Bladder Leaks, Pelvic Floor Changes, and What Women Need to Know

Conversation Takeaways

• Why having a baby 20 years ago might still matter to your bladder today.

• What's actually happening when you leak, suddenly have to go, or feel pressure down there.

• Why menopause can change more than just your periods.

• Why doing a hundred Kegels might not be the answer.

• A few practical things you can start doing and when it's time to get some help.

I have a question for you, and I want you to be honest with me.

Have you ever sneezed and thought, Oh, shoot, I hope I didn't just pee a little?

Or maybe you've been laughing really hard with your girlfriends, and suddenly you're not laughing quite as hard because you're trying to figure out whether you need to go change your underwear.

And if you've had children, I bet at some point somebody has made the joke about how you can't jump on a trampoline anymore without peeing your pants.

We laugh about these things because, well, sometimes they're pretty funny. But I also think we laugh because nobody really talks about them, and it's a whole lot easier to make a joke than to admit that your bladder has started making decisions without consulting you first.

And here's what I find interesting after spending more than 30 years taking care of women.

So many of us just accept this stuff.

We tell ourselves it's because we had babies, or we're getting older, or we're going through menopause, and we figure it's just another one of those things that comes along with being a woman.

But I want to talk about that today because, while bladder leakage is incredibly common, it isn't something you automatically have to live with.

And there's actually quite a bit going on down there that most of us were never taught.

Wait, You're Telling Me Having a Baby 20 Years Ago Still Matters?

Let me tell you about something I was reading recently.

There was a conversation on Reddit where a 49-year-old woman was talking about how she'd been leaking a little urine when she laughed or went running. She had pretty much chalked it up to getting older and maybe not keeping up with her strength training.

But then she started noticing something else.

She was feeling this pressure down in her pelvis, almost like things were pushing downward, and she described it in a way that made me laugh because I thought, Well, that's certainly one way to put it.

She basically felt like gravity was trying to make everything fall out.

And other women started chiming in with their own experiences.

Some were leaking when they sneezed, some were having that sudden urge to go to the bathroom, and others were describing pressure or heaviness that they hadn't experienced before.

Now, I'm not telling you this because a Reddit conversation is medical research. It isn't. But I do think it's a wonderful example of something I see in women's health all the time.

We tend to put all these symptoms into one big category and say, "Well, I guess my pelvic floor is getting weak."

But here's the thing.

Those women might all be having pelvic-floor-related problems, but they aren't necessarily having the same problem.

And that's why I want to explain a little bit about what's actually happening in your body.

Let's Talk About What's Going On Down There

Okay, I'm going to give you a little anatomy lesson, but I promise we're not going back to nursing school.

I want you to picture your pelvis like a bowl.

And at the bottom of that bowl, you've got this group of muscles and connective tissues that help support your bladder, your uterus, your vagina, and your rectum.

That's your pelvic floor.

Those muscles also help you control when you pee and poop, and they play a role in sexual function. They're working with your abdominal muscles, your diaphragm, and the rest of your core to manage pressure as you move throughout the day.

And just like other muscles in your body, they need to be able to contract when they're supposed to and relax when they're supposed to.

Now think about what happens when you're pregnant.

For months, you've got this growing baby putting additional pressure on those muscles and tissues. And if you delivered vaginally, those muscles and tissues may have been stretched or injured during childbirth.

Then you have your baby, everybody tells you congratulations, you go to your six-week postpartum appointment, and assuming everything looks okay, you're pretty much sent on your way.

Meanwhile, your body has just gone through something pretty extraordinary.

And then life happens.

You're working, raising kids, carrying groceries, lifting toddlers, maybe eventually lifting grandchildren. Some of us develop constipation and spend years straining to have a bowel movement. Maybe you've got a chronic cough, or you're doing activities that repeatedly increase pressure inside your abdomen.

And while all of that is happening, you're getting older, your tissues are changing, and eventually your hormones start changing too.

So when a woman comes to me in her late forties or fifties and says, "Michele, why in the world am I suddenly peeing when I sneeze? I had my last baby 20 years ago!"

I want her to understand that those things can actually be connected.

But I also want her to know that we shouldn't automatically blame everything on having babies.

