Urinating should normally feel like a truly satisfying experience. One that involves a sense of relief as the pressure sensation within the bladder is alleviated. But for some, this experience is fraught with distress and anxiety. Some people spend many minutes to hours in the bathroom just to get one little extra drop of urine out. It can take multiple attempts at the toilet to even get the flow of urine started. The stream can suddenly stop in the middle or feel like a weak dripping tap as opposed to a strong and satisfying stream. These experiences are not normal. This is called urinary retention, hesitancy, or impaired bladder emptying and should be immediately discussed with your primary care physician as soon as they are detected.

There are a multitude of factors that may contribute to impaired bladder emptying and are categorized as obstructive, infectious/inflammatory, pharmacologic, or neurologic. Obstructive urinary retention can occur where there is a physical blockage somewhere within the bladder and/or urethral tract. The most common obstructive cause is benign prostatic hyperplasia (BPH) which narrows the bladder neck. Inflammatory urinary retention can result from vulvovaginitis which causes urethral swelling or acute prostatitis which will inflame and swell the prostate gland. Some medications, such as tricyclic antidepressants, may decrease bladder muscle contractility, thereby causing urinary retention. Neurologic urinary retention occurs when there is disruption of the complex signals that occur along the pathway between the brain, autonomic nervous system, and somatic nerves supplying the bladder and urethra.

The muscles that make up the pelvic floor act like a sphincter that wraps around the urethral tube.  This sphincter is called the external urethral sphincter (EUS).  Normally, when the bladder contracts to empty urine into the urethra, the EUS must coordinate this activity by fully relaxing in tone.  This relaxation of the sphincter, helps “opens the door”, so to speak, to allow urine to flow through the urethra unobstructed.  The inability to coordinate relaxation of the EUS can contribute to impaired bladder emptying.

Those who notice a weakened stream or a hesitation to start the flow may end up compensating for these changes by developing poor strategies to empty their bladder. One such strategy is to push or bear down to start the flow or increase the stream strength.

This is a very problematic approach as this is not the ideal physiological strategy to adopt.  When mechanical straining or pressure from the abdomen pushes on the bladder to expel urine, this reduces the need for the bladder muscle itself to contract and the EUS to relax.  The body then relies on this strategy more and more for bladder emptying.  Over time, this excessive downward pressure toward the pelvic floor can result in pelvic organ prolapse, pelvic floor muscle weakness, and believe it or not, further exacerbation of incomplete bladder emptying.

Pelvic floor physical therapy is an excellent treatment for those who have poor ability to coordinate EUS relaxation when they are attempting to urinate.  We work on altering adopted strategies that involve physical straining to empty the bladder.  Instead, we optimize body positioning, discuss strategies to be mindfully present in the bathroom to help calm the autonomic nervous system, practice breath strategies and muscle tension release proximal to the pelvis thereby connecting to and optimizing the strategy of pelvic floor relaxation.  We also work to ensure bowel emptying is optimal as it has been found that retained stool in the rectum has the ability to compress and obstruct the urethral tube and inhibit the relaxation of the sphincter located around the bladder neck. A pelvic floor evaluation will seek to identify changes to the position of the bladder, rectum, and uterus.  This is called pelvic organ prolapse and when organs shift downwards within the pelvic cavity, this can alter the position of the urethra thereby obstructing or weakening urine flow.  

A sudden onset of complete inability to empty the bladder even when it is full is considered a medical emergency and would require immediate emergency treatment.  However, long term difficulties with emptying the bladder would benefit from a pelvic physiotherapy evaluation to further assess whether the pelvic floor muscles may be a contributing factor.  

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472851/

By Leeanna Maher
Pelvic Health Physiotherapist
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