Read This If You Hold Your Pee (To Prevent Irreversible Damage)

You are at the movie theatre, watching an amazing film (think Get Out), there are 30 minutes left and you have to pee from your oversized drink. Do you 1) Get up and go to the bathroom? or 2) Hold your pee? I’m often faced with this quandary and I used to choose the second option, until a year ago . . .

I was with my family at a restaurant, holding my pee, everyone wanted me to go to the bathroom but I was acting stubborn and then Naz glared at me with the winning-I’llconvinceher-look and said,  “Don’t hold in your pee because you can lose your nerves, never regrow them and cause irreversible damage . . .” Yup, that convinced me to go… And I’ve been confused about kegels and strengthening my pelvic floor vs. ruining it ever since. Especially since my pelvic floor PT taught me to hold my kegels to prevent postpartum incontinence.

So, last week I sat down with my sister, Dr. Nazema Siddiqui, Associate Professor of Obstetrics and Gynecology at Duke University Medical Center, to clarify this once and for all. Dr. Siddiqui (hereinafter referred to as “Naz”) is a urogynecologist, which is an OB/GYN subspecialist who specifically deals with pelvic floor issues. She primarily does reconstructive surgeries for urologic issues or prolapse. Readers: She gets esoteric real quick, so I’m going to do my best to simplify.

Naz, you once told me that if you hold your pee, you lose the nerves in your bladder and you can never regrow them. EXPLAIN!

When I said that, I was referring to something that can happen when women hold back from urinating repeatedly and over many years’ time. If you start to repeatedly delay voiding (clinical term for peeing) when you are young (in your teens, 20s or 30s) on a daily basis, this can become a problem later in life.

I’m not getting it, how does this work?

When we pee, it involves a complex interaction of nerves and muscles. There are nerves that sense how full the bladder is and send signals up the spinal cord to the brain. There are other nerves that send signals down from the brain and spinal cord towards the bladder to squeeze the bladder muscle (also called the detrusor muscle) when it is time to pee. This is how the bladder empties.

However, there are also nerves and muscles of the pelvic floor that can change some of these signals. The pelvic floor muscles are the ones that we can voluntarily control and squeeze when we “Kegel”. Squeezing the pelvic floor muscles sends different relaxing nerve signals to the bladder. It’s basically a feedback loop that helps delay voiding when it’s socially inappropriate to do so. That’s why when we have to pee and we want to hold it, we reflexively squeeze the pelvic floor. Doing this repeatedly will temporarily calm the bladder and give yourself some time to get to the bathroom. Squeezing these muscles to delay voiding here or there is fine (and something that many of us have done!). But if you delay voiding frequently it can cause irreversible nerve damage.

Hold up, irreversible nerve damage?

Yes, if you hold your pee over and over again for many years you will “denervate” the bladder, or deaden the normal nerve signals. A healthy person feels the signal to pee when there are 300 ml of fluid in the bladder and this happens every 3-4 hours. Someone who has been continually suppressing the urge to urinate daily over many years may no longer feel the urge to pee when there are 300ml – that person may start to only feel the urge when there is more fluid (for example 500 ml) in the bladder. If this continues or progresses over decades, the woman can get to a point where the detrusor (bladder) muscle has stayed chronically stretched, and the bladder “squeezing” nerve signals have been constantly over-ridden by the pelvic floor, and the bladder no longer effectively empties.

So for example, I see women who have worked in teaching or nursing where they felt that they could not get away to the bathroom during an 8 hour period of time. When I see them, these women are often in their 6th or 7th decade of life and worked in that profession for a long time. We have to develop strategies to allow them to empty their bladder more effectively. When decades have gone by, you can’t regrow the nerves that squeeze the bladder, and so sometimes these women have to go onto a self catheterization program where they use something that looks like a straw to drain their bladder. This sounds kind of extreme, and thankfully it is relatively rare overall, but something I see often in my profession.

How does one know if they are at risk of LOSING THEIR BLADDER NERVES?

If you are ever on a long trip, hold your pee for a long time, finally get to the bathroom, and then try to go but the urine doesn’t come out with the usual force (slowly dribbles out), this is a sign that you have held it too long and the bladder muscle is not squeezing effectively. If this is happening to you, then I would recommend voiding more frequently (like every 3-4 hours) or when you first get the signal to pee, so the bladder muscle does not STAY stretched out.