Because pregnancy and childbirth are only part of the picture, and plenty of women who have never had children experience pelvic-floor problems too.

Now, Here's Where I Want You to Pay Attention

Let's say we're all sitting around the table together, and three of you start telling me what's going on with your bladder.

The first woman says, "Michele, I only leak when I sneeze, cough, laugh really hard, or try to exercise."

Okay, that's what we call stress urinary incontinence.

And don't let the word stress confuse you because we're not talking about being emotionally stressed out, although heaven knows we have enough of that.

We're talking about physical pressure.

When you sneeze or cough, the pressure inside your abdomen increases. Normally, your pelvic support system and the muscles that help keep your urethra closed can handle that pressure.

But when that system isn't working as well as it should, a little urine can escape.

Now, the second woman says, "Well, that's not really my problem. I can be sitting there perfectly fine, and all of a sudden I have to go to the bathroom so badly that I'm practically running down the hallway."

And sometimes she doesn't make it.

That's a different situation.

We call that urgency urinary incontinence when that sudden urge is accompanied by leakage.

And I think most of us can appreciate just how inconvenient that can be.

You're standing in the grocery store, minding your own business, trying to decide which avocados aren't going to turn brown by tomorrow, and suddenly your bladder announces that you have approximately five seconds to locate a bathroom.

Not exactly the kind of excitement we were looking for.

Now, the third woman says, "I'm not really leaking, but I've started feeling this heaviness or pressure in my vagina, especially toward the end of the day. Sometimes it almost feels like something is falling down."

That makes me think about pelvic organ prolapse.

And what that means is that one or more of the pelvic organs may have shifted downward because the muscles and connective tissues supporting them aren't providing the same support they once did.

Some women notice a bulge. Others describe pressure or heaviness, and I've had women describe it as feeling like a tampon isn't sitting in the right place.

Now, I want you to notice something about those three women.

They're all describing something going on in the same general area of their bodies, but they're describing very different symptoms.

And that's why I don't want you diagnosing yourself with a weak pelvic floor just because you're having bladder issues.

I want you to understand what's happening so you can get the right kind of help.

And by the way, you can have more than one of these problems at the same time.

Because apparently our bodies didn't think one was enough.

And Of Course, We Have to Talk About Peri/Menopause

You knew I wasn't going to get through an entire conversation about women's health without bringing up estrogen, didn't you?

But I don't want you thinking that every bladder problem is automatically an estrogen problem, because it isn't.

And this is something I talk about in another conversation, “I’m on HRT. Why Don’t I Feel Better?” Hormones matter, but they're not the entire story. Sometimes we need to look at the other systems involved to understand why we're experiencing certain symptoms.

What I do want you to know is that the tissues around your vagina, urethra, and bladder are influenced by estrogen.

And as estrogen levels change during perimenopause and decline after menopause, those tissues can change too.

You may have heard me talk about something called genitourinary syndrome of menopause, or GSM.

Now, I know that's a mouthful, but it basically describes a collection of symptoms involving the vaginal, vulvar, and urinary tissues that can happen because of hormonal changes.

And here's why I think this is so important.

When most women hear about vaginal changes during menopause, they think about dryness or painful sex.

But urinary symptoms can be part of that picture too.

You might notice more urgency, burning, irritation, or recurrent urinary tract infections.

And sometimes women are going back and forth to their healthcare providers saying, "I think I've got another UTI," when the underlying situation may be more complicated.

Now, please don't hear me saying that burning or urgency automatically means GSM.

An actual urinary tract infection still needs to be considered, and there are other conditions that can cause similar symptoms.

But I do want you to know that hormonal changes can affect more than just your periods, your hot flashes, and your sleep.

And this is another reason I talk so much about looking at the whole picture instead of chasing one symptom at a time.

Because maybe you're having vaginal dryness, some discomfort with sex, and now you've started noticing urinary urgency.

Those may not be three completely unrelated things.

They may be pieces of the same story.

And when you understand that, you can have a much more useful conversation with your healthcare provider about what treatment options might help, including whether vaginal estrogen or another treatment for GSM would be appropriate for you.

Okay, Michele, Should I Just Start Doing Kegels?

