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Let me introduce myself. My name is Mark Sisson. I’m 63 years young. I live and work in Malibu, California. In a past life I was a professional marathoner and triathlete. Now my life goal is to help 100 million people get healthy. I started this blog in 2006 to empower people to take full responsibility for their own health and enjoyment of life by investigating, discussing, and critically rethinking everything we’ve assumed to be true about health and wellness...

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October 31 2018

Urinary Urgency and Incontinence: Why It’s Not Just Age

By Mark Sisson
28 Comments

Most people chalk urinary incontinence and excessive urgency up to age. We get old, stuff stops working, we wake up to wet sheets. Cue jokes about adult diapers and investing in “Depends” futures. It’s not entirely out of line. Aging matters. There’s just more to it. Like other aspects of “aging,” incontinence and unreasonable urgency don’t just “happen.” Aging may hasten or accompany the decline, but it’s by no means inevitable, unavoidable, or unmitigated.

There are surgical treatments available, many of which involve the implantation of balloons and slings and rings and hammocks. Those are beyond the scope of this post, which will focus on exercises and other less invasive interventions and preventive measures.

What’s the Deal With Urinary Incontinence?

The most well-known type is stress incontinence. When you do anything intense enough to create pressure, such as a sneeze, a particularly boisterous laugh, a trampoline session, a power clean, or a box jump, the pressure escapes through the weakest point of your body—your slack pelvic floor muscles which support and enable bladder function. The result is inadvertent leakage.

The most common type is urgency incontinence. That’s when you can control your bladder well enough, but you feel like you have to go more frequently than you’d like. This can disrupt sleep and place you in uncomfortable situations.

There’s also prostate-related urinary incontinence. If men have incontinence, it’s usually because of prostate issues or prostate surgery altering the normal flow and function of their urinary tract. Today’s post won’t deal with this explicitly, although many of the exercises I’ll discuss that help women treat incontinence can also help men treat prostate-related incontinence. For more info on this, revisit my post on prostate health from a few weeks back.

Both stress incontinence and urgency incontinence usually have the same cause: pelvic floor dysfunction. The pelvic floor acts as a taut, supple sling of muscle and connective tissue running between the pelvis and the sacrum that supports the pelvic apparatus, including organs, joints, sex organs, bladders, bowels, and various sphincters. We use it to control our urination, our bowel movements, even our sexual functions. It’s very important.

What Goes Wrong?

It gets weak and tight and pulls the sacrum inward (the tail gets pulled toward the front of the body), interfering with urination and urinary control.

What causes pelvic floor dysfunction?

Childbirth is one potential cause, but it’s not a foregone conclusion. Women who have vaginal deliveries are more likely to display more pelvic floor dysfunction than women who have cesareans, while a more recent study found that tool-assisted vaginal delivery and episiotomy were the biggest risk factors for vaginal delivery-associated incontinence, not vaginal delivery alone. Allowing passive descent in the second stage of labor, rather than active pushing from the get-go, might also reduce the association.

Muscular atrophy of the pelvic floor muscles. The pelvis is where the magic happens. It’s where we generate power, walk, run, procreate, dance, and move. To keep it happy, healthy, and strong, we have to move. And then keep moving. Through all the various ranges of space and time and possible permutations of limbs and joints. That’s what all our muscles expect from the environment. It’s what they need. When that doesn’t happen, they atrophy—just like the other muscles.

Who Develops Incontinence?

Stress incontinence is more common among women than men. And most women with stress incontinence are older, although childbirth can increase the incidence.

Signs of Poor Pelvic Floor Function

Besides urinary incontinence and urgency incontinence—which are pretty tough to miss—what are some warning signs of poor pelvic floor function?

Low-to-no glute activity when walking. According to expert Katy Bowman, the glutes play a crucial role in pelvic floor function and incontinence prevention.

Lack of lower back curvature. This suggests your pelvis is being pulled inward due to poor glute activity and/or overly tight pelvic floor musculature.

Muscle atrophy elsewhere. If the muscle’s disappearing from your arms and legs, what do you think is happening in other areas?

What Can You Do?

Work On Your Squat

If you can’t sit in a full squat, with shins fairly vertical and heels down on the ground, you need to work on your form.

I suggest reading this old post by Kelly Starrett describing optimal squat form. He focuses on performance and strength training, but the technique applies equally to basic bodyweight squatting for pelvic floor health.

