“Small bladder” or something else?
Have you ever heard someone say they have a "small bladder" because they need to urinate frequently? While this is a common belief, the reality is that the concept of a "small bladder" is often a myth. In many cases, frequent urination can be due to various factors, including underlying issues such as Painful Bladder Syndrome (PBS) or Interstitial Cystitis (IC). In this blog post, we'll explore what these conditions entail and how to differentiate between them. We will also discuss the role of pelvic floor therapy in management of the symptoms of a “small bladder”.
What is typical or “normal” bladder function?
Let’s first establish what is typical when it comes to bladder function.
Frequency: Empty bladder every 2-3 hours, this typically is equally to around 6-7 times/day
Nighttime frequency: We should wake 0-1 times per night to urinate. It is normal for older adults to wake once in the night to empty their bladder,
Volume: Around 250-400 mls (or 1.5-2 cups), consistently voiding small amounts may indicate something else is going on
Urge and control: A healthy bladder should give you enough warning to get to a bathroom without rushing. You should be able to hold urine for a reasonable amount of time.
No leaks: Do we need to say more on this? If you are leaking, there is something else going on!
No pain: Urinating or holding urine should not be painful.
What can cause “small bladder” symptoms?
A “small bladder” or what people may think is a small bladder, are the symptoms we experience when we empty our bladder frequently. Various factors can lead to this that are not actually due to the size of the bladder.
Bladder irritants: The bladder lining is sensitive to what we put in it. The most common bladder irritants are caffeine, carbonation, spicy foods, acidic foods, and artificial sweetener. If we are filling our bladder with tons of irritants and not drinking enough water to dilute it, our urine can then become irritating to our bladder, making it want to empty more frequently.
Poor voiding habits: If we teach our bladder that we need to empty every 20 minutes, it will soon continue giving us the urge to empty every 20 minutes. This is all based off of a reflex loop in our nervous system. We can “train” our bladder to have to empty more frequently, which can then make us think we have a “small bladder”.
Pelvic floor muscle dysfunction: The pelvic floor muscles are a group of muscles that sit in the crotch of our pants. When these muscles are not properly relaxing and contracting at the right time, this can cause us to have urinary frequency.
Other medical diagnosis: There are various inflammatory conditions that can cause more sensitivity or irritation to the bladder, causing it to be “fussy”. Sometimes these symptoms are due to inflammation in or near the bladder, or due to the poor mobility of the bladder because of the coinciding conditions.
Painful bladder syndrome or Interstitial Cystitis: Let’s go into more detail on this now.
What is Painful Bladder Syndrome or Interstitial Cystitis?
Painful Bladder Syndrome (PBS), also known as Interstitial Cystitis (IC), is a chronic condition characterized by bladder pain and pressure. Ultimately, this is a “sensitive” bladder or an “irritated” bladder. Symptoms of painful bladder syndrome often include:
Frequent Urination: Needing to urinate more than 7 times a day or frequently waking up at night to urinate.
Pelvic Pain: Discomfort in the lower abdomen, bladder, pelvic area, or “bladder”
Urinary urgency: A sudden, strong need to urinate, often without much urine output.
People with PBS may feel like they have a "small bladder" because they need to urinate so frequently. However, this is due to the typically due to the condition and not because their bladder capacity is smaller than average.
How is Painful Bladder Syndrome or Interstitial Cystitis diagnosed?
Diagnosing PBS can be complex and often involves ruling out other conditions that cause similar symptoms by a urologist or urogynecologist. Here are the key steps typically involved in diagnosing either condition:
1. Detailed Medical History
The first step in diagnosing PBS is a thorough medical history. Your healthcare provider will ask about:
Symptoms: Frequency, urgency, and nature of pain.
Duration: How long you've been experiencing symptoms.
Triggers: Any activities or foods that worsen your symptoms.
Medical Conditions: Any other health issues you may have.
Previous Treatments: Any treatments you’ve tried and their effectiveness.
2. Physical Examination
A physical examination, including a pelvic exam for women, can help identify any obvious medical conditions that might be causing the symptoms.
3. Urine Tests
Urine tests are used to rule out infections and other conditions:
Urinalysis: Examines the physical, chemical, and microscopic aspects of urine.
Urine Culture: Checks for the presence of bacteria or infection.
4. Cystoscopy
A cystoscopy is a procedure that allows the doctor to look inside the bladder using a thin tube with a camera (cystoscope). This can help:
Visualize the Bladder: Identify any ulcers, inflammation, or other abnormalities.
Biopsy: If needed, small tissue samples may be taken for further examination.
5. Urodynamic Testing
Urodynamic tests measure how well the bladder and urethra store and release urine. These tests can help identify issues with bladder function that may be contributing to your symptoms.