Now, I know what some of you are thinking.

"Well, Michele, I was always told to do Kegels. Isn't that what we're supposed to do?"

And yes, pelvic-floor muscle exercises can absolutely help some women.

But I want to tell you why I don't love the blanket advice that every woman with a bladder problem should just start doing a hundred Kegels a day.

First of all, a lot of women aren't even sure they're doing them correctly.

And second, not every pelvic-floor problem is simply a matter of weak muscles.

Some women have muscles that are overly tense or have difficulty relaxing. Others have trouble coordinating those muscles with their breathing and movement.

And sometimes women think they're squeezing and lifting their pelvic-floor muscles when they're actually bearing down.

So imagine being told to do more exercises when you don't even know whether you're using the right muscles.

That's not particularly helpful, is it?

It's kind of like me telling you to go strengthen your shoulder when I haven't figured out whether your shoulder problem is related to weakness, stiffness, or something else entirely.

We need to know what we're working with first.

And this is where I want to introduce you to something that I wish more women knew about.

Have You Ever Heard of Pelvic-Floor Physical Therapy?

If you haven't, I want you to tuck this information away because it could be incredibly useful to you or someone you know.

A pelvic-floor physical therapist is someone who has specialized training in evaluating and treating problems involving the pelvic floor.

And I don't mean that they simply hand you a sheet of Kegel exercises and send you home.

They can assess how those muscles are functioning, whether you're able to contract and relax them appropriately, and how your pelvic floor is coordinating with the rest of your body.

They can also help with things like bladder training, breathing, movement patterns, and strategies for managing pressure during everyday activities.

And depending on what they find, your treatment may involve strengthening, relaxation, coordination, or a combination of approaches.

Now, I realize the idea of pelvic-floor physical therapy may sound a little intimidating, especially if you've never heard of it before.

But I want you to think about it this way.

If you were having trouble with your knee or shoulder, you probably wouldn't think twice about seeing a physical therapist.

So why do we treat the muscles supporting our bladder and pelvic organs as though we're just supposed to figure them out ourselves?

And yes, sometimes a pelvic-floor evaluation may involve an internal examination, but that should always be explained to you, discussed with you, and done only with your consent.

You have a say in your care.

I really want women to understand that there are people who specialize in this, and you don't have to spend the next 20 years avoiding jumping jacks because nobody told you help was available.

So What Can You Actually Start Doing?

All right, now let's get practical because I don't want you finishing this conversation thinking, "Well, that was interesting, Michele," and then going right back to crossing your legs every time you sneeze.

The first thing I'd love for you to do is start paying attention to your pattern.

And you know me, I'm always going to bring us back to understanding what our bodies are telling us.

For the next week or two, just notice what's happening.

Are you leaking when you cough, sneeze, laugh, or exercise? Or is it more that sudden urge where you feel like you have to get to the bathroom immediately?

Are you going to the bathroom frequently even when you don't really need to, just because you're afraid you might have to go later?

Are you waking up several times at night to urinate?

What about constipation? Are you straining when you have a bowel movement?

Have you noticed vaginal dryness, irritation, pressure, or a feeling of heaviness?

You don't need to turn this into another full-time job, and I'm certainly not asking you to create a spreadsheet about every trip to the bathroom.

Although knowing some of you, I suspect you could make a pretty impressive one.

I'm just asking you to become a little more aware of what's happening.

Because there's a big difference between walking into your healthcare provider's office and saying, "I think my bladder is getting old," and saying, "Over the last six months, I've started leaking when I sneeze and lift weights, and I've also noticed more pelvic pressure at the end of the day."

See how much more useful that second conversation becomes?

Now, something else I want you to pay attention to is constipation.

We don't always think about our bowel habits when we're talking about our bladder, but they're connected through the pelvic floor.

If you're regularly straining to have a bowel movement, you're repeatedly increasing pressure on those supporting tissues.

So making sure you're getting adequate fiber, drinking enough fluids, moving your body, and addressing persistent constipation can be part of taking care of your pelvic health.

And please don't automatically stop exercising because you're leaking.

I know that's tempting, especially when you find an activity that seems to trigger it.

But movement and strength are so important for us as we get older, and I don't want you becoming afraid to use your body.