One thing to emphasize: go as low as you can without reaching “butt wink” threshold. The butt wink is when the pelvis begins rotating backward underneath the body. If you’re butt winking all over the place, you’re shortchanging your glutes and preventing them from balancing out the pelvic floor situation. Stop short of the butt wink.

Squat a Lot

You don’t have to load up the bar, although that’s a great way to build glute strength. In fact, I’d refrain from heavy squatting if you’re currently suffering from urinary incontinence, as the stress placed on that region of the body during a heavy squat can make the problem worse and cause, well, leakage.

I’m mainly talking about everyday squatting: while playing with the kids, picking up dog poop, unloading the dishwasher, brushing your teeth, cleaning the house, gardening. If you can incorporate squatting while using the bathroom, perhaps with a Squatty Potty or similar product, that’s even better. Katy Bowman recommends women squat to pee in the shower as an integral part of her therapy for pelvic floor disorder.

Squat To Use the Toilet (or At Least Get Your Feet Up)

I wrote an entire post almost ten years ago exploring the virtues of squatting to poop. Not only does it improve symptoms in hemorrhoid sufferers, reduce straining, and alleviate constipation, but squatting to poop turns out to relieve a lot of excessive pressure on the pelvic floor musculature.

Not everyone’s going to hoist themselves up over the toilet standing on a stack of thick books, or go all out and build a Southeast Asian-style squat toilet in their bathroom, or even get the Squatty Potty. It’s probably the best way to do it—and it’s certainly the most evolutionarily concordant way to poop—but it’s not totally necessary. What matters most is getting those feet up and those knees above your hips. If you can achieve this by placing your feet on a stool (not that kind of stool) as you sit on the toilet, it should do the trick.

Take a Walk and Feel Yourself Up

Next time you walk, rest your palms on the upper swell of your butt cheeks. Every time you step through, you should feel your glutes contract. If they contract, awesome. You’re unconsciously using your glutes to propel yourself forward. If they don’t, you’ll have to train them to contract when you walk.

Do this by going for a ten minute walk (minimum) every single day while feeling your glutes. Consciously contract them enough and feel yourself up enough and the resultant biofeedback will make glute activation a passive behavior, like breathing. Eventually you’ll start doing it without thinking. That’s the goal.

Do Kegels—Differently

The classic therapy for pelvic floor disorder is to train the pelvic floor muscles directly using kegels. This is the muscle you contract to stop yourself from peeing midstream. “Doing kegels” means contracting and releasing that muscle for sets and reps. A common recommendation is to hold for ten seconds, release for ten seconds, repeated throughout the day. Waiting in line? Kegels. Eating dinner? Do some kegels. Remember that man at the DMV last week who would randomly tense up and start sweating as you both waited for your number? He was probably doing kegels.

It’s definitely part of the story—studies show kegels work in men, women, and seniors—but it’s not enough.

Consider  Katy Bowman’s take on the subject. She thinks kegels by themselves make the problem worse by creating a tight but ultimately weakened pelvic floor muscle that pulls the sacrum further inward. Combine that with weak or underactive glutes that should be balancing the anterior pull on the sacrum but don’t and you end up with rising pelvic floor dysfunction and incontinence.  She recommends doing kegels while in the squat position to ensure that the glutes are engaged and all the other contributing muscles are in balance.

Do More Than Kegels

The bad news is that we don’t have controlled trials of Katy Bowman’s protocols with deep squats and frequent daily movement and going barefoot over varied surfaces and squat toilets. We mostly just have basic “pelvic floor exercises,” which usually just mean “kegels.” The good news is that even these suboptimal exercise therapies seem to work on anyone with incontinence, whether they’re just coming off a pregnancy, a 70th birthday, or a prostate procedure. Young, old, middle-aged, male, female—exercise works.

Actually, we do have one small study that suggests kegels will work much better if you balance them out with exercises that target the glutes and hips. In the study, women suffering from urinary incontinence were split into two treatment groups. One group did pelvic floor muscle exercises (kegels). The other group did pelvic floor muscle exercises, plus exercises to strengthen the hip adductors, the glute medius, and glute maximus. Both groups improved symptoms, but the group that did the combo exercises had better results.