6. Bladder Diary
Keeping a bladder diary can provide valuable information. You may be asked to track:
Fluid Intake: How much and what types of fluids you consume.
Urination Frequency: How often you urinate and the volume of urine each time.
Symptoms: When and what symptoms you experience throughout the day.
7. Exclusion of Other Conditions
Before diagnosing PBS, it’s crucial to rule out other conditions that can cause similar symptoms, such as:
Urinary Tract Infections (UTIs)
Bladder Cancer
Kidney Stones
Endometriosis (in women)
Sexually Transmitted Infections (STIs)
Treatment Options for PBS or IC
There are various treatment options for the management of IC and BPS. Pelvic floor therapy is the most proven treatment for these conditions. There are several other treatments that can help with the symptoms which we will discuss below.
1. Pelvic Floor Physical Therapy
Pelvic floor therapy is recommended by the American Urological Association (AUA) as a first-line medical treatment in their IC Guidelines, and is the only treatment given an evidence grade of ‘A’. It is also the sole intervention that provides sustained relief. Research has demonstrated that at least 85% of patients with interstitial cystitis also have pelvic floor dysfunction. Pelvic floor therapy for PBS or IC should be individualized to the symptoms and findings of each individual patient. Treatment can include:
Improving pelvic floor muscle health: Tightness or trigger points in the area of the pelvis can cause pain to spread throughout the pelvic area. By restoring normal blood flow and function, inflammation in the pelvis and around the bladder is cleared out. The muscles are able to return to their natural length and function appropriately after the stress is relieved.
Lifestyle modifications: By modifying small ways we live our daily life, we can have a significant impact on the symptoms of IC or PBS. Pelvic floor therapists education on topics including diet, fluid intake and stress management as well as self-care techniques such as toileting habits and bathroom hygiene.
Posture and body mechanics: Body mechanics and posture can significantly impact pelvic floor health. Therapists provide guidance on maintaining optimal alignment to reduce stress on the pelvic region.
Movement dysfunction: Certain movement patterns can contribute to continued pelvic floor muscle imbalance. By addressing the body from head to toe and improving movement that may be continuing to stress the are of the pelvic floor, we can have a significant effect on PBS or IC symptoms.
Visceral manipulation: Visceral manipulation is a form of gentle manual therapy that helps to release mobility restrictions and restore the organ’s mobility and motility. When an organ does not have normal movement it can be a cause of pain and impede the organ’s normal physiological functions. With PBS or IC, oftentimes movements of the bladder or surrounding organs is impaired which can lead to continued symptoms.
2. Medications
Various oral and IV medications can be utilized to help with the symptoms of PBS or IC. The purpose of these medications is multifaceted and aims to alleviate symptoms, improve bladder function, and enhance the patient's quality of life.
3. Bladder Distension
Bladder distension is a procedure in which the bladder is filled with fluid to stretch it. This can sometimes provide temporary relief from symptoms and can also be used diagnostically.
4. Nerve Stimulation
Nerve stimulation than can help reduce the overactive firing signals of the baldder that are contributing to symptoms of PBS and IC.
Sacral Nerve Stimulation (SNS): Implantation of a device that stimulates the sacral nerves, which can help reduce urinary frequency and pain.
Percutaneous Tibial Nerve Stimulation (PTNS): A less invasive option that involves stimulating the tibial nerve near the ankle.
5. Alternative Therapies
Some people find benefit to acupuncture, chiropractic or mental health therapy for management of PBS or IC. These therapies are often aimed at regaining balance within the body.
Wondering if you might have Painful Bladder Syndrome or Interstitial Cystitis?
Oftentimes a “small bladder” will mimic Painful Bladder Syndrome or IC. If you suspect you have PBS, consult with your healthcare provider to first achieve proper diagnosis and then develop a personalized treatment plan. Treatment for this will often require a process of trial and error to find the most effective combination of therapies for each individual. A multidisciplinary approach, involving urologists, physical therapists, dietitians, and other healthcare professionals, can provide comprehensive care and improve quality of life for those with PBS.
If your provider is resistant to diagnosing you with PBS or IC but your symptoms mimic the condition, we must rule out anything more serious first. Once this has been done, seek out a pelvic floor therapist, as this is first line treatment for management of the condition. In many states, such as Nebraska where we are located, do not require a referral for physical therapy. Reach out today to schedule an evaluation. If you need help finding a skilled pelvic floor therapist in your area, read our previous blog post.
Additional Resources Regarding IC and PBS
https://hermanwallace.com/blog/pelvic-floor-physical-therapy-for-interstitial-cystitis
https://www.pelvichealing.com/blog-/interstitial-cystitis-hope-healing
