So Many Ways to Pee Your Pants: Let Me Count The Ways

This is the blog post that explores jokes like “I laughed so hard pee ran down my leg” and other assorted bullshit.

There are quite a few ways a person can pee themselves. I am going to start this blog off with a beautiful gallery of some of the “fun” memes that are rolling around there on the internet. Being in pelvic health, people LOVE to send me these memes. And yes, they are cute, they are funny, and they are also a HUGE problem. Because society and some members of the medical community have decided that leaking urine is part of life for some individuals. The biggest groups are individuals who have been pregnant, birthed babies, had prostate surgery, lift really heavy weights or are over a certain age. 

Let’s review the types of pee leakage with the fancy medical term known as urinary incontinence.

• Stress Incontinence
• Urge Incontinence
• Mixed Incontinence 
• Overactive Bladder
• Functional Incontinence
• Overflow Incontinence
• Transient Incontinence

Before I jump into defining each of these types of incontinence, we should first talk about how the bladder works. Why? Because this helps to explain when the bladder is NOT working properly and find a solution for the issue.

What is normal for our bladder?

Our bladder should empty 5 – 8 times a day. We should get the urge to go when our bladder starts to get full. We should be able to easily hold our urine to find a bathroom, undress our bottom half, and sit down to relax our pelvic floor. We should have up to 30 minutes to make it after that first “urge” to go. It is never NORMAL to leak urine. No one under 75 years of age should get up to urinate at night unless they are pregnant. A full bladder should empty for “8 Mississippis/ seconds” or more. 

What is bladder urge?

I like to talk about hunger when I talk about urge to give it some perspective. Think about when you’re hungry. There is,”I could eat”….”I’d really like some food”…AND…”I will eat your face!” Same with bladder urgency. There is, “I could pee”…“I really need to find a bathroom soon”…and then there is the, “I will push small children and old ladies out of my way to get to the bathroom.” Our typical goal for finding a bathroom is around the second urge level of “I’d like to go to the bathroom soon.”

How do the bladder and pelvic floor interact?

The bladder is an involuntary muscle called the detrusor. It is not something that can be controlled by thinking about the muscle. Our pelvic floor muscles are a combination of automatic muscles and muscles we can voluntarily control by thinking about them. There is a system called the “Bradley’s Loops of Micturition” and these describe how the bladder, pelvic floor, and pelvic nerves communicate with the brain and spinal cord. I like to think of this process like a game of telephone.

When the Bradley’s Loops are functioning normally, we should have normal bladder function. As the bladder is filling, the muscle around it must be relaxing. The pelvic floor muscles are doing the opposite and contracting at a low level to close off the neck of the bladder. When it is time to void urine, the pelvic floor muscles must relax, and the bladder muscles must contract to empty urine out. They always work in opposition to each other. During the filling phase, the bladder relaxes, and the pelvic floor stays contracted. During the emptying phase, the bladder contracts and the pelvic floor relaxes. 

We have urine loss or incontinence when something disrupts these systems of the bladder, and there are many ways that this urine leakage can occur. 

What is Stress Incontinence?

This kind of incontinence means leaking pee when you “stress” the pelvic floor. Examples of when this might happen include during a cough, sneeze, laugh, yelling, running, jumping, lifting, bending, vomiting, etc. This is what MOST people are referencing in their memes and jokes about people who leak urine after childbirth.

Why Does Stress Incontinence Happen?

Our pelvic floor is the basement of a system called our abdominal canister. It coordinates with our back, our belly muscles, our diaphragm and rib cage. This system works together in a pressurized system, described by Mary Massery as a “Soda Pop Model.” This is the idea that if the soda can is intact, pressure on it from any aspect does not drastically affect it. Pop the top, and pressure on the can can cause all sorts of changes.

In an ideal world, these all work together, transferring forces like coughs, sneezes, and jumps easily without dysfunction or leakage. But time, age, pregnancy, weight gain and loss, sedentary lifestyle, abdominal surgery, and more can cause a disruption to this system.

Since the pelvic floor is the basement, where are leaks likely to happen? You’re hopefully not leaking out your back, belly or diaphragm, so gravity forces the pressure down into your pelvic floor, creating increased force on the bladder that the pelvic floor muscles fail to counteract. 

What is Urge Incontinence?

Urge incontinence is defined as urinary leakage (leaking of pee) related to the urge to urinate. Basically, you feel the urge to pee and cannot make it to the potty in time. It can be a few drops of leakage or a full emptying of the bladder.

Why Does Urge Incontinence Happen?

Urge incontinence typically occurs when there is a disruption to the Bradley’s Loops of Micturition. The brain sends the signal for the bladder to start squeezing urine out before the person is ready and able to urinate. These are the people who leak urine with certain triggers like keys in the door, pulling into the driveway, washing dishes/ hands, showering, being near running water, etc. 

What is Mixed Incontinence?

This is when a person experiences a combination of types of urinary incontinence, usually stress and urge at different times in life. This could include leaks with coughs and sneezes sometimes, and related to feeling the urge to void and not quite making it at other times. 

What is an Overactive Bladder?

Sometimes with urinary urge incontinence comes urinary frequency, which is that “got to pee all the time” person. Think of those commercials with the jingle, “Gotta go, gotta go, gotta go right now.” These are my folks who know where all the bathrooms are and plan their day around their urinary habits. Some people who have experienced any type of urine leakage begin to go to the bathroom all of the time to avoid leaks, and end up creating an overactive bladder as a habit. If you find yourself knowing where all the bathrooms are at all times and plan your life around trips to the bathroom, you might have an overactive bladder

What is Functional Incontinence?