For hip adduction, you can use that hip adduction machine where you straddle the chair with legs spread and bring your knees together against resistance. Another option is to use resistance bands. Attach one end of the band to a secure structure and the other to your ankle. Stand with legs spread, then bring the banded leg inward toward the unbanded leg; you should feel it in your inner thigh. Do this for both legs.

For glutes, you have many options. Glute bridges, hip thrusts, squats, deadlifts, lunges, resistance band glute kickbacks.

If you want to get deep into this subject and really learn the optimal exercises for pelvic floor dysfunction, I’d pick up a copy of Katy’s Down There For Women.

Get Strong and Stay Strong

One of the strongest predictors of urinary incontinence is physical frailty. The more frail—weak, fragile, prone to falling, unable to handle stairs, unsteady on one’s feet—the man or woman, the more likely they are to suffer from urinary incontinence. This mostly comes down to muscle atrophy; the frail tend to have low muscle mass all over, including the pelvic floor.

Studies show that strength training improves urinary control in both men coming off prostate procedures and women.

The best option is to never get frail in the first place. If you’re younger and in shape, keep training and moving. Don’t lose it. If you’re younger and trending frail, get training and moving. Don’t squander the time you have. It goes quickly. If you’re older and frail, you have to start today. Fixing this doesn’t happen overnight. Being frail makes it harder to do the things necessary to get strong, but that doesn’t absolve you of the responsibility.

The Bottom Line

None of this stuff is a guarantee against incontinence. Guarantees don’t really exist in life. But I’d definitely argue that anyone who employs all the tips and advice mentioned in today’s post will have a better shot at maintaining bladder control than their doppelganger in some parallel universe who never tries anything—the earlier the better.

If you have any experience with urinary incontinence, let us know in the comments down below. What worked? What didn’t? What worked for a while, then stopped?

Thanks for reading—and sharing here. Happy Halloween, everybody.

References:

Bernstein IT. The pelvic floor muscles: muscle thickness in healthy and urinary-incontinent women measured by perineal ultrasonography with reference to the effect of pelvic floor training. Estrogen receptor studies. Neurourol Urodyn. 1997;16(4):237-75.

De araujo CC, Coelho SA, Stahlschmidt P, Juliato CRT. Does vaginal delivery cause more damage to the pelvic floor than cesarean section as determined by 3D ultrasound evaluation? A systematic review. Int Urogynecol J. 2018;29(5):639-645.

Kokabi R, Yazdanpanah D. Effects of delivery mode and sociodemographic factors on postpartum stress urinary incontinency in primipara women: A prospective cohort study. J Chin Med Assoc. 2017;

Handa VL, Harris TA, Ostergard DR. Protecting the pelvic floor: obstetric management to prevent incontinence and pelvic organ prolapse. Obstet Gynecol. 1996;88(3):470-8.

Dokuzlar O, Soysal P, Isik AT. Association between serum vitamin B12 level and frailty in older adults. North Clin Istanb. 2017;4(1):22-28.

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28 thoughts on “Urinary Urgency and Incontinence: Why It’s Not Just Age”

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  1. Men don’t usually get urinary tract infections. I have had three, confirmed by urinalysis, in the last two years. IMHO, I have had more in the past. Since men don’t usually get them, my doctors have always said it was just arthritis, until one went septic and gave me a heart attack. Now, if I have urgency, I ask them to check.

    1. Most urinary tract infections are caused by eating undercooked chicken… it’s true, E. Coli is a major source of UTIs.

      1. I am VERY careful about cooking chicken. May not have always been in the past. Yes, most UTIs are caused by E. Coli.

  2. “The pelvis is where the magic happens.”

    Truer words were never spoken.

  3. I read in I think Men’s Health that according to studies pumpkin seeds are healthy for the prostate and will reduce night time urination.

  4. Interstitial Cystitis is a common cause of urgency, pelvic pain, and even urinary tract infections in men of no typical origin. There is often urgency and incontinence related to lower urinary tract epithelial dysfunction. It’s often mis diagnosed and mistreated as part of the prostatitis spectrum of disease (chronic prostatitis or abacterial prostatitis). LIke IC in women it can respond to dietary measures but there are other treatments related to histamine/allergies and other triggers. Too complex to address here.
    Read this article. [Rev Urol. 2002;4(suppl 1):S49–S55]

