757
- Paraiso MFR, Abate G. Times voiding and fluid management. In: Davila GW, Ghoniem GM, Wexner SD (eds). Pelvic Floor Dysfunction- A Multidisciplinary Approach. London: Springer Verlag: 2006