Blog Cover Causes of Urinary Leakage

Causes of Urinary Leakage

Stress Urinary incontinence is a symptom of mechanical pelvic floor dysfunction. Just as knee pain is a symptom that you experience as part of a greater problem; not a diagnosis. Stress urinary incontinence is when a force, such as coughing, sneezing, jumping or running (it may even be sit to stand or rolling over in some individuals), causes greater pressure then the pelvic muscle strength is able to handle. Today’s post (and Dr. Janet’s webinar below) is a comprehensive guide to the causes of urinary leakage, specific symptoms related to each cause, and urinary leakage treatment.

We will go over:

  • Causes of Urinary Incontinence
  • Symptoms of urinary incontinence
  • Treatment for urinary incontinence
Above is the webinar version of this blog on causes of urinary incontinence.

Causes of Urinary Leakage

There are 2 major causes of stress urinary incontinence;

  • connective tissue integrity and outer pelvic floor muscle layer
  • urethra muscle strength.

Within the 2 major causes there are different factors contributing to leakage. It is very important to target the specific reason for urinary leakage in order to achieve the best treatment outcome. 

Poor Deep Pelvic Floor Muscle Strength

People are often told that performing Kegels will improve pelvic floor strength, and in turn a “stronger” pelvic floor will improve incontinence. However, this is not always true. The deep pelvic floor muscles are attached to the connective tissue, fascia, surrounding the bladder. When you contract your deep pelvic floor muscles, they pull on the connective tissue making it stiffer to support the bladder. So as you run, jump, cough, sneeze, your pelvic floor muscles contract, pulling on fascia, thereby the lifting the bladder.


The pelvic floor muscles may be weak from not adequately being able to use them. This creates a sort of “use it or lose it” type of situation. Generally I see this as a result of an injury, such as a fall on the buttock, or over stretching from child birth as the main contributors to weakness of the pelvic floor muscles.


A symptoms of urinary leakage caused by pelvic floor muscle weakness is generalize leakage. This is a contributing factor in which the best assessment is a pelvic floor assessment by a physical therapist specializing in pelvic floor. An internal assessment of the pelvic floor will let us know how strong the muscle is.


If you suspect deep pelvic floor weakness, focusing on deep muscle training is most helpful. The best cue to train is “ squeeze the anus”. Working with a pelvic floor physical therapist is important for this training; among other things, they will be able to provide you real time feedback on if your muscles are contracting appropriately.

Poor Fascia Integrity

Fascia and connective tissue surround the bladder providing support. This fascia has to remain intact in order to help lift the bladder up against high forces such as a cough, sneeze and running/jumping.


As mentioned above, fascia can be overly stretched, or even torn, during childbirth. When your tissue is stretched or torn this decreases the stiffness and support it provides to the bladder. When there is increase in force (cough, sneeze, run, jump) the support is decreased which causes urinary leakage. Click here for more information about prolapse.


With poor connective tissue integrity you may notice the onset of progressive symptoms/end of day symptoms as the connective tissue stretches throughout the day. The reason this occurs is because over the course of the day the connective tissue stretches due to gravity. The prolonged stretch over time limits the ability of the tissue to create the firmness necessary to support the bladder. This can cause urinary leakage.


If your symptoms are due to fascia stretching try decreasing the amount you bear down during bowel movements

In the case of torn fascia, a pessary may be a good option. Optimize Pelvic Health is the only pelvic floor clinic in the Bay Area specializing in fitting people for pessaries. Learn more about pessaries here.

Urethra muscle strength

New research indicates that URETHRA STRENGTH has a greater influence on urinary incontinence than deep pelvic floor muscles and/fascia. The urethra is the external muscle of the bladder, and is a part of the urinary system. There are multiple factors in urethra muscle strength. The muscle tone of the urethra helps prevent leakage. There are 3 main ways the urethra muscle strength can be impacted:

  • Pelvic floor nerve stretch
  • Pelvic floor nerve compression
  • Low estrogen. 

Pelvic Floor Nerve Stretch

There is a nerve, called the pudendal nerve, that goes through the pelvic floor. It weaves around ligaments, muscles and bony prominences.


