“Gotta Go” Greta: Why did she need to pee every hour?

Greta is not the patient’s real name, and some details have been changed for confidentiality. 

Meeting Greta

Greta was a 45 year old real estate agent with interstitial cystitis, also known as bladder pain syndrome (BPS). BPS causes urinary urgency and urinary frequency, or the sudden need to urinate, many times throughout the day and night. Anyone who has seen a positive cystogram study diagnosing interstitial cystitis cringes at the sight of the bright red sores inside the bladder wall. It is a very challenging diagnosis, and can greatly reduce a patient’s quality of life. Surgery was not an option for Greta’s condition, so her urologist sent her to me in the hopes that physical therapy could help.

I learned that Greta had 4 pregnancies, 3 of which were vaginal deliveries, with some vaginal tears but no episiotomies. Three years before coming to see me, she had undergone a hysterectomy, and ever since then she had urine frequency every hour as well as pain during intercourse and upon penetration. Her gynecologist recommended Kegel exercises, and asked her to start and stop her urine stream every time she went to the bathroom. The exercises did not help at all. 

She was fed up with her medical care, and felt defeated. She woke up 3 to 4 times a night to go to the bathroom. She needed to work, but that required her to be on her feet and show homes to prospective buyers. She wanted to return to her daily one-hour walk but after ten minutes she needed to find a bathroom. Normalizing sleep, work and exercise was nearly impossible because she so frequently needed to use a bathroom. And this had been going on ever since the hysterectomy.

I was concerned about how to approach her and earn her trust, but in fact she was amenable to a physical exam and hoped we could come up with a solution. 

The examination

I went through the physical exam and found Greta’s pelvic floor strength to be weak and the sensation inside her vagina to be impaired. She did not visibly have any leakage with bearing down or coughing, which I thought was a good sign. But the exam was uncomfortable for Greta because her vaginal opening was sensitive and her muscles atrophied. The tailbone didn’t move much when I tried to stimulate the further contraction of the pelvic floor, and it appeared that the length tension relationship of the levatorani muscle had been overstretched. In addition, we talked about her lifestyle and diet, and I learned that she drank coffee and orange juice every day, but did not drink water. 

Contributing factors to consider

Let’s look at her doctor’s advice to start and stop her urine stream in order to strengthen the pelvic floor muscles. It is okay to tell a patient, “If you can’t feel a contraction of your pelvic floor, test it out by trying once a week to stop your urine mid-stream.” This way, if they can stop it, they know they are correctly performing a shortening contraction of the muscle. But once they contract the pelvic floor, the urethral sphincter communicates to the bladder muscle that it’s done. This means that the bladder starts slowing down the emptying process and cannot completely empty, leaving the patient needing to have an urge to go to the bathroom again sooner than normal. 

Next, let’s examine her diet. Greta had a low fluid intake, which was working against her. Worse, the fluids she did drink consisted primarily of bladder irritants, including caffeinated drinks, coffee, iced tea, orange juice and other fruit juice. Without using water to dilute these irritants, these fluids create too much acidity inside the bladder, causing reflexive contractions, and giving frequent urges to go to the bathroom. I gave Greta some urine strips to pee on so she could determine how acidic her urine was. The strips came back completely acidic (5.0 ph) instead of in between acidic and alkaline (7.0 ph). Our bodies process acid at around 2 to 3 am when our bodies are resting. But Greta was getting up 3 to 4 times a night, and consistently around 3 am, so her system was not working optimally. 

I reviewed my findings about her pelvic floor musculature, her fluid intake and the acidity of her urine, and then discussed some biological factors. As I explained to Greta, the detrusor muscle (muscle around the bladder) and the urethral sphincter can’t both be on at the same time. When one is contracted, the other is relaxed (Bradley’s Loop). The essence of timed voiding / urge suppression is that a strong pelvic floor squeeze will buy an individual 15 minutes to find a bathroom, because it tells the detrusor to relax by squeezing hard. But if that pelvic floor contraction is twitchy or sketchy, the detrusor muscle doesn’t get the message to turn off and it continues to stay on and push urine out. The detrusor turns off when the sphincter turns on.

