BEHAVIORAL THERAPY FOR OVERACTIVE BLADDER

CHRISTOPHER K. PAYNE

ABSTRACT
What is behavioral therapy? On the one hand there is no consensus in the literature as to the definition of
the treatment or the optimal mode of delivery. On the other hand, it is possibly the “best” single treatment
for urinary incontinence when viewed from a risk:benefit analysis. There is general agreement that within this
framework wide variations exist in intensity of treatment, expertise required to deliver the treatment, and
the subsequent cost of therapy. A definition of behavioral therapy should include at least the following
techniques: first, education and explanation of normal lower urinary tract function; second, micturition
charts and diaries; and finally, timed voiding/bladder training regimens. All of the behavioral methods are
demonstrably effective, with improvement rates in incontinence episodes uniformly in excess of 50%. Our
challenge is to define the critical parts of behavioral therapy and develop algorithms that can be delivered
to the incontinent population in the most cost-effective manner. UROLOGY 55 (Suppl 5A): 3–6, 2000.
© 2000, Elsevier Science Inc.

B ehavioral therapy describes a group of treat-

ments that are based on the idea that the incon-
tinent patient can be educated about the condition
and develop strategies to minimize or eliminate the
incontinence. It is sometimes erroneously reduced
to the combination of fluid restriction and timed
voiding, but actually is a far richer therapy. In fact,
one of the main problems with the term “behavior-
al therapy” is that it has been used so differently by
various practitioners that its meaning has become
diluted and vague. There is no single standard pro-
tocol or “best” methodology. This review summa-
rizes three very different approaches to behavioral
therapy, identifies their common elements, and ex-
plores some of the unanswered questions regard-
ing optimal implementation of this treatment.
DEVELOPMENT OF BEHAVIORAL THERAPY
The development of behavioral therapy is usu-
ally credited to the British gynecologist William K.
Frewen, but contributions were made by a number
of other investigators. The initial description of the
treatment included written educational materials,
strict application of progressive timed voiding
(bladder drill) and bladder diaries, plus short-term
From the Center for Female Urology and NeuroUrology, Stan-
ford University Medical Center, Stanford, California
Reprint requests: Christopher K. Payne, M.D., Assistant Pro-
fessor of Urology, Director, Center for Female Urology and Neur-
oUrology, Stanford University Medical Center, 300 Pasteur
Drive, S-287 Stanford, CA 94305-5118
anticholinergic use and oral sedatives.1 This inten-
sive therapy was delivered in an inpatient setting
for 1 to 2 weeks. Forty consecutive patients with
urge incontinence and detrusor instability were
treated, with a cure (symptomatic and urody-
namic) rate of 82.5%. Emphasis was placed on
teaching the patients about the etiology of their
disorder; failures were attributed to overwhelming
psychosocial stressors. Frewen2 later proposed
that patients who had a condition of urge inconti-
nence and frequency but no or minimal inconti-
nence could be treated as outpatients. The author
noted that patients with stable bladders responded
better than those with instability, and that medica-
tions were not required for all patients.2 Similar
results were obtained by Elder and Stephenson us-
ing the same technique.3
At about the same time, two other investigations
studied the role of drug therapy in this program.
Bladder drill alone outperformed treatment with a
combination of flavoxate and imipramine.4 Outpa-
tient bladder training without drugs was shown to
be effective, but less so than in the studies cited
above.5 Finally, the durability of behavioral ther-
apy was established by Holmes et al.,6 who re-
ported initial response rates of 85% and 3-year re-
sponse rates of 48% (Table I). It should be noted
that once bladder control was obtained, medica-
tions were discontinued (typically after 3 months)
with the idea that the bladder had been “retrained.”
Results were better in patients with urodynami-

