Incontinence Prevention and Management: Behavioral Treatment

Behavioral treatment for urinary incontinence depends on careful instruction of the patient. The following tools are examples of patient education materials for bladder training, bladder urge control, and pelvic muscle (Kegel's) exercises that have been found to be clinically useful. See the Geriatrics Review Syllabus chapter on "Urinary Incontinence" for discussion of the use of behavioral approaches.

BLADDER TRAINING

Bladder training involves following a strict schedule for bathroom visits. The schedule starts with bathroom visits every 2 hours or so, but the time between visits is gradually increased. The longer stretch of time between bathroom visits gives you increased bladder control and independence. If you have a habit of using the bathroom more than once every 2 hours due to urgency-with or without urge incontinence-you may benefit from bladder training. Bladder training has been shown to be effective for both stress and urge incontinence. Goals Bladder training has several goals. It helps you

Lengthen the amount of time between bathroom visits.
Increase the amount of urine that the bladder can comfortably hold.
Improve self-control over bladder urges by voiding on a schedule, not when the urge strikes.
Reduce or eliminate incontinence.
Increase independence in bladder management.

How To Do Bladder Training Bladder training requires motivation for starting and maintaining a schedule for voids. Each week, as incontinence decreases, the schedule is changed slightly so that your bathroom visits occur less often. Bladder training will take between 6 and 8 weeks for success, but noticeable improvements will occur early in the program.

Start with a Bladder Diary. Record your bathroom visits and urine leaks on the Bladder Diary for 1 week. Measure the urine you produce during bathroom visits with a calibrated cup. This will help determine the amount of urine your bladder is able to hold.
Review the Bladder Diary with your doctor, who will set a bladder training schedule according to the amount of time between your usual bathroom visits. For many people, the bathroom visits are scheduled for every hour.
For the first week, use the bathroom strictly according to the schedule. If a strong bladder urge strikes, use the Bladder Urge Control Procedure (below) to regain control and wait until the next scheduled time to void. If the urge is too strong and it cannot be suppressed, use the bathroom, but then resume the bladder schedule
Each week, increase the time between bathroom visits by 15 or 30 minutes, as tolerated. As incontinence decreases week by week, the schedule can be further increased. For many individuals, bathroom visits every 3 to 6 hours is desirable. For most older persons, every 2 to 3 hours is optimal.
Monitor the number of urine leaks each day and for the entire week. Also monitor the amount of each leak. For example, a person may have 2 leaks a day, but instead of large leaks that saturate a pad, they are small dribbles that slightly dampen the pad. This is considered good improvement.
If the number of urine leaks does not lessen in 1 week, then maintain the same bladder training schedule for another week. Adjust the schedule in the next week when urine leaks decrease.

BLADDER URGE CONTROL PROCEDURE

When a bladder urge strikes, you may be tempted to rush to the bathroom to prevent incontinence. This response can cause more harm than good, since the already overactive bladder becomes more stimulated and irritated with the rushed movement to the toilet. To get control over the bladder, practice the Bladder Control Procedure when the urge strikes. In this procedure, you

Stand quietly or sit still. This prevents over-stimulation of the bladder.
Take slow, relaxed breaths.
Contract the pelvic floor muscles repeatedly. This helps keep the urethra closed to prevent urine from leaking. This also calms the bladder through special signals that are carried to the brain.
Concentrate on making the urge go away. Use mental imagery and self-talk to help suppress the urge. Think to yourself, "I am in control of my bladder and this bladder has one job only and that is to hold urine until I am ready to go to the toilet."
Use mental distraction to reduce the awareness of the discomfort of the urge. Hum a tune, do mathematical calculations (subtract 7 from 100, then continue subtracting 7), or balance the checkbook.
When the urge subsides, do not use the toilet until the next scheduled void. When used with every urge, this procedure becomes more effective and gives you greater control over your bladder. Be encouraged by even small improvements in your symptoms. Although progress may seem slow, you are developing entirely new habits for bladder control. These healthy bladder habits will remain an important part of your life style. This takes both time and patience, but the rewards are worth the effort.

PELVIC MUSCLE (KEGEL'S) EXERCISES

Pelvic muscles, like other muscles, can become weak. Pelvic muscle exercises strengthen weak muscles around the bladder. To find the right muscle, imagine that you have eaten food that has caused you to have gas. The muscle that you use to hold back gas is the one you want to exercise.

Do your pelvic muscle exercises several times each day. Usually it takes about 10 minutes, two or three times a day, to do the exercises. Your doctor will give you exact instructions about how many times you should perform the exercises and the number of times a day.
Practice anywhere and any time. It is usually best to begin practicing them when lying on your bed. Once you have mastered the exercises lying down, practice them sitting in a chair. Then advance to practicing them standing. Soon you will be able to do them anywhere.
Never use your stomach, leg, or buttock muscles. To find out whether you are also contracting your stomach muscles, place your hand on your abdomen while you squeeze your pelvic muscle. If you feel your abdomen move, then you are also using these muscles.
Avoid holding your breath. Inhale and exhale slowly while counting. In time, you will learn to practice effortlessly.
If you forget to do your exercises for several days, do not be discouraged. When you have realized you have forgotten, begin your program again as instructed. Do not try to make up for lost days by doing more exercises or you will have sore muscles.

After 4 to 6 weeks of following your prescribed exercise routine, you will begin to notice that you are having fewer urinary accidents. After 3 months, you will see an even bigger difference. It may help to keep a diary of the times you practice your exercises and the times that you leak urine. This will give you a picture of the progress you are making. SOURCE: Adapted from Busby-Whitehead J, Kinkade J, Granville L. Urinary Incontinence: Management in Primary Practice. Tool Kit 2, Practicing Physician Education Project, ed. BE Robinson. New York: The John A. Hartford Foundation and The American Geriatrics Society; 2000. Reprinted with permission .