Let's Talk About Urination
Top tips on going with the flow 💦
ICYMI 👉
I just spent a weekend away with three longtime girlfriends. The beauty of friendships like these is that we can sit on a porch in rural Pennsylvania for hours at a time, talking about everything and nothing at the same time. Pesky chin hairs? Me too! Annoying sleep partner? YES!!! Apprehension and joy about the future? Simultaneous nodding. We laughed and cried, without secrets or shame, savoring the last sips of summer together.
While we covered many topics you might expect middle-aged women to discuss (kids and parents, loss and grief, health woes and life goals), a repeated theme of this brief getaway was something that lies at the core of our everyday lives: Urination.
It was a great weekend!
It turns out there’s a downside to uproarious laughter in midlife. “I just wet my pants,” I jumped up and quickly alerted the group after letting out a loud guffaw. “Oh! I was up all night in the bathroom!” another friend replied. It turns out she’d had to pee four times in the night. Our other friend wondered aloud whether her bladder had shrunk during menopause. Our fourth friend took matters one step further, reporting the dual disruption of fecal and urinary leakage whenever she jogs midday.
(Apparently no topic was off limits.)
As the conversation veered from bold comedy to bodily curiosity, my friends asked my advice. While I’m no urinary Olympian myself, I have indeed collected a few pearls of wisdom about urinary frequency, flow, and overall bladder function—and how to improve all three.
So, here is what I told them:
Limit your intake of caffeine
Caffeine can affect the bladder and urinary flow in several ways. First, it acts like a diuretic, stimulating the kidneys and to increase urine production. Caffeine can also irritate the bladder lining, which can lead to increased urgency and frequency of urination. This is particularly relevant for individuals with bladder conditions like interstitial cystitis or overactive bladder. Caffeine also affects the muscles that control urine flow. Specifically, it can relax the internal bladder sphincter, which can contribute to an increased urge to urinate or even involuntary leakage in some cases.
Drink more water in the daytime and fewer liquids before bedtime
Caffeine, alcohol and water consumption will increase urine production. Instead of drinking a bunch of liquids at night (which you may feel inclined to do if you are dehydrated from all that coffee and Diet Coke you drink during the day!), try spreading out your fluid consumption throughout the day. Keep a water bottle near your desk or in your car in order to make daytime hydration unavoidable. Try to reduce the amount of fluids you drink starting two or three hours before bedtime. Also try urinating twice before going to bed—once in the late evening and again just before sleep. Another trick to avoid nighttime urges to pee? Elevate your legs in the daytime to “empty out” the fluid that collects in our legs. This is particularly important for people with varicose veins or leg swelling for other reasons.
Manage constipation
I like to remind my patients that the lower abdomen and pubic region are like Manhattan. There’s heavy traffic in a very small space. This means that if you are constipated (i.e., your bowels are distended with stool), your bladder can feel “smaller” when, in reality, your bladder is simply being compressed by adjacent structures. My point: it’s important to manage your constipation to reduce pressure on the bladder and to allow yourself to urinate with intention.
For men: check your prostate
The prostate gland, if enlarged, can interfere with urinary flow. Many men will experience benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate, as they age. BPH is common, with symptoms typically becoming more noticeable in men over the age of 50. If you notice that you experience urinary symptoms such as frequent urination, especially at night (i.e., “nocturia”), difficulty starting or stopping urination, weak urine stream, and a feeling of incomplete bladder emptying, you should see your doctor to get your prostate checked.
For women: consider HRT (local or systemic)
Genitourinary Syndrome of Menopause (GSM) is a term used to describe a range of symptoms that occur in the genitourinary system due to decreased estrogen levels during menopause. GSM encompasses changes in the vaginal, vulvar, and urinary tissues, which can significantly impact a woman's quality of life. In addition to vaginal symptoms (such as itching, burning, pain, and dryness), pelvic symptoms (such as pressure or pain), the absence of estrogen can cause urinary symptoms such as urinary frequency, urgency, incontinence, and an increased susceptibility to recurrent urinary tract infections. The mainstay of treatment for GSM is hormone replacement therapy, first in the form of local (i.e., topical) estrogen administered intravaginally as a cream or tablet. Note that vaginal estrogen has been deemed safe even for patients with breast cancer. It is the standard of care for women with peri- or menopausal GSM symptoms. Some patients who take systemic HRT (i.e., estrogen and progesterone therapy that increased the woman’s blood level of both hormones) also need topical estrogen in addition in order to ameliorate the vulvovaginal or pelvic floor symptoms of menopause.
Use it or lose it
Your pelvic floor muscles are key to your urinary wellbeing and more. The ability to appropriately squeeze and relax your pelvic floor muscles helps move waste from your body. Pelvic floor muscles coordinate with the urethra, the tube that carries urine out of the body, and the anus, the organ where stools pass.
A strong pelvic floor is critical for maintaining continence, particularly while exercising. When we lunge for a tennis ball, for example, our pelvic floor muscles work in conjunction with our glutes, hip flexors, and quadriceps to stabilize our pelvis and maintain proper alignment.
For men and women alike, the pelvic floor is a set of muscles that tend to become weaker with age, gravity, and (for women) the absence of estrogen. However, these muscles can remain strong if you strategically work on them! So, I suggest trying the five exercises in this video here—or the six exercises in this New York Times article here, recognizing that there is no substitute for in-person, one-on-one physical therapy to address unique pelvic floor problems. Indeed, there are physical therapists who specialize in the pelvic floor. It may be worth asking your doctor for a referral to one.
The upshot
Everyone in midlife and beyond wants the luxury of peeing only when they want to. But that takes work and maintenance. And everyone needs close friends, with whom they can talk about the stuff of life, even if it’s messy.
Most of all, everyone needs friends who love them unconditionally and who can go with the flow—literally and metaphorically.
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Disclaimer: The views expressed here are my own and are not a substitute for advice from your personal physician.
What synchronicity!! My friend and I were discussing all things urinary incontinence tonight. I used HRT during perimenopause and throughout my fifties. I reached full menopause at age 51. I used FemRing, a flexible intra-vaginal ring that fits over the cervix.The ring emits estradiol systemically for 90 days. For the opposing progesterone, I had a Mirena IUD which emits progesterone and only needs to be changed every 5 years (approximately). Suffice it to say that it was a super convenient way to replace progesterone.I stopped HRT around age 62. I am now 72 and have been struggling with full on urinary incontinence. I need to see my doctor. My guess is that I have an overactive bladder and need to strengthen my pelvic floor muscles. I am excited to read that my problem could also benefit from intra-vaginal estrogen in the form of a cream or a pill. Thank you, Dr Lucy, for this very helpful information (including the two films which I will watch. You’re the BEST!!
Probably 10 years ago I spent a priceless $1000 on 8 sessions of pelvic floor PT offered at our gym. Have been doing daily exercises ever since. Now, even at 78, rarely leak, and only a drop or two then.