    1. Interstitial Cystitis is a common cause of urgency, pelvic pain, and even urinary tract infections in men of no typical origin. There is often urgency and incontinence related to lower urinary tract epithelial dysfunction. It’s often mis diagnosed and mistreated as part of the prostatitis spectrum of disease (chronic prostatitis or abacterial prostatitis). LIke IC in women it can respond to dietary measures but there are other treatments related to histamine/allergies and other triggers. Too complex to address here.
      Read this article. [Rev Urol. 2002;4(suppl 1):S49–S55]

      Interstitial Cystitis and Lower
      Urinary Tract Symptoms in Males
      and Females—The Combined Role
      of Potassium and Epithelial
      Dysfunction
      C. Lowell Parsons, MD
      Division of Urology, UCSD Medical Center, San Diego, CA

  5. Thank you for bringing light to this. I had sudden urgency during a bad viral infection in feb 2016 and sadly once the infection passed the urgency stayed.. non-stop, for a year. Imagine feeling like you’re about to burst 24/7… I was 28 and losing my mind. Drs told me I had interstitial cystitis and went so far as to perform surgery with no results. I urge anyone with these symptoms to see a physiotherapist who specialises in this! Through months of learning to relax muscle tension, retraining my pelvic floor and now building strength with an exercise physiologist I’m finally symptom free. My physio would tell me about the hundreds of women who live with this for years before seeking help, just assuming its the norm – crazy. Good luck to anyone dealing with this 🙂

  6. Go see a Pelvic Health PT!!!!!!!!!

    Wanted to write that in ALL CAPS but it felt too aggressive. But seriously… you can self diagnose and try to correct, but you may be actually making it worse.

    My PF was tight after birth and I couldn’t relax it. So if I put it under a load like jumping rope, the muscle would be squeezed tight… until it just couldn’t do it anymore and then I would end up peeing. All the kegels in the world would’ve just made my condition WORSE.

    I feel like people don’t want to seek help because it’s “embarrassing” but going to see a pelvic floor specialist could be life changing!

    1. Absolutely agree – if you have urinary problems, see a pelvic health specialist! It took two years and a misdiagnosis of overactive bladder to find out I had a hyper-tonic (too tight) pelvic floor. Simple physical therapy made a huge difference without unnecessary medications.
      Also, do not believe the seemingly American idea that women just have to suffer these things. It is not normal and can be addressed!

  7. I am in my mid 60’s and have had a lot of trouble with urinary incontinence, urgent bladder that wouldn’t wait until I got to the bathroom, etc.

    I have lost over 50 lbs on LC/HF over the last year or so. Recently, when I got more serious, I lost 30 lbs of it and my bladder is a LOT more manageable. I no longer need pads during the day. I have not be exercising any more than I did before, just eating differently and losing some weight. Something to think about!

    1. I am with Carol.

      I am a female, age 66. Since starting keto this past April, I have lost 6 clothing sizes and more than 50 pounds. I also lost incontinence and urinary urgency as a result of weight loss and change in diet. I work a full time sedentary job and my only real exercise is walking.

  8. If you have any sign of incontinence and urgency, get your prostrate checked.

    If your prostate is even slightly enlarged, you are already creating damaging back pressure in your bladder, Detrusor Muscle and Kidneys.

    You can use exercise and nutrition but you still need your prostate monitored and urine retention measured and tracked.

    There are all sorts of “cures” that may relieve the symptoms of a swollen Prostate. What still may be happening is that you may be retaining urine which stretches your bladder and damages your Detrusor Muscle. You may also be causing Urine to back up into your Kidneys which causes other problems.

    Once your Detrusor Muscle atrophies from being stretched you may need to self cath if you retain more than 100ml.

    Until the actual mechanism of an enlarged Prostate is found, I would not depend any pill or nutrient. Genetics is the only firm correlation to an enlarged prostate. There is a difference between fixing a broken mechanism and relieving symptoms of the broken mechanism.

    Saw Palmeto will relieve the symptoms but suppresses Testoterone. The Pharmaceuticals for enlarged Prostate mess with sexual function. Many positive reports of Blackstrap Molasses and Pumpkin Seeds but I think you are just buying time especially if you are already on a nutritious diet.

    15 years prior to my surgery, I did Kegels, when I first noticed the problem. That helped. Then 10 years of VA contract Physician Assistants who never had me get a prostate exam. I ended up in the emergency room with 1.2 liters in a bladder which normally holds only 400 ml.