This is where a person cannot get to the bathroom in time and leaks along the way. This can happen at any point in life, including during pregnancy, after a medical event like surgery, or when a person has their function limited by something like a fracture. 

What is Overflow Incontinence?

Overflow incontinence means that a person has the urge to urinate but can release only a small amount. This can be due to a weak contraction of bladder muscle or to blockage, typically due to bladder prolapse or prostate enlargement. Since the bladder is not fully empty, it gets too full. Urine leaks later, even though a person may feel no urge to urinate at that time. 

What is Transient Incontinence?

This is incontinence that comes during certain times and seasons of life. This could be related to a urinary tract infection, pregnancy, postpartum, during a bad cold/cough, or during a stomach bug. The good news is that, again, peeing oneself should never be “normal,” and that these episodes can be treated to go back to normal bladder and pelvic floor function. Think about the person who has COVID and leaks while having a constant heavy cough but not any other time.

Did you know there were so many ways to have incontinence? Probably not. 

The great news is that pelvic health therapy is a great way to treat and address urinary incontinence of pretty much any type. Pelvic floor therapists take extra training to learn about the anatomy and overall function of the abdominal canister. This includes the abdomen, back, rib cage, and diaphragm, as well as knowing things like body mechanics, load transfer, and pressure management of the body. Additional time is spent learning about the physiological function of the internal organs as well, to better understand the function of the bladder, kidneys, bowels, and everyone else that needs to be involved in urinary function. The last piece is a very thorough understanding of the nervous system, because the whole “fight or flight” and “rest and digest” parts of our brain ALSO affect how pee (and poop) leave our bodies. 

You may be wondering what a visit looks like with a pelvic floor therapist, and you can check out this blog for that information. Long story short, it is not nearly as bad as you are thinking. If you have survived any type of gynecological or rectal exam, this will feel easy, AND the internal part is never required!

Why are we counting all the ways to pee our pants? Not really sure, except to point out that there are a lot of them and none are really as funny as the memes would make us think. I would like to take a moment to talk about some of the reasons people avoid doing anything ABOUT urinary incontinence. 

• Their medical provider tells them urine leakage is a normal part of “motherhood,” “aging,” “menopause,” “pregnancy,” “life”
  • Therapist answer: Urine leakage is never normal. It is always a symptom of something. There are times in life where it may become more evident or more of an issue, but it does not mean this has to be accepted as a new normal. I would love to think this comes from a place of assuaging a patient’s fears/concerns/embarrassment, but in doing so, it has taught people to accept something that should be unacceptable. 

• They do not think there is anything to do to fix the problem aside from surgery.
  • Therapist answer: According to the literature, pelvic floor therapy is actually more effective than most surgeries for urinary incontinence. Also, if surgery is chosen, the surgical outcomes are improved if done in conjunction with pelvic floor therapy. So it’s a win-win either way, avoid surgery all together OR have better surgical results with pelvic floor therapy. 

• They do not know pelvic floor therapy exists.
  • Therapist answer: Once you have “seen the light,” make sure to share it with your friends and family. Patients come to me thinking they are the only ones with these issues. I am always willing to bet that is not true. I encourage them to talk about it with friends. You do not have to get into all the details. Just a, “Hey, I’m seeing this therapist to help my pelvic floor function better, ever heard of that?” They usually come back shocked that their friends were experiencing some similar issues!

• They think pelvic floor therapy is something they cannot access.
  • Therapist answer: This CAN be true, but usually is not. The codes and such that are used to bill insurance for pelvic floor therapy are the same we would bill if we were treating a knee or a back. We are working on muscle coordination, strength, and range of motion and function, just in a different area. If your insurance covers physical therapy, it covers pelvic floor physical therapy! Same for occupational therapy! The other thing that people seem to think is, “I had to do PT 3x per week for 12 weeks for my knee (back/hip/ankle/ insert body part). I do not have that time to give to my bladder.” The good news is that pelvic floor therapy is usually only once a week (sometimes biweekly or monthly) and then you have homework to be done at home!

• They are afraid to access pelvic floor therapy.
  • Therapist answer: Do your research. Read reviews. Look at credentials. Call and talk to pelvic health providers. Find a therapist that you feel comfortable with. Ask your healthcare provider, friends or family members for referrals. You can also use provider finders like this one. 

• They have become complacent in their adaptations to incontinence, such as making trips to the bathroom every 30 minutes, or living life wearing an incontinence pad.
  • Therapist answer: It is not normal to have to pee every 30 minutes during the day. This teaches your bladder bad habits which allows it to run your life, causes a lot of extra irritation to the perineum, and wastes a ton of your precious time. Incontinence products are EXPENSIVE. The amount of money spent on pads for leakage would probably be MORE than paying for pelvic floor therapy out of pocket!!! Just say no to adaptations, PLEASE!

• They have been told incorrect information such as that they have “a weak bladder,”  “a small bladder,” or “everyone leaks with sneezing,” and do not know to seek other answers.
  • Therapist answer: Question things. Ask the experts. Remember that common does not mean normal. Do not trust that “everyone in your family has a weak bladder.” It probably just means everyone in your family needs some help from a pelvic health professional.

Thanks for hanging around for show and tell on all the ways to leak pee out of your body, and why pelvic floor therapy is literally the best answer to the question, “How do I make it stop?”

If this post resonates with you contact me to start your therapy!

Practically Yours,

Dr. Mo