To pee or not to pee

The undeniable link between trauma and lower urinary tract symptoms

It was a strange pattern to uncover.

Wake in the night, coming out of a hard sleep confused and foggy, conscious of only one thing: I’m picking my nose.

Sometimes really aggressively. Picking my nose, with no objective.

As I slowly make my way to consciousness, I notice something else: I have to pee.

I stumble to the bathroom, then back to bed, and sleep (sometimes, but that’s an anecdote for the sleep convo).

Over and over, most nights of the week. Wake, pick, pee. For months, years. I can’t really say. And it wasn’t really until after my trauma memories started surfacing that I realized the two were even related. That picking my nose was a work-around. My body had shut down signaling from my pelvis, leaving my bladder to fill without the normal messages to tell my brain: hey! We gotta gooooo. So my body mobilized my finger to reach for my face and scratch me awake.

So brilliant, when you really think about it. How creative our bodies can be, compensatory.

But it didn’t answer my deeper question: why?

I’ve always had issues with urinating. Weird things, like having to pee reallllyyyy bad on a road trip, rushing to the back of the highway gas station, so relieved to find no one else had beat me there. Only to sit down on the toilet and….nothing.

My brain begged, pleaded, with my bladder to empty. Crying with the discomfort, quickly turning to pain. But it stayed stubbornly full, not even a drip drop falling into the toilet below. How I longed to hear a tinkle that never came.

And so many more stories like this one.

The bladder is an organ with its own unique story to tell. It’s tucked into the lower part of the pelvic bowl, sitting just in front of the uterus for those with that reproductive set-up, which is why many pregnant people pee more frequently and may even feel little kicks on the bladder (for me these felt like little lightning zings). The bladder is fed from two long tubes that drain from the kidneys, the main filter system for electrolytes, blood glucose, and other minerals. All unwanted items get added to the solution we eventually call urine and sent down the ureter tubes for storage in the bladder.

Like other internal organs, the bladder is composed of smooth muscle. The lining, however, is made of urothelium, or “transitional epithelium”, which is specifically designed to expand and contract, while still maintaining its shape. This means the bladder can fill with urine because the muscle stretches and allows more space. After emptying, it shrinks back to original volume.

Neurologically, the regulation of the bladder is incredibly complex. Sensors in the epithelium help communicate fullness, while the sympathetic nervous system helps to constrict the muscles surrounding the ureter, keeping you from peeing your pants while driving on the highway. As you find your way to a bathroom and let out a sigh of relief, the parasympathetic nervous system steps in and allows for release and relaxation.

One of the most important players in all of this, and especially in those with a traumatized body, are the neurotransmitters.

If you can, imagine the nervous system operating like electricity lines, the nerves flowing from the spinal roots just like the wires that cross your yard, flowing out from the poles near the street. In the body, nerves extend out just close enough to the receptors without touching, just like the electricity comes right into your home but waits, at the sight of the outlet, for you to connect to it when you’re ready.

When the timing is right and the communication is ready to be received or sent, the neurotransmitters are released and find the receptors they bind to. The neurotransmitters act as a “plug” essentially, connecting the communications from the nervous system to the muscles at the right time.

In other words, nothing happens without a neurotransmitter.
Just as nothing happens unless that appliance is plugged in.

Enter acetylcholine, one of the main neurotransmitters in this whole process. Acetylcholine works directly and indirectly, on a variety of processes that include bladder muscle relaxation. And acetylcholine has a unique relationship with cortisol, the main stress hormone released in response to traumatic experiences. While acetylcholine has the ability to prompt cortisol release from the adrenal gland, chronic elevations of cortisol (such as what happens when the body is feeling constantly under threat) actually suppresses acetylcholine release.

What does this mean?

For starters: experiences of chronic trauma can dramatically interrupt the system that keeps us peeing.

A study done with women between the ages of 18-60 who had been diagnosed with PTSD due to childhood sexual assault seems to correlate this relationship. All participants in the study had been admitted to a psych ward with increasing levels of dysfunction in day-to-day activities and their participation in the study was voluntary (I, personally, find this to be very important; they had autonomy which is not something people get in psych wards very often). They were assessed specifically for lower urinary tract symptoms—urgency, frequency, nocturia (increased frequency of peeing during the night), retention, and incontinence—and found direct relationship to severity of abuse and severity of symptoms. Suggesting not only that childhood sexual assault has a direct impact on our urinary systems, but also that the severity of experiences (including duration) can actually make symptoms worse.

This study also introduced another concept I found really interesting: expression suppression. I hadn’t heard this phrase before, but understand it to describe how a survivor might have been forced to keep their trauma hidden, oftentimes from themselves as much as others. Examples include but are not limited to: not being allowed to cry if something hurt, not allowed to tell others what happened, receiving more assault if any type of “complaining” happened, etc.

With the women in the study, the authors found a strong history of expression suppression in each participant. It was so present they went so far as to suggest that “ES may play a role in modulating physical symptoms and markers of health”. To me this validates and affirms what many of us already know: that the trauma was just one part of the injury, with our inability to speak or express how we felt about the trauma being the other.

For those of us with urinary symptoms, it may also explain why conventional approaches to treatment aren’t affective on their own. We need unique healing containers that provide relief of symptoms while also addressing the underlying healing of the pathways directly impacted by our trauma.

To see if working with me could be the healing path you’re looking for, schedule your complimentary Fit Check today.

Sources:

Handelzalts, J. E., Tevet, M., Padoa, A., & Shlomi, I. (2025). Urinary symptoms in sexual abuse survivors with severe post-traumatic morbidity: the impact of emotion regulation strategies. European Journal of Psychotraumatology, 16(1). https://doi.org/10.1080/20008066.2025.2510726

 Yoshimura, N., & Chancellor, M. B. (2003). Neurophysiology of lower urinary tract function and dysfunction. Reviews in urology, 5 Suppl 8(Suppl 8), S3–S10.

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