Is it time to let go of "holding it"?

View Transcript

Did you know that fighting the urge to pee could rewire your brain, and not in a good way? A neuro-urologist and pelvic reconstruction specialist explains. Read the full story on the Health Lab website.

More Resources

Links for resources mentioned in the episode:

• Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction patient resources
• American Urological Association Urology Care Foundation
• Bladder Training Modules for Urinary Incontinence, created and validated by Janis Miller, Ph.D., from University of Michigan

Transcript

Host:

Welcome to Health Lab, your destination for news and stories about the future of healthcare.

Today: Did you know that fighting the urge to pee could rewire your brain, and not in a good way?

“General guidance is that you should empty your bladder every 3–4 hours while you’re awake, assuming you’re drinking a normal amount in a regular day,” explained Giulia Ippolito, M.D., a neuro-urologist and pelvic reconstruction specialist.

When examining bladder function, Ippolito says they look at three different levels of “sensations” as the bladder is filling.

The first time you feel you could sit on the toilet and empty your bladder, but you don’t have to go, is called first desire.

“In general, in adults, we think first desire happens around 200 milliliters, so a little less than 7 ounces,” Ippolito said.

The next level is called strong desire, meaning you’re looking for a restroom, but it isn’t necessarily an emergency yet. For instance, if you’re on a road trip, you’d take the next exit or, if you’re in the grocery store, you’d start looking for the restroom.

Then there’s capacity: that’s when you’ve hit your absolute max.

“It stops you in your tracks. Those are situations where you pull over on the side of the road to go or leave your cart in the middle of the grocery store to find a bathroom,” explained Ippolito.

But if you push your bladder on a daily basis, your brain actually starts ignoring these important signals.

“We know holding behaviors can remodel how the brain and bladder communicate and potentially reshape how bladder and pelvic floor muscles work. When not urinating on a regular basis, or delaying urination, the sensations to empty your bladder aren’t recognized by your brain until higher and higher volumes.”

Some life situations, like a long car ride, may make it inevitable at times. And, for some professions like drivers, teachers, and nurses, delaying urination for entire shifts may be routine.

“What happens with holding patterns is that the point at which your brain recognizes your bladder is full begins to shift,” says Ippolito.

The bladder-brain communication gets suppressed, meaning your brain gets smart enough to ignore the signals, shifting your first desire to happen at a higher volume, such as 400 milliliters, or 13 ounces, with the strong desire happening at an even higher point.

It’s also sometimes hard to reverse, because the bladder muscle changes with chronic stretching.

That’s why she cautions against it.

“If you have these constant high capacity holds, it stretches the bladder, making it harder for the organ to contract or squeeze. This changes the bladder muscle over time and could make it underactive and cause the bladder to have trouble emptying completely.”

Small bladders vs. large bladders?

Anatomically speaking, there’s not a lot of difference in bladder size or stretchiness.

“The urinary bladder is a hollow muscular organ whose main job is to store different volumes of urine at low pressures. For those without bladder issues, there’s generally not a lot of difference in bladder size or stretchiness,” said Ippolito.

Where someone may feel full at 400 milliliters, someone with an overactive bladder could have the sensation of fullness at lower volumes, like 200 milliliters.

Large bladders, or large bladder capacity, can be due to the stretching of the muscle over time, as discussed above.

Interestingly, for both small and large bladders, bladder retraining can sometimes be helpful. “For those with frequent urination, training the bladder to incrementally hold urine can be helpful,” she explained.

Distraction exercises (counting backwards from 100 by 7) and deep breathing can help delay the urge to urinate.

“For those with infrequent urination or underactive bladders, increasing the frequency of urination with timed voiding (going to the bathroom every few hours whether or not you have the urge to urinate) can be helpful.”

Health issues from holding your urine

Walking around with a lot of urine in your bladder could put you at risk for a urinary tract or bladder infection.

