By Sami Ashenbrener, PT, DPT, PCES; Pelvic Health Doctor of Physical Therapy and Partner at CPR Physical Therapy + Performance

As a pelvic floor physical therapist, one of the most common concerns I hear from patients of all ages is, “Why am I leaking urine, and what can I do about it?”
Urinary leakage, or urinary incontinence, is incredibly common. Yet, it’s also one of the least discussed topics in healthcare. Many people quietly adapt—using pads, limiting fluid intake (which can actually worsen the problem), or avoiding certain activities—without realizing that very effective, non-surgical solutions exist in pelvic health physical therapy.

Two of the most common types of urinary incontinence are stress incontinence and urge incontinence. While they may share the same frustrating symptom (leakage), their causes, triggers, and treatment approaches are quite different. Understanding these differences is the first step toward lasting improvement and regaining control of your bladder.

What Is the Pelvic Floor, and Why Does It Matter?

Before diving into the two types of bladder incontinence, let’s talk briefly about the pelvic floor muscles.

The pelvic floor is a group of muscles, ligaments, and connective tissues that form a supportive “hammock” at the base of the pelvis. These muscles run all the way from the pubic bone at the front of the pelvis to the tailbone and sacrum at the back of the pelvis. These muscles play key roles in:

• Supporting the bladder, uterus (in women), prostate (in men), and rectum
• Maintaining urinary and bowel continence
• Sexual function
• Core and postural stability

When these muscles are either too weak, too tense, or poorly coordinated, they can’t do their job effectively—leading to problems such as urinary leakage, pelvic pressure, or pain.

Stress Incontinence: When Pressure Overwhelms the System

What It Is Stress Urinary Incontinence (SUI) occurs when physical pressure or “stress” on the bladder causes leakage.

Typical triggers include:

• Coughing or sneezing
• Laughing
• Jumping, running, or exercising
• Lifting heavy objects
• Getting up quickly from a chair

In these moments, the intra-abdominal pressure (the pressure inside your abdomen) spikes. Normally, your pelvic floor and urethral sphincter contract reflexively to close the urethra and prevent leakage. But if those muscles or connective tissues are weakened or not responding in time, urine escapes.

Why It Happens

Stress incontinence often results from pelvic floor weakness or lack of support around the bladder and urethra.
Common causes include:

• Pregnancy and childbirth, especially vaginal deliveries
• Hormonal changes during menopause (estrogen affects tissue elasticity)
• High-impact exercise without proper pelvic floor coordination
• Chronic coughing, constipation, or heavy lifting
• Pelvic surgeries or trauma
• Elevated levels of stress or anxiety which lead to muscle tension, most commonly in the pelvic floor and the upper trapezius (neck muscles).

It’s important to note that stress incontinence isn’t limited to postpartum women. It can affect young athletes, older adults, and even men after prostate surgery.

What It Feels Like:

People with stress incontinence often describe small, involuntary leaks during specific moments of exertion—usually without any warning or strong urge to urinate. They might say, “I leak when I laugh too hard,” or “I can’t run without wearing a pad.” Sometimes people think that this leakage is normal, such as, “I don’t have leakage unless I jump on a trampoline, but everyone does after having babies,” when in reality, people should NEVER experience leakage.

How Pelvic Floor Therapy Helps:

From a physical therapy standpoint, treatment for stress incontinence focuses on strength, coordination, and timing of the pelvic floor muscles.
A few key elements include:

• Pelvic floor muscle training (“Kegels,” done correctly): Teaching patients how to isolate, strengthen, and relax the pelvic floor without overusing surrounding muscles. But please understand, pelvic floor therapy is SO much more than kegels. Understanding how to properly engage and relax these muscles is just the foundation.
• Breath and pressure management: Learning to exhale and engage the pelvic floor during moments of exertion to prevent spikes in intra-abdominal pressure, and training this to become automatic in the body through motor control training.
• Functional training: Integrating pelvic floor activation into everyday movements (lifting, squatting, sneezing) and connecting pelvic floor activation to higher level exercise activity.
• Postural and core re-education: Since the pelvic floor works closely with the diaphragm and deep abdominal muscles, improving posture and breathing patterns can enhance support.
• Bladder habit retraining: Because our patterns and habits affect our bladder signals to our brain, PT works on understanding our habits and adjusting these to improve function.
• Recognizing patterns of how emotional stress can influence our physical muscle function: stress can subconsciously increase tension of the pelvic floor muscles, so tools to manage stress (mindfulness, breathing, body scans) can help to improve muscle function.

When done consistently and under guidance, many patients experience noticeable improvement within a few weeks to months.