You may need to modify certain activities while you're figuring out what's happening, and a pelvic-floor physical therapist can help you learn how to manage pressure and movement more effectively.

But the goal isn't to make your world smaller.

The goal is to help you keep doing the things you enjoy.

And one more thing.

Please don't start restricting your water intake just because you're afraid of leaking.

I know women do this, especially when they're traveling or going somewhere they aren't sure they'll have access to a bathroom.

But becoming dehydrated isn't a good long-term bladder strategy, and concentrated urine can sometimes make bladder irritation worse.

Instead, let's figure out why the leaking or urgency is happening.

Here's What I Want You to Ask Your Healthcare Provider

I want you to feel comfortable bringing this up, even if it feels a little embarrassing.

Believe me, after 30 years in women's health, there isn't much you could say about your bladder, vagina, or bowel habits that would shock me.

And I would much rather have you tell me what's going on than quietly rearrange your life around a symptom because you were too embarrassed to mention it.

You can simply say, "I've started leaking urine when I cough or exercise, and I'd like to understand why."

Or, "I'm having a lot more urgency than I used to, and sometimes I don't make it to the bathroom."

Or maybe, "I've noticed some pressure or heaviness in my vagina, and I'm wondering whether I could have prolapse."

And then ask whether a pelvic-floor evaluation or referral to pelvic-floor physical therapy would be appropriate.

If you're in perimenopause or menopause and you're also experiencing vaginal dryness, burning, recurrent urinary symptoms, or discomfort with sex, ask whether GSM could be contributing.

And don't be afraid to ask what other conditions need to be ruled out.

That's an important part of being involved in your own healthcare.

You're not supposed to walk into the appointment knowing the diagnosis.

That's what the evaluation is for.

But you can walk in knowing your symptoms, understanding a little about what might be contributing, and being ready to ask good questions.

And There Are Some Things I Don't Want You to Ignore

Now, before we wrap up, I want to mention something important.

There's a difference between having a little urine leakage when you sneeze and developing symptoms that need more prompt medical attention.

If you're seeing blood in your urine, having significant pelvic pain, experiencing recurrent urinary tract infections, having trouble emptying your bladder, or noticing a new vaginal bulge or pressure, please get evaluated.

And if you're suddenly unable to urinate, especially with significant pain, that's something that needs urgent medical attention.

I also don't want you assuming that every new urinary symptom is simply menopause or aging.

Sometimes it is related to hormonal changes or pelvic-floor function, but sometimes there's something else going on.

And that's why we evaluate instead of guessing.

Can I Leave You With One More Thought?

You know what I've noticed about women over the years?

We are incredibly good at adjusting our lives around things that aren't working quite right.

We wear the pad.

We stop jumping.

We go to the bathroom before we leave the house, again when we get somewhere, and one more time before we head home.

We stop running because we're afraid of leaking.

We put up with constipation.

We tell ourselves that pressure or heaviness is probably just what happens when you get older.

And before we know it, we've made all these little changes to our lives without ever stopping to ask whether we actually have to live this way.

And that's the part I want you to think about.

Because this conversation really isn't just about peeing when you sneeze.

It's about paying attention to the changes happening in your body instead of automatically dismissing them.

Maybe your pelvic floor needs some support. Maybe your bladder symptoms are related to changes in the tissues around your urethra and vagina. Maybe constipation is contributing. Or maybe there are several things happening at once.

The point is, you don't have to figure it all out on your own.

But you do have to be willing to recognize that something has changed and start the conversation.

And that's what I want for you, whether we're talking about your bladder, your hormones, your energy, your sleep, or anything else going on in your body.

I want you to understand enough about yourself to recognize when something deserves attention, and I want you to feel comfortable asking for help.

Because being an active participant in your health doesn't mean you have to become your own healthcare provider.

It means you know your body, you notice when something changes, and you're willing to ask questions until you understand what's going on.

And if there's one thing I hope you remember from our conversation today, it's this:

Just because something happens to a lot of women doesn't mean you have to quietly accept it as your new normal.

And if you happen to sneeze on your way to your next appointment?

Well, at least now you'll have something very specific to talk about.

Michele Broad NP-C