Why do women do pelvic floor physical therapy to strengthen the Kegel muscles?

This is because many women develop overactive bladder or stress incontinence, which are issues that contribute to bladder leakage. Strengthening the pelvic floor can help to counteract leakage. Working to have a strong pelvic floor is not a bad thing – in fact it is a very good thing to have a strong pelvic floor.

But if you overuse a strong pelvic floor and delay voiding when you have a full bladder you can suppress the normal nerve signaling involved with peeing. This can have its own set of serious consequences later in life. So like most things, moderation is key.

Why in the world did I not know of this until my late 30s?

Neuro-urology is fairly complex and certainly not something that is taught in detail in health class or even in most medical schools! Also, much of this wasn’t well described until the 1980s and unless you work in a specialized urologic field, many doctors simply do not know the details about this. For example, urologists deal with the male anatomy and most are not as familiar with the female anatomy. I had a patient come to me after seeing a urologist who put her on a crazy regimen of medications. She didn’t need any of those meds, she just needed pelvic floor physical therapy downtraining. Similarly, OB/GYNs are not trained to evaluate the pelvic floor muscles or nerves.

Clare Fowler is a British professor who first described ““Fowler’s Syndrome”” in 1985. We now call this pelvic floor dysfunction. It is when overly tight pelvic floor muscles interfere with the normal ability of the bladder to empty.

Although you might not have learned about this until your late 30s, I think it is really important that women (and parents) know more about this issue. As schools have changed and evolved, one thing that seems to be different from our youth is how teachers manage bathroom breaks. I work in a urologic field and often hear stories about how kids and adolescents are not allowed to use the bathroom when they need to. For some kids, this results in problems with nerve signaling to the bladder.

Hold up. Teachers who prevent students from bathroom breaks can deleteriously affect their students’ bladder nerves?

Yes. If you start holding your pee too long when you are a child or adolescent, you may change the overall nerve signals that are happening between the brain and bladder. If you override these signals too often, the brain-bladder-circuit can get “confused” and one may not sense that their bladder is full, and it will “overflow” and get leaky. Or they may feel like they will burst when their bladder is not very full. These are the kinds of things that can happen to adolescent girls and younger women. We call that pelvic floor dysfunction and it is very responsive to pelvic floor physical therapy (downtraining). This is what is increasingly happening with girls and young women who have restrictions with bathroom breaks. It is on the spectrum of “voiding dysfunction” but not nearly to the same extent as older women where the nerves/bladder muscle have stopped functioning.  

Is anyone pushing back against this?

Yes. Some doctors are pushing back and advocating for free access to bathrooms in schools as you can read here and here. If you think this isn’t a real thing, check out this teacher’s post.

The Society for Women’s Health Research is an advocacy group working to change these school bathroom policies. They authored this article, which provides many references.

How should parents advocate for their children?

If you are a parent and your child is having urologic issues, I would be sure to advocate for my child with their school and get a medical pass if needed.

Earlier you mentioned pelvic floor physical therapy downtraining. What is that?

Downtraining is for pelvic floor dysfunction where one is on the path to denervation. Pelvic floor physical therapy uptraining is for incontinence.

Now that you have scared the s*&t out of us, can you provide any tips to prevent us from permanently losing our bladder nerves?

1. Holding your pee once in awhile is not bad but try not to hold it every day.
2. If you get the urge to pee and it has been 3-4 hours since your last pee, GO!
3. If you are someone who has been holding it for some time, talk with a health-care professional about “pelvic floor physical therapy for downtraining”.
4. If you notice that it has been taking longer for your pee to start or if your urine stream is less forceful than it has been in the past, seek advice from a female urologic provider. They will double check your female parts to ascertain that nothing else is found and then they can refer you to pelvic floor physical therapy. That really is the best way to regain function.

Do you find joy in cutting up vaginas and bladders all day long?

OMG. I like solving problems and helping people figure out how their body works. I do find joy when I can help someone restore lost function which helps to increase the quality of their life.