During childbirth or chronic constipation this nerve can be stretched, injuring the nerve, and limiting it’s ability to signal the urethra to contract. 


A prolonged labor and pushing phase can contribute to pelvic floor nerve stretch. Common symptoms are leakage with coughing, and sneezing. Chronic constipation can also contribute to stretch of the nerve due to bearing down during a bowel movement. In this case your symptoms of leakage would be worse after a bowel movement. Meaning there may be leakage with a cough or sneeze after a bowel movement, bet with the absence of a bowel movement, leakage doesn’t occur under similar conditions.

Pelvic Floor Nerve Compression

The pudendal nerve splits into 2 nerves, one branch runs along the butt bone directly into the urethra. When there is tightness of the pelvic floor it causes compression of the nerve along the butt bone. 


This compression irritates the nerve, limiting the signal to the urethra to contract. This is the foundation of how we treat patients at Optimize Pelvic Health: the pelvic floor is the only group of muscles directly impacted by stress nerves. This means the more stress, the more you might experience leakage. Another factor impacting nerve compression is alignment. When we hold our babies and kids, we tend to shift back in our heels and jut the pelvis forward to create a “mom shelf.” However, this shift in posture contributes to pelvic floor tightness by compressing the pudendal nerve. Lastly, we have been told to consciously squeeze our glutes while we exercise to provide “stability”. However, this just causes tightness of the pelvic floor. Simply, it is not how muscles work. All these are various factors that contribute to a tight pelvic floor and irritation of the nerve to the urethra.


Symptoms of compression of the pelvic floor nerve include an increase in leakage during times of stress, and after working out.

It is important to note that urinary leakage during times of stress, is not that same as urgency (urgency is a whole separate topic). Here, I am referring to the increase in leakage with coughing, sneezing, jumping/running when there is more stress. At Optimize Pelvic Health we utilize techniques to address the stress nerves and decrease leakage. 

I hear from a lot of our patients: ‘I have always been told to squeeze my glutes during squats’ or other core exercises. However, this constant gripping contributes to the overuse of the pelvic floor and glutes. It also limits your range of motion during exercise. The resulting tightness contributes to compression of the pelvic floor nerve, leading to leakage. 


To improve leakage and reduce the tension that leads to it we must focus on improving whole body relaxation, pelvic floor muscle flexibility and alignment. This will allow the pelvic floor nerve to move more freely when signaling the urethra.


The last item I want to talk about today is estrogen. Did you know there are estrogen receptors in the urethra? With normal estrogen levels, the urethra muscle has bulk making it easier to close (preventing leakage). When there is low estrogen the muscle becomes thin, thus making it harder to achieve full closure (causing leakage).


In both the postpartum nursing state and perimenopause, your body is in a low estrogen state. This decreases the bulk of the muscle tissue making it hard to have complete urethra closure. Imagine if a valve was not closed all the way, there would be a leak. Leakage that is cyclical in accordance with your monthly cycle is a sign of low estrogen. Another sign of low estrogen is vaginal dryness.


Discuss with your OBGYN the use of topical estrogen. The use of topical estrogen needs to be closely managed due to it’s impact on the surrounding fascia. The surrounding fascia will change collagen fiber type depending on the amount of estrogen. To date, there is no research to indicate topical estrogen will negatively impact breastfeeding. 

Summary of Causes of Urinary Leakage

There are so many factors and causes of urinary leakage; each requiring specific assessments and treatment. Here at Optimize Pelvic Health, our doctors of physical therapy have advanced training in stress urinary incontinence. We will be able to tell you the major factors contributing to urinary leakage. When you go to pelvic floor physical therapy, they should be able to tell you how deep pelvic floor muscle strength, fascia integrity, pelvic nerve stretch, pelvic nerve compression, and estrogen play a role in your urinary symptoms.

We utilize a collaborative team approach for all patients so there’s always more then “one pair of eyes” reviewing your care. We distinguish between the different causes of stress urinary leakage, and provide different treatment strategies to tackle your specific case.

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