**3. Reduced bladder sensation and increased bladder functional capacity**

This same mechanism (many years of maintaining increased resting tone in the pelvic floor muscles) may also be developed by female patients whose bladders have increased functional capacity, with a weakened feeling of bladder fullness and urination reflex, and urethra with normal closing pressure. Just as in the group of patients with chronic lowpressure urethra or abnormal urethral pressure, these patients were unaware of the abnormal reactions involved in voiding, and had repressed any memories of involuntary micturition or bedwetting (due to overfilling) in childhood or adolescence. They most often associated the onset of symptoms with the most dramatic medical event in their childhood or adolescence (hospitalization for a urinary tract infection, or for difficulties in urinating), or the beginning of sexual intercourse, or with childbirth. When we suggested that the patients collect a history of their urinary disorders from their parents, it became possible during the next visit to confirm that episodes of UI, voiding problems, or urinary tract infections had occurred with varying intensity since childhood, and/or had occurred much more often than these women had reported during the first visit. Maintaining the pelvic floor muscles in a state of increased resting tone for many years had limited the number of episodes of UI due to overfilling, while the unconscious or sometimes recommended abdominal pressing had prevented undue urinary retention. It was only weakening or damage in the mechanisms of retaining urine, most often postnatal or iatrogenic, resulting from bladder emptying using the abdominal press, that over time had reduced the effectiveness of the mechanism used since childhood to cope with this form of voiding disorder. Static disturbances (whether postnatal or caused by other factors, such as changes in the posture of the pelvis, cf. Nguen 2000), regardless of the congenital weakening of the urinary reflex and the increased capacity of the bladder, can reveal congenital voiding disorders, previously masked by the defense mechanisms.

When there are no static disturbances, however, the unconscious use of abdominal pressing to support urination since childhood, due to constantly contracted muscles and a weakened urination reflex, has usually been rather effective in preventing urine retention and frequent infections. The strategy of behavior and ways of coping with bladder emptying, maintained

This explains why in some previous investigations these women had been diagnosed with high urethral pressure. Most likely, when the previous urodynamic testing had been done without prior training in muscles relaxation with visualization of muscle function, these women had not relaxed the pelvic floor muscles even for a moment (first of all, they were unaware of the problem). The increased resting tone in the pelvic floor muscles, or slight muscle tone changes during the various phases of urodynamic testing, could lead to an incorrect diagnosis, despite the EMG record from the skin electrodes, which results from the

The great majority of patients in this group reported, that after the first visit (complying with our recommendations), they had fewer disturbances of voiding and recurrent infections. Some of them, who had periodic episodes of UI, decided on rehabilitation with electrical muscle stimulation (EMS) and EMG biofeedback therapy, or surgical treatment with sling procedures for better urethral support, supplemented by post-operative

**3. Reduced bladder sensation and increased bladder functional capacity** 

This same mechanism (many years of maintaining increased resting tone in the pelvic floor muscles) may also be developed by female patients whose bladders have increased functional capacity, with a weakened feeling of bladder fullness and urination reflex, and urethra with normal closing pressure. Just as in the group of patients with chronic lowpressure urethra or abnormal urethral pressure, these patients were unaware of the abnormal reactions involved in voiding, and had repressed any memories of involuntary micturition or bedwetting (due to overfilling) in childhood or adolescence. They most often associated the onset of symptoms with the most dramatic medical event in their childhood or adolescence (hospitalization for a urinary tract infection, or for difficulties in urinating), or the beginning of sexual intercourse, or with childbirth. When we suggested that the patients collect a history of their urinary disorders from their parents, it became possible during the next visit to confirm that episodes of UI, voiding problems, or urinary tract infections had occurred with varying intensity since childhood, and/or had occurred much more often than these women had reported during the first visit. Maintaining the pelvic floor muscles in a state of increased resting tone for many years had limited the number of episodes of UI due to overfilling, while the unconscious or sometimes recommended abdominal pressing had prevented undue urinary retention. It was only weakening or damage in the mechanisms of retaining urine, most often postnatal or iatrogenic, resulting from bladder emptying using the abdominal press, that over time had reduced the effectiveness of the mechanism used since childhood to cope with this form of voiding disorder. Static disturbances (whether postnatal or caused by other factors, such as changes in the posture of the pelvis, cf. Nguen 2000), regardless of the congenital weakening of the urinary reflex and the increased capacity of the bladder, can reveal congenital voiding

When there are no static disturbances, however, the unconscious use of abdominal pressing to support urination since childhood, due to constantly contracted muscles and a weakened urination reflex, has usually been rather effective in preventing urine retention and frequent infections. The strategy of behavior and ways of coping with bladder emptying, maintained

limitations of this method of registration.

disorders, previously masked by the defense mechanisms.

rehabilitation.

over many years, give the patient a false sense of being in good health, and make it difficult to establish the cause-and-effect relationship of psychosomatic factors. Along with the appearance of static disturbances (e.g. due to childbirth or disturbances in the innervation of the pelvic floor muscles due to discopathy), the previous mechanism for voiding an overfilled bladder and reducing urine retention ceases to be effective, and difficulties with urination intensify. They are caused by the exacerbation of deformities (folding of the urethra), along with prolapse of the anterior vaginal wall when the effort is made to assist urination by abdominal pressing. In these patients, just as was the case in the group of patients with congenitally low or abnormal urethral pressure and with a normally sensitive and properly innervated bladder of the correct volume and an active urination reflex, there is an identical defense mechanism, i.e. permanently increased resting tone in the pelvic floor muscles. This mechanism is likewise the cause of psychosexual disturbances and a worse HRQOL. The lack of a diagnosis reached early enough using surface electromyography with vaginal electrode (or rectal electrode in children), produces a similar history of largely ineffective treatment. Unfortunately, some physicians still do not have the possibility to make an objective evaluation of the rest tone in the pelvic floor muscles with surface electromyography.