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 TABLE I. Initial and long-term results of inpatient behavioral
therapy
Patient Group
Cystometrogram negative
Reduced compliance
Idiopathic instability
Neurogenic
Data from Holmes et al.6
TABLE II. Behavioral therapy reduces episodes of incontinence
by >50% for both stress incontinence and detrusor instability
Incontinence Type n Treated/Control
Stress incontinence 88
Detrusor instability ⫾ 35
stress incontinence
Detrusor instability 14
Detrusor instability ⫹ 20
stress incontinence
Data from Fantl et al.7
cally stable than unstable bladders, but long-term
relapse-free rates of ⬎50% were demonstrated in
all patients except those with neurogenic disor-
ders.
OPERANT LEARNING
Jean Wyman and Andy Fantl headed the most
widely quoted modern study of behavioral thera-
py.7 Their technique has been well described8; it
focuses on patient education to regain cortical con-
trol of micturition. Patients are given written, oral,
and audiovisual instructions. The basis of this
technique is “operant learning,” in which the sub-
ject sets a behavioral goal and repeatedly tries to
approximate the goal with his or her own behavior.
Bladder training through progressive timed void-
ing was still an integral part of the therapy, but the
philosophy was not as strict as in the British stud-
ies. Patients were allowed to void before the set
goal if they did not think that they could make the
full interval. Drug therapy was not employed. Sim-
ple Kegel exercises were employed as one method
for urge inhibition. In a large, prospective study of
community-dwelling women over age 55, a 57%
decrease in the number of incontinent episodes
and 54% decrease in urine loss was reported. This
result was achieved with only six weekly, half-hour
visits after the initial assessment and training visit.
Interestingly, outcomes were similar among those
patients with urge incontinence and those with
stress incontinence (Table II).
4 UROLOGY 55 (Supplement 5A), May 2000
Cure/Improve Relapse
15/16 (94%) 1 (6%)
19/21 (90%) 8 (42%)
9/10 (90%) 4 (44%)
3/6 (50%) 3 (100%)
Number of Incontinence
Episodes per Week
Baseline 6-Week Response
Treated/Control
23/22 10/19
16/24 6/19
11/20 5/18
20/29 7/20
BEHAVIORAL THERAPY VERSUS
PHARMACOTHERAPY
Work from the group led by Kathryn Burgio9
illustrates yet another approach to behavioral ther-
apy. While using some of the same educational
techniques discussed above, their focus is strongly
oriented toward using the pelvic floor muscles to
inhibit the overactive bladder. Anorectal biofeed-
back is routinely used to teach pelvic floor exer-
cises, and more sophisticated bladder-sphincter
biofeedback is used if patients do not respond to
the initial therapy. Burgio et al. compared their
version of behavioral therapy with anticholinergic
medication (oxybutynin chloride in titrated doses)
in a group of patients with urge and mixed incon-
tinence.9 In this prospective, randomized study,
patients receiving four sessions of behavioral ther-
apy over 8 weeks reported an 80.7% reduction in
the number of incontinence episodes compared
with 68.5% in the drug group and 39.4% in the
placebo group (P ⫽ 0.04, behavioral versus drug
therapy). Patient-perceived improvement was
74.1% in the behavioral group, compared with
50.9% and 26.9% in the drug and placebo groups,
respectively. At the conclusion of therapy, only
14% of the behavioral group wished to change to
another treatment compared with 75% of patients
in both of the other groups (Table III).
This study is consistent with the other good re-
sults reported with behavioral therapy and with the
high patient satisfaction reported with conserva-
 TABLE III. Behavioral therapy is superior to oxybutynin for
patients with urge and mixed incontinence
Reduction in
Incontinence
Group Episodes
Behavioral 80.7%
Oxybutynin 68.5%
Placebo 39.4%
Data from Burgio et al.9
tive therapy in general. However, several issues
need to be reviewed. First, this study grouped pa-
tients with pure urge incontinence with those hav-
ing mixed incontinence. While it would certainly
be reasonable to offer either therapy to these two
groups of patients,7 there is no reason to expect
that anticholinergics would be beneficial for the
stress incontinence component, biasing the study
in favor of behavioral therapy. Thus, the study
probably should have been limited to patients with
pure urge incontinence or the results stratified by
diagnosis. Second, although each treatment ses-
sion was administered by a nurse practitioner and
efforts were made to make visits as similar as pos-
sible, all behavioral therapy subjects had sophisti-
cated biofeedback training and 25% of subjects had
two sessions. This substantially changes the nature
of the treatment beyond what many would con-
sider behavioral therapy. Finally, drug therapy
should always be administered with instructions
for timed voiding as no anticholinergic seems to be
able to improve the patients’ “warning time.”
PATIENT EDUCATION
All investigators share some basic concepts as to
what constitutes behavioral therapy, as illustrated
in Figure 1. Education is always central. Behavioral
FIGURE 1. Common elements of behavioral therapy
among different investigators. Education must be the
central focus.
UROLOGY 55 (Supplement 5A), May 2000
Perceived Want to
Improvement Change
74% 14%
50.9% 75%
26.9% 75%
therapy must start with instructions about normal
lower urinary tract anatomy and function. The pa-
tient needs to understand the role of the bladder
and the pelvic floor muscles. A voiding diary is
used to teach the patient about his or her own
function. The diary becomes the basis for evalua-
tion and goal-setting, aiming for the patient to be-
come continent with a reasonable voiding interval.
Each group uses some form of bladder training/
timed voiding and differences are in the relative
emphasis. In each case, repeated evaluations are
made in which the patient’s performance is com-
pared with their goals and new goals are set, pro-
viding positive reinforcement. Patients are taught
some form of urge inhibition, and the goal of di-
vorcing the sensation of urgency from normal
voiding is emphasized. On the other hand, there is
no unanimity on fluid and dietary management,
though the voiding diary will clearly identify the
subset of patients with extreme fluid intake. There
is no agreement on use of pelvic floor therapy,
though it seems that Kegel exercises are at least
mentioned as part of explaining the normal anat-
omy and role of the pelvic muscles. Recent work
has clearly separated pharmacologic treatment
from behavioral therapy, whereas the two were
routinely combined in earlier studies.
CONCLUSIONS
Behavioral therapy should be the initial treat-
ment for the vast majority of patients with overac-
tive bladder, with or without associated stress in-
continence. When a patient with overactive
bladder suffers from urge incontinence there is not
only a bladder problem but usually also a problem
with the pelvic floor or a functional problem (Fig.
2). Behavioral therapy is the only treatment that
can address each of these areas of deficit (Fig. 3).
The data presented above convincingly demon-
strate the effectiveness of behavioral therapy,
which is the kind of treatment that many patients
want. In the fifth National Association for Conti-
nence survey of 130,000 members, 50% of patients
ranked conservative therapies in general and 25%
pelvic floor muscle exercises specifically as “most
5