Urge Incontinence: When the Bladder Has a Mind of Its Own

What It Is:

Urge urinary incontinence (UUI) is characterized by a sudden, intense urge to urinate, followed by involuntary bladder leakage before reaching the toilet.
This is often associated with an overactive bladder—where the bladder muscles contract too soon or too often.

Typical triggers include:

• Hearing running water
• Returning home (sometimes called “key-in-the-door” sensation)
• Cold weather
• Drinking coffee, tea, or alcohol
• Just sitting down to relax

Why It Happens:

Urge incontinence is related to pelvic muscles dysfunction with bladder overactivity and poor communication between the bladder and brain.

Some potential contributing factors include:

• Pelvic floor muscle overactivity: an overactive pelvic floor can actually worsen urgency by increasing tension and sending false signals to the bladder.
• Bladder habits: repetitive “just in case” bathroom trips or habits of emptying the bladder due to environmental triggers (such as walking into a certain store or past a bathroom) can train our bladder to have urgency.
• Bladder irritation from caffeine, carbonation, acidic foods, or certain medications.
• Chronic bladder infections or inflammation.
• Neurological conditions (such as multiple sclerosis, Parkinson’s disease, or spinal cord injury).

What It Feels Like:

People with urge incontinence often describe a sense of panic or lack of control—“When I have to go, I have to go right away or I leak.”
They may void very frequently out of fear of leaking or because they feel a strong urge, even if the bladder isn’t really full.

How Pelvic Floor Therapy Helps:

Pelvic floor therapy for urge incontinence looks quite different from that for stress incontinence.
Instead of primarily strengthening, the focus is on downtraining, coordination, and bladder retraining:

• Urgency suppression techniques: Using specific strategies (such as calming, diaphragmatic breathing, gentle pelvic contractions, toes scrunches, or distraction techniques) to calm the bladder when the urge hits.
• Pelvic floor relaxation training: Teaching the muscles to let go and reduce excessive tension. This includes decreasing tension in not only the pelvic floor muscles, but the hip, abdomen, and back muscles as necessary.
• Bladder retraining: Gradually increasing the time between voids to restore normal bladder capacity and signaling.
• Behavioral and dietary modifications: Identifying and eliminating bladder irritants, figuring out appropriate fluid intake and ideal timeframes, and creating a voiding schedule.
• Neuromuscular re-education: Helping the brain and bladder reconnect properly through biofeedback (muscles activation readings from sensors) and sensory awareness training.

With consistency, patients often regain control over their bladder signals, reducing both frequency and urgency.

What If You Have Both?

It’s very common to experience mixed incontinence, meaning a combination of stress and urge symptoms.
For example, someone might leak when they cough (stress) and feel a sudden urge on the way to the bathroom (urge). In these cases, a skilled pelvic floor therapist will tailor a plan that addresses both muscle function and bladder behavior.

When to Seek Help

If you’re leaking urine—even a few drops—it’s worth talking to a healthcare provider or pelvic floor physical therapist. It is also advantageous to be proactive prior to leakage throughout the course of your life or with major changes such as pregnancy, postpartum, perimenopause, menopause, and with aging. While occasional leaks might seem minor, they often signal that your pelvic floor or bladder habits need some attention. People are surprised how relatively minor changes can make a major impact in their quality of life. You do not have to live with pads, plan bathroom trips around your day, or give up activities you enjoy.

A pelvic floor therapist will typically perform a thorough evaluation, which may include assessing:

• Pelvic floor muscle strength, endurance, and coordination via subjective questions and/or an internal pelvic floor examination
• Breathing and core mechanics
• Posture and movement patterns
• Bladder diary or voiding habits

From there, you’ll receive a personalized plan of exercises, education, and lifestyle strategies.

The Takeaway

The difference between stress and urge incontinence comes down to why leakage occurs:

• Stress incontinence = pressure exceeds pelvic floor support.
• Urge incontinence = bladder contracts involuntarily.

Both can be frustrating, but both are highly treatable.

Through pelvic health physical therapy, most patients see significant improvements or complete resolution – all without surgery or medication. And don’t forget: pelvic floor PT can also address bowel incontinence, pelvic organ prolapse, pelvic pain such as pain with intercourse, sexual pleasure dysfunction, constipation, abdominal, hip, or back pain, tailbone pain, and a myriad of other pelvic symptoms.

Remember: bladder leakage is common, but it’s not normal. Please don’t let yourself or your friends, family, loved ones live with these symptoms. With the right knowledge, support, and guidance from a pelvic health physical therapist, you can empower yourself to take control of your health and improve your life!