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Conservative Management of Urinary

Incontinence

Behavioral and Pelvic Floor Therapy, Urethral and

Pelvic Devices

Diane K. Newman; Kathryn L. Burgio

Questions

1.A person with cognitive impairment may not be a candidate for which behavioral interventions?

a.Prompted voiding

b.Timed voiding

c.Bladder training

d.Habit training

2.A bladder diary is integral to behavioral therapy because it can:

a.determine functional bladder capacity.

b.provide information about symptom improvement.

c.determine adherence to pelvic floor muscle training.

d.provide understanding of patient's voiding pattern.

e.b and d.

3.Which of the following statements is TRUE about pelvic floor muscle training?

a.Pelvic floor muscle training is effective for treating stress, urge, or mixed incontinence in men and women of any age.

b.Pelvic floor muscle training is appropriate for stress or mixed incontinence, but not for urge incontinence.

c.Pelvic floor muscle training works for women, but not for men.

d.Pelvic floor muscle training is not effective for older people.

e.Pelvic floor muscle training is only useful for mild-moderate incontinence, but not severe incontinence.

4.When teaching the urge suppression technique, patients are encouraged to:

a.stay near a bathroom as much as possible, so they won't have far to go when they feel an urge to void.

b.stay away from the bathroom until they feel an urge to void. Then get to the bathroom as soon as possible.

c.stay away from the bathroom until they feel the urge to void. Then stay still and wait until the urge has passed before going to the bathroom.

d.wait as long as possible to go to the bathroom to increase bladder capacity.

5.When patients are trying to calm down urgency and prevent leakage, which of the following works BEST?

a.Crossing the legs

b.Squeezing the pelvic floor muscles (PFMs) while rushing to the bathroom

c.Squeezing the PFMs while sitting still until the urgency goes away, then walking to the bathroom

d.Relaxing the pelvic floor muscles to help relax the bladder

6.When using fluid management as a treatment for urgency incontinence, patients are told to:

a.consume a normal amount of fluid to avoid dehydration as well as sudden urgency.

b.increase fluid intake to ensure adequate hydration and train the bladder.

c.decrease fluid intake to minimize bladder filling.

d.increase fluid intake to prevent the loss of functional bladder capacity

7.When attempting to reduce dietary bladder irritants, patients should be told to:

a.avoid spicy foods, tomatoes, and citrus fruits.

b.eliminate caffeine.

c.keep a diary to see which foods or beverages increase urgency.

d.all of the above.

8.When conducting PFM training, clinicians should:

a.ensure that patients are contracting the PFMs selectively.

b.prescribe a specific set of exercises for the patients to do each day.

c.teach patients to contract PFMs whenever they engage in activities that

precipitate leakage.

d.all of the above.

9.Which of the following statements is TRUE of caffeine reduction as a lifestyle modification for the treatment of incontinence?

a.Patients should be told to eliminate caffeine gradually.

b.Patients should be encouraged to try eliminating caffeine for a few days to see how it affects their bladder.

c.Patients should be encouraged to reduce caffeine gradually.

d.Patients should be advised to eliminate coffee only, as it the main source of caffeine.

Answers

1.c. Bladder training. Bladder training is an example of "patient-dependent" interventions: It relies on active patient participation. There must be adequate function, learning capability, and motivation of the individual. Bladder training involves patient education regarding lower urinary tract function, setting incremental voiding schedules, and teaching urge control techniques to help patients postpone voiding and adhere to the schedule.

2.e. b and d. A bladder diary provides information on the type and amount of fluid intake, type and frequency of symptoms such as incontinence episodes, frequency of urination, the urgency associated with each, and the circumstances or reasons for incontinence episodes, which helps the provider plan appropriate components of behavioral intervention. A bladder diary is also the best noninvasive tool available to objectively monitor the patient's voiding habits and the effect of treatment on symptoms guiding the use of various treatment components.

3.a. Pelvic floor muscle training is effective for treating stress, urge, or mixed incontinence in men and women of any age. Behavioral interventions are well established for treating stress and urgency urinary incontinence and overactive bladder. Because behavioral treatments are effective and essentially risk free, they are the mainstay of conservative treatment and are recommended by several guidelines and consensus panels as first-line therapy for both men and women of all ages.

4.c. Stay away from the bathroom until they feel the urge to void. Then stay still and wait until the urge has passed before going to the bathroom.