FIGURE 2. The clinical manifestation of urge inconti-
nence results from an overactive bladder plus a weak
pelvic floor that cannot oppose the abnormal contrac-
tion. In addition, functional and behavioral factors may
aggravate the problem.
FIGURE 3. Behavioral therapy attacks urge inconti-
nence in a variety of ways. Patients are taught urge
inhibition strategies that can reduce the overactive
bladder, and dietary strategies such as elimination of
caffeine and other bladder irritants. Timed voiding and
fluid management may overcome functional limitations.
Instructions about normal pelvic floor function and Ke-
gel exercises may allow the patient to prevent inconti-
nence when an unstable contraction does occur.
helpful.”10 Despite this, behavioral approaches are
misunderstood and poorly used for a variety of rea-
sons. As practitioners, we have a great opportunity
to define this treatment and its application. There
6 UROLOGY 55 (Supplement 5A), May 2000
are a number of questions that remain to be an-
swered about behavioral therapy. Future research
protocols should address the following issues:
● Should behavioral therapy be the first-line
treatment for all patients with overactive blad-
der? For mixed incontinence? For stress in-
continence?
● Should anticholinergic therapy be started with
behavioral therapy? If so, how do we identify
the patients who can discontinue medication?
● How can the educational techniques of behav-
ioral therapy be most efficiently communi-
cated to the large population of incontinent
patients?
● Can early intervention with behavioral ther-
apy prevent incontinence? If so, how can we
identify and reach “at risk” patients?
● Which patients require sophisticated pelvic
floor rehabilitation techniques? Can these be
identified on initial screening? Is it easier to
simply use these techniques with patients who
fail to respond adequately to behavioral ther-
apy?
In the meantime, every effort should be made to
provide at least the basics of behavioral therapy in
an efficient, streamlined fashion to all patients with
overactive bladder.
REFERENCES
1. Frewen WK: An objective assessment of the unstable
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2. Frewen WK: The management of urgency and fre-
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3. Elder DD, and Stephenson TP: An assessment of the
Frewen regime in the treatment of detrusor dysfunction in
females. Br J Urol 52: 467– 471, 1980.
4. Jarvis GJ: A controlled trial of bladder drill and drug
therapy in the management of detrusor instability. Br J Urol
55: 565–566, 1981.
5. Pengelly AW, and Booth CM: A prospective trial of
bladder training as treatment for detrusor instability. Br J Urol
52: 463– 466, 1980.
6. Holmes DM, Stone AR, and Barry PR: Bladder training 3
years on. Br J Urol 55: 660 – 664, 1983.
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der training in older women with urinary incontinence. JAMA
265: 609 – 613, 1991.
8. Wyman JF, and Fantl JA: Bladder training in ambula-
tory care management of urinary incontinence. Urol Nursing,
September: 11–17, 1991.
9. Burgio KL, Locher JL, Goode PS, et al: Behavioural vs
drug treatment for urge urinary incontinence in older women:
a randomized control trial. JAMA 280: 1995–2000, 1998.
10. National Association for Continence, Consumer Focus
1999, Spartanburg, SC, USA.