“If people have trouble clearing UTIs or get recurrent ones, we first check that they’re emptying their bladder all the way and that they empty it regularly. The thought is once bacteria is introduced, it has the opportunity to replicate more easily,” said Ippolito.

It could also cause bladder stones.

“Stones that form in the bladder are related to urinary stasis, which is when concentrated urine is allowed to stay for long periods of time without being fully drained. These are different than stones that initially form in the kidneys and pass to the bladder,” she explained.

“Urine is a super concentrated solution, and once you have something that the minerals can start sticking to, then the mineral will continue to stick to that stone and grow and grow.”

For some people, doctors catch the bladder stones when patients keep getting infections, notice blood in the urine, or have pain emptying their bladder.

But Ippolito reassures it’s rare.

She also mentions it could cause kidney issues.

“In most people with holding behaviors, the bladder is stretching but there’s a certain point it can’t stretch anymore and then urine backs up into the kidneys causing kidney issues,” Ippolito explained.

“It’s like having a blocked pipe in your house. Kidneys feel that pressure and there’s nowhere for the urine to go so they get backed up, which can cause kidney issues.”

The population usually impacted? Older men.

“There can be multiple factors contributing to the inability for older men to empty their bladders, including enlarged prostate tissue (a gland that the urine must pass through to empty), other health conditions that make bladder sensation more difficult (like neuropathy) and patterns of chronic holding.”

So, is holding your pee at night bad for you?

As far as how many times you need to pee during the day, that varies depending on how much liquid you’ve consumed.

“For well hydrated people, we recommend seeing around two liters of output per day from your liquids and food, noting it should mostly be water,” explained Ippolito. “Alcohol, caffeine, carbonated drinks and citrus can irritate the bladder, which can make you feel the urge to urinate at a lower bladder volume.”

Overnight gets tricky. 

“In general, nocturia, or waking up to pee, shouldn’t be occurring during a sleep cycle of 6–8 hours.”

Normally, you shouldn’t wake up again to pee if you went before bed. At middle age though, in your 50s and higher, you often get up once or twice a night.

“There’s a lot that goes into nocturia and urine production at night. If you’re having an issue, our initial recommendations are to limit fluids 2–3 hours before bedtime and avoid caffeine after lunchtime.”

The urine you make at night isn’t just based on what you’re drinking, but it’s also your body filtering what wasn’t in your vascular system after being up all day.

When you lay flat, fluid that was pushed into your tissues (like swelling in your feet and ankles) has a chance to return to your blood supply for kidneys to filter.

Aging and obstructive sleep apnea can also cause nocturia.

“Older people and people with untreated obstructive sleep apnea may have changes in a hormone that decreases urine production at night. In these people, the kidneys aren’t getting the signal to slow down overnight. We often refer people with nocturia with risks for OSA to sleep medicine consultation.”

Nocturia can also be a symptom of overactive bladder.

Ippolito stresses it’s important to understand whether the urge to urinate wakes you up or you wake up for another reason and get into the habit of peeing since you’re already awake.

She says you can also retrain your brain to prolong time between nighttime voids, just like bladder retraining can be used during the day.

If you’re experiencing any issues, talk to your primary care doctor to find out if seeing a urologist or urogynecologist is right for you.

Ippolito recommends patients also check out the Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction patient resources, the American Urological Association Urology Care Foundation and the Bladder Training Modules for Urinary Incontinence created and validated by Janis Miller, Ph.D., from University of Michigan.

A reminder that all Health Lab content including health news, best practices and research insights are for informational purposes only and are not a substitute for professional medical guidance. Always seek the advice of a health care professional for questions about your health and treatment options.

For more on this story and for others like it, visit michiganmedicine.org/health-lab where you can also subscribe to our Health Lab newsletters to receive the latest in health, wellness and medical research information to your inbox each week. Health Lab is a part of the Michigan Medicine Podcast Network, and is produced by the Michigan Medicine Department of Communication. You can subscribe to Health Lab wherever you listen to podcasts.