Patients are taught not to feel compelled to rush to the nearest bathroom when they feel the urge to void, believing that they are about to lose control. With behavioral training, they learn how this natural "gotta go" response is actually counterproductive, because it increases physical pressure on the bladder, increases the feeling of fullness, exacerbates urgency, and triggers detrusor contraction. Further, while the patient approaches the toilet, visual cues can trigger urgency and incontinence. To avoid this conditioned response, patients are taught not to rush to the bathroom when they feel the urge to void. Instead, they are advised to stay away from the bathroom, so as to avoid exposure to cues that trigger urgency. They are taught strategies to suppress urgency before walking to the toilet.

5.c. Squeezing the PFM while sitting still until the urgency goes away, then walking to the bathroom. Patients are taught not to rush to the bathroom when they feel the urge to void. Instead, they are advised to stay away from the bathroom, so as to avoid exposure to cues that trigger urgency. They are encouraged to pause, sit down if possible, relax the entire body, and contract PFMs repeatedly, without relaxing in between contractions, to diminish urgency, inhibit detrusor contraction, and prevent urine loss. They focus on inhibiting the urge sensation, giving it time to pass. Once the sensation subsides, they walk at a normal pace to the toilet.

6.a. Consume a normal amount of fluid to avoid dehydration as well as sudden urgency. Fluid intake modifications depend on the patients' pattern of intake, which can be assessed by asking each patient to complete a 24-to 48hour diary of intake and output, including voided volumes when possible. Reviewing such a diary can reveal excessive fluid intake, inadequate fluid intake, and diurnal patterns of intake that may be contributing to lower urinary tract symptoms. Although it may seem counterintuitive, it is usually good advice to encourage patients to consume at least six 8-ounce glasses of fluid each day to maintain adequate hydration. Fluid intake should be regulated to six to eight 8-ounce glasses or 30 mL/kg body weight per day with a 1500 mL/day minimum at designated times, unless contraindicated by a medical condition. The Institute of Medicine issued a report in 2004 with guidelines for total water intake for healthy people.

7.c. Keep a diary to see which foods or beverages increase urgency. A diary of food and beverage intake is useful for identifying which substances are in fact irritants for individual patients; a trial period of eliminating these substances one at a time can be used to confirm the relationship.

8.d. All of the above. It is important to verify that patients have identified and can contract the PFMs properly before initiating an exercise regimen. Specific exercise regimens vary considerably in frequency and intensity, and the ideal exercise regimen has not yet been determined.

However, good results have been achieved in several trials with the use of 45 to 60 paired contractions and relaxations per day. We use an "exercise prescription" to prescribe the daily exercise program. It is important to teach patients how to prevent urine loss in daily life by occluding the urethra by using active contraction of PFMs. Although exercise alone can improve urethral pressure and structural support and reduce incontinence, this motor skill enables patients to consciously occlude the urethra at specific times when urine loss is imminent. A careful history or examination of a bladder diary can alert the provider and patient of the circumstances during which each individual patient commonly experiences urine loss. Patients then learn to anticipate these activities and prevent leakage by contracting the PFMs to occlude the urethra prior to and during coughing, sneezing, lifting, or any other physical activities that have precipitated urine leakage.

9.b. Patients should be encouraged to try eliminating caffeine for a few days to see how it affects their bladder. Many patients are reluctant initially to forgo their caffeine-containing products, but they may be convinced to try it for a short period of time, such as 3 to 5 days, to determine whether they are sensitive to its effects. If they experience relief from their symptoms, they are often more willing to reduce or eliminate caffeine from their diet.

Chapter review

1.When conservative measures are used to treat voiding dysfunction, improvement is gradual.

2.Contracting certain abdominal muscles when performing pelvic floor muscle training can be counterproductive.

3.Well-timed contractions of the external urethral sphincter can abort a detrusor contraction, defer a contraction, and suppress the sensation of urgency.

4.Patients who retain fluid during the day may benefit from support stockings, daytime elevation of the legs, and selective late-afternoon use of a diuretic to reduce nighttime voiding.

5.Caffeine is a diuretic and bladder irritant.

6.Dietary bladder irritants include caffeine, sugar substitutes, citrus fruits,

highly spiced foods, and tomato products.

7.Constipation may play a significant role in voiding dysfunction.

8.Obesity is a risk factor for urinary incontinence.

9.A bladder diary is the best noninvasive tool available to objectively monitor the patient's voiding habits and the effect of treatment on symptoms guiding the use of various treatment components.

10.It is important to verify that patients have identified and can contract the pelvic floor muscles properly before initiating an exercise regimen.