I recommended a treatment plan to turn the situation around. She was skeptical but said, “What do I have to lose?” She was ready to try to make a change. 

Greta’s plan of treatment

1. Tracking Fluid Intake
   Fluid intake is easy to track, and extremely valuable for treatment, when patients are honest and responsible about writing down not only how much they drank but also what they drank. Greta’s Intake Journal revealed just how much her diet consisted of bladder irritants. She began to replace and/or dilute all of those bladder irritants with water, which not only hydrated her but also, she noticed, made her constipation and hemorrhoids go away.

2. The Bladder Journal
   Many patients arrive at my clinic with a poor self-image, filled with shame, and just barely able to admit that they have a pelvic related problem. I understand that it has taken them a long time to come in and talk, and it’s critical that I help them overcome any feelings of blame or shame. With that in mind, one of the reasons for recording the volume of bladder over a period of time is to use the resulting data to motivate a patient to change behavior without causing any self-recrimination or guilt. 
   
   Patients can record volume eliminated by placing a collecting receptacle in the toilet that exactly measures ounces. But of course they most likely will not carry that receptacle around with them in their car or to work or to any outing. So, I ask the patient to count Mississippi’s: one Mississippi, two Mississippi. If their flow lasts 12 Mississippi’s, they probably are eliminating 400-600 CCs of fluid, which is an average full bladder (2 to 3 glasses of fluid). 
   

3. The Timed Voiding / Urge Suppression Program
   Knowing that Greta voided almost every hour and was up 3 or 4 times a night, I asked that she schedule her bathroom trips in 75 minutes intervals, going to the bathroom every 75 minutes whether she feels an urge or not. I also said that if she gets an urge before the allotted time is up, she must do a quick pelvic floor contraction to postpone the urge. 
   

4. Correct Kegel Exercises
   I advised her to stop the midstream Kegel test and instead do Kegel exercises in an appropriate way. I had her lie down, with her knees bent, pillows under her knees and a pillow under her pelvis. I initially used electrical stimulation to help improve her awareness of her pelvic floor muscles. With the stimulation and the proper positioning, she could easily feel how to contract her pelvic floor. I demonstrated how she could use deep diaphragmatic breath to help her contract her pelvic floor, since the expanding diaphragm bears down on the pelvic floor and the pelvic floor pushes back by contracting, followed by exhalation.
   

5. Passive Bladder Emptying
   Lastly, I taught her to empty her bladder passively instead of pushing the pee out. I taught her the Crede maneuver and made her promise not to bear down anymore during a bowel movement. The Crede maneuver is accomplished by placing thumbs on hips and fingers towards the belly button. The patient leans forward as the fingers press in toward the tailbone. The patient then stays leaning forward until the stream is done. This action completely eliminates everything in the bladder. Hopefully, once the bladder is completely empty, the patient will be able to postpone longer before they have to go again. 

Four weeks later…

By the fourth week, Greta was able to postpone urges to every 2-3 hours. She could do pelvic floor contractions in sitting and standing positions without the need for electrical stimulation or diaphragmatic breathing to initiate the contractions. Best of all, she was only getting up twice a night. 

Results after 12 weeks of treatment 

The icing on the cake was that at 12 weeks, Greta was able to return to pain-free sexual activity. Her pelvic floor strength was better and her prolapse was gone. Her vaginal vault resumed its original length and her organs were supported due to stronger, more muscular vaginal walls. She was no longer defeated. Knowing that she could gyrate her pelvis without leakage, she signed up for a belly dancing class, which turned out to be her ongoing therapy for maintaining continued pelvic health. Now “Gotta Go” Greta is “Gotta Groove” Greta!  

A few words about caffeine

A Starbucks on every corner is proof that we value stimulants all hours of the day.  Caffeine is an irritant, is often acidic, and comes in many forms: coffee, tea, chocolate, some sodas, coffee ice cream and coffee candy, energy drinks, and weight control pills. Even decaffeinated coffee has 10-20% caffeination in it. Caffeine stays in your body for 72 hours. Also, caffeine interrupts the biological connections at the molecular level and causes muscles to twitch. Patients are often surprised by how much caffeine they consume, and many find that reducing their caffeine and irritant intake provides great physical and emotional relief.