    Having the passage through my Prostate surgically enlarged was the best thing for me and got my Kidney functioning again.

    I will focus on the exercises Mark lays out here as I still retain slightly less than 100ml. Though I tried similar exercises after the operation, once the Detrusor atrophies, there is not much hope.

    Hope this helps someone.

  9. This article was really helpful, Mark, thank you.

    Three thoughts/ideas:

    1) Massage and/or Yoga. I’ve had a physical therapist work hard on my sacrum, as one side is very tight from a horseback fall almost 20 years ago. (I’ve ignored it until last month!) So massaging out and stretching all those muscles/tendons/fibers that insert from there can help. And yoga, I’ve been told, is great for that. The Plow is a great pose to stretch that area out (although I do it without touching my feet to the ground so as to stretch that area. I also will hold the pose at an angle to stretch out each side)

    2) Fibroids. For women, fibroids can also put pressure on the bladder and create that urgency.

    3) Food/Drink. I’ve also noticed that caffeine can create that effect, an urgency to pee plus a shot of annoyance in the form of a pinching feeling. So does mineral water; not sure why.

  10. Just a word about nighttime urgency.I used to get up 4-5 times a night and when I woke I had to go RIGHT NOW. Turns out it was one sign that my body was desperately trying to get me upright and taking in adequate air…because I had sleep apnea. There is an entire cascade of reactions to inadequate breathing that your body attempts to keep you on this good earth and one of them is frequent urination. So if anyone you sleep with ever gets up and goes to the couch in the middle of the night because of your snoring, or tells you they hear you stop breathing, go to your doctor and get a sleep study.

  11. Hi Mark
    This article hit home for me as I’m 57 and living with a slightly enlarged prostate. One of my favourite activities is getting out on my road bike for a good 50 to 75 km ride. I’m wondering if you would know if that is aggravating my prostate? I’ve read so many conflicting reports I’m hoping you may have some insight. Thanks !

    1. Hi Marek, as a nurse I do know that bicycle riding will aggravate a man’s prostate, especially if it is enlarged, & can also elevate your PSA. If you have been seen by a urologist be sure to let him/her know that you bicycle. They may request you to stop for a few weeks before checking your prostate & lab work again.

  12. As an 85 year old that birthed 4 children over a span of 20 years (yes, much spacing) so have a worn out pelvic floor, they tell me. In 2007 I complained to my OB/GYN and was prescribed a medication. A bladder sling put in 2014, not better, new medication 2 months later, not better, Bio-feedback therapy in late 2014, not better. New medication again early 2016, which today I can say has helped with night time trips after taking the extended pill early in the day. I have had the sleep study and do sleep with the CPAC.
    Obviously at my age and after knee double replacement, most exercise is out of the question as I can’t get down on the floor. Just living with it as best I can and try to answer any urges if possible.

  13. Very interesting article. I notice that the few times I go off the Primal way of eating and eat wheat, the entire next day I pee alot, and can barely make it to the bathroom in time. Has anyone else noticed that?

    1. Yes I have the same issue. My diet is usually the main factor in my frequent urination. I figure its something with inflammation triggering my bladder.

  14. I had a lot of uterine fibers, a traumatic c-section, subsequent internal bleeding, and, months later, a partial hysterectomy. I couldn’t work out, cough, sneeze, jump, run, or anything similar without leaking. With the help of my doctor, I finally decided on surgery earlier this year. It was one of the best decisions I’ve made.

  15. As a midwife of over 20 yrs, it is the pregnancy itself that causes pelvic floor weakness. Yes instrumental deliveries and episiotomies can contribute to weakness, as do c-sections due to surgical cutting of and the resulting scar tissue to abdominal muscle. Multiple pregnancies also contribute. For those considering pregnancy, being of optimal health and weight is paramount to long term post delivery recovery. Not gaining excessive weight during pregnancy is incredibly important despite some laxness with this in the last 15yrs. Women with gestational diabeties and pre-eclampsia are also at higher risk. It has become something of an urban myth that a c-section will preserve your pelvic floor. Its absolute rot. 9mths carrying a developing human being is hard work on a woman’s body.

  16. For men, Swedish Flower Pollen is a supplement that might be worth looking into.

    1. Yes! Flower Pollen works great for both men and women! My husband and I both use it, we are in our 50s 🙂

      1. Sorry for leaving out the female side of the equation FG!