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When you’re feeling anxious or nervous, do you often find yourself needing to use the bathroom more? That’s because stress physically affects bladder function.
A range of conditions are characterised by altered bladder functioning. Some common ones are bladder pain syndrome/interstitial cystitis, overactive bladder and lower urinary tract infections. Symptoms associated with these conditions range from discomfort, pain, urinary incontinence (leaking), increased urinary frequency, reduced bladder capacity, urinary retention, and decreased voiding. Bladder issues affect men and women but there seems to be a higher proportion of women affected.
Stress is a broad term and so it’s important to clarify that it can come in many forms and on a continuum; from the daily pressures of life to violence or trauma. Stress can refer to a stressor (e.g. deadline upcoming), the experience of stress (feeling pressured) or even an active process or verb (e.g. to “stress out” or to stress about something).
At a neurobiological level, stress is the body’s reaction to being under threat or pressure. It’s important to remember that we may not be consciously worried when we are under stress. For example, if you have a busy day, your body (brain included) is under stress as you demand more of its resources. However, you may not consciously be thinking “I’m so stressed” and you may not be feeling particularly overwhelmed.
The impact of stress on the bladder applies to everyone, with or without a bladder condition. Our autonomic nervous system activity (the fight or flight system) can increase bladder contractions, making us need to pee more. Research shows that as stress levels increase, so does bladder dysfunction [1, 2]. The catch22 for people with bladder conditions is that the experience of such symptoms is very stressful. Having bladder symptoms can have a profound impact on quality of life, sleep, sexual function, and mental health [3].
Understanding some more about the mechanisms of the brain-bladder connection can put into context how stress can disrupt communication between them. Bladder functioning is coordinated via the nervous system through a series of steps. The pontine micturition centre (PMC) is an area of the brain that is responsible for regulating activity in the bladder. Information is sent back and forth between the brain and bladder through connecting nerves. The role of nerve activation in the bladder is to signal to the brain when the bladder is reaching capacity, and subsequently, the brain relays signals to the bladder to create sensations of urinary urgency and to facilitate the contraction of muscles in the bladder wall. However, stress can interfere with nerve activity. This connection can therefore be disrupted in both directions, from the bladder to the brain and vice versa.
A sensitised bladder
The nerves in the bladder can become hypersensitive due to repeated activation (e.g. due to recurrent urinary tract infections or a period of stress), meaning that people experience the sensation of bladder fullness even when the bladder isn’t full [4]. The brain receives signals from the bladder that it is full at lower pressure thresholds than usual, and therefore the urge to urinate is more frequent. On the other end, the signals from the brain to the bladder can be altered. The release of stress hormones in the bloodstream increases bladder contractions and can lead to overactivity of the bladder [5]. Research has found that increasing stress directly increases bladder contractions, contributing to increased urinary frequency [6].
The bladder-stress cycle
As would be expected under the circumstances, the symptoms of bladder dysfunction are distressing and uncomfortable, contributing to worry about the symptoms, feeling upset, frustrated, and anxious. Consequently, the symptoms can themselves become a source of additional stress that further dysregulates the brain-bladder connection and a vicious cycle starts to form. Research has shown that in individuals with overactive bladder, those with higher anxiety symptoms experience more severe symptoms and a worse quality of life compared to those without anxiety [7].
With the experience of discomfort, pain and other symptoms, the body and brain can move into a threat detection mode. Our bodies are wired to try and protect us, so this may not necessarily happen consciously as underlying neural processes occur without conscious thinking. This is called “neuroception”. The nervous system subconsciously makes decisions as to whether something is deemed safe or dangerous. For an individual experiencing uncomfortable and distressing symptoms, the nervous system can have an altered sense of threat and safety. As symptoms can also lack predictability, the neuroceptive state can go into overdrive as it continually seeks out potential risks and threats to try and keep you safe. At this subconscious level, the processing of danger cues can trigger protective reflexes and result in increased sensitivity to bladder symptoms.
At a more conscious level, stress-induced behavioural changes may occur such as monitoring symptoms. This increases attentional focus on sensations of discomfort and implicitly communicates to the brain the idea that this is a threatening experience. Another common behavioural change in response to symptoms is avoidance. As we feel more depleted by our physical state, we feel less able to engage in life as normal. Avoidance can worsen symptoms via a number of mechanisms. It increases isolation, low mood and decreases the scope for positive distraction (which can help recalibrate nervous system functioning).
What next?
It’s clear from the research that a connection between exposure to stress and bladder dysfunction exists. Although we have started build a good understanding of how stress impacts the bladder, further research is still necessary to help shape treatments that consider this link. Currently, medicines prescribed for depressive and anxiety disorders have shown some success in treating urinary problems [8]. Although there is a limited amount of research currently available in this area, it suggests that targeting anxiety and stress improves symptoms and thus incorporating a psychological approach could be a promising next step. It is, however, important to acknowledge that bladder dysfunction is more complicated than stress and anxiety and requires a tailored approach to recalibrate the brain-bladder connection. Thinking about our neuroceptive state and subconscious evaluations, we should also be exploring ways to cultivate a sense of safety for our bodies to dampen the defensive system. Building on our understanding of the brain-bladder connection as well as the wider biopsychosocial mechanisms can help to inform appropriate treatments.
At Mind Body Blossom, we are developing tailored interventions with the aim to empirically assess them and be informed by patient experiences. The first step is to get data on the holistic experience of chronic bladder conditions. If you currently or previously experienced recurrent or chronic urinary tract infections, you may like to contribute to this research by completing this survey. This is research being conducted in collaboration with Teesside University.
References
[1] Lai, H., Gardner, V., Vetter, J., & Andriole, G. L. (2015). Correlation between psychological stress levels and the severity of overactive bladder symptoms. BMC urology, 15(1), 1-7.
[2] Rothrock, N. E., Lutgendorf, S. K., Kreder, K. J., Ratliff, T., & Zimmerman, B. (2001). Stress and symptoms in patients with interstitial cystitis: a life stress model. Urology, 57(3), 422-427.
[3] Eapen, R. S., & Radomski, S. B. (2016). Gender differences in overactive bladder. Can J Urol, 23(Suppl 1), 2-9.
[4] Mills, K. A., West, E. G., Sellers, D. J., Chess-Williams, R., & McDermott, C. (2021). Psychological stress induced bladder overactivity in female mice is associated with enhanced afferent nerve activity. Scientific Reports, 11(1), 1-12.
[5] Chess-Williams, R., McDermott, C., Sellers, D. J., West, E. G., & Mills, K. A. (2021). Chronic psychological stress and lower urinary tract symptoms. Lower urinary tract symptoms, 13(4), 414–424. https://doi.org/10.1111/luts.12395
[6] Mingin, G. C., Peterson, A., Erickson, C. S., Nelson, M. T., & Vizzard, M. A. (2014). Social stress induces changes in urinary bladder function, bladder NGF content, and generalized bladder inflammation in mice. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, 307(7), R893-R900.
[7] Lai, H. H., Rawal, A., Shen, B., & Vetter, J. (2016). The relationship between anxiety and overactive bladder or urinary incontinence symptoms in the clinical population. Urology, 98, 50-57.
[8] Kinjo, M., Yamaguchi, T., Tambo, M., Okegawa, T., & Fukuhara, H. (2019). Effects of mirabegron on anxiety and depression in female patients with overactive bladder. Urologia internationalis, 102(3), 331-335.