CONTINENCE

REVIEW
Behaviour change to treat overactive bladder syndrome
17 NOVEMBER, 2011

Nurses are ideally placed to offer patients who have overactive bladder syndrome behavio
treatments to help manage the problem and improve their quality of life

Abstract

Overactive bladder syndrome has a negative impact on quality of life. This article discuss
definition of the condition and its the prevalence and aetiology, as well as some of the m
common behavioural therapies. Although there is a good evidence base for bladder retra
there is often conflicting research to support other interventions including caffeine redu
the amount and types of fluid recommended, smoking cessation and weight reduction. A
standardised approach from a national level is needed; nurses also need to demonstrate
robustly the effectiveness of their interventions.

Citation: Patterson A (2011) Behaviour change to treat overactive bladder syndrome. Nur

Times [online]; 107: 46, 16,18-19.

Author: Angela Patterson is lead clinical nurse specialist in bladder and bowel dysfunctio
Continence Service, Bangor Community Hospital, Bangor, Northern Ireland.

This article has been double-blind peer reviewed

Scroll down to read the article or download a print-friendly PDF including any tables and figures

Introduction

Overactive bladder (OAB) syndrome is a symptom complex characterised by urinary urgen

without urgency-associated urinary incontinence. Urinary urgency is defined as a sudden
We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to
learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can
compelling desire
be found in the cookie to
policy. By pass
using our site, urine
you agree tothat iscookies.
our use of difficult to defer, and should be differentiated from
Accept
strong desire to void that occurs in situations when a healthy person has to refrain from m
(Abrams et al, 2003). OAB is often associated with urinary frequency (voiding frequently d
day) and nocturia (voiding once or more overnight) in the absence of pathologic or metabo
conditions that may cause or mimic OAB. Examples of such conditions include:

Urinary tract infections;

Polyuria;
Transitional cell carcinoma of the bladder;
Underlying neurological abnormalities (Ellsworth, 2008);
Cystitis;
Bladder calculus;
Prostate cancer (Yamaguchi et al, 2009).

Prevalence and aetiology

Studies have found broadly similar prevalence rates for OAB, which are higher than those
common long-term conditions such as diabetes (8%) and asthma (4.5%) (Ong et al, 2008
NOBLE study found 17% of women and 16% of men had the condition in a US population
et al, 2003), while Milsom (2001) found similar rates, adding that men tend to develop OA
life than women and that women were more likely to develop urge incontinence than men
prevalence rates for OAB are 11% in men and 13% in women from a sample population in E
and Canada (Coyne et al, 2008).

OAB has a detrimental effect on quality of life including professional, social and recreatio
activities; sexual health and function; and relationships with family members (Stewart et
Liberman et al, 2001; Abrams et al, 2000). The condition with or without urinary incontine
also associated with increased comorbidities including depression, urinary tract infection,
infections, falls and fractures, and vulvovaginitis (Wyman et al, 2009), as well as increase
mortality and institutionalisation in older people (Nuotio et al, 2003).

The causes of OAB can be multifactorial in both aetiology and pathophysiology (Ellsworth
The complete aetiology is not fully understood; the same applies to the relationship betw
the potential contributory or causative factors. More research is needed to fully understan
mechanisms of this complex syndrome, which would help to guide new treatment approa
ForWepractitioners, this uncertainty has several implications: the treatment of OAB can be c
use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to
learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can
andbemultifaceted,
found in the cookie policy. Byand as
using our site,it
youis not
agree to ourfully understood there may not be a wealth of empirical
use of cookies.

Accept
to support current treatments. It may be prudent to question some of our interventions, a
patients must be treated holistically.

Treatment

Proposed guidelines from the European Association of Urology (Thuroff et al, 2011), Yama
(2009), NICE (2006) and the Scottish Intercollegiate Guidelines Network (2004) all recomm
that, as long as all organic reasons for OAB symptoms have been excluded, first-line treat
should involve conservative therapies including:

Behavioural interventions;
Lifestyle changes;
Use of antimuscarinics.

Behavioural interventions for the treatment of OAB aim to change patient lifestyle and be
and teach techniques to suppress urgency and improve continence skills. They can be clas
two main categories:

Habit modification to promote bladder health and alleviate bladder symptoms;

Training techniques that aim to teach skills to control the symptoms of bladder dysfunction (Wyman et al, 2009).

It is important to recognise that there is no definitive cure for OAB; the mainstay of treatm
improve quality of life and minimise symptoms.

Bladder retraining

The usefulness of bladder retraining programmes, with or without the use of pelvic floor m
exercises as a suppression technique, is well supported in the literature as a successful an
treatment for patients with OAB (Burgio, 2004; Mattiasson et al, 2003). Some studies hav
bladder retraining to resolve 12-73% of urge incontinence, with improvement rates cited f
87% (Wyman, 2005). Burgio (2004) argued that bladder retraining is as effective as drug t
The purpose of bladder retraining is to try to extend intervals between each void incremen
eventually re-establish a normal voiding pattern and bladder capacity, and to suppress ur
However, to be successful patients must be motivated to adhere to the programme and f
understand its principles.

Bladder retraining
We use cookies may
to personalize and not
improve be suitable
your experience for
on our site. Visit our those with
Privacy Policy learning
and Cookie Policy to difficulties or cognitive imp
learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can
be found in the cookie policy. By using our site, you agree to our use of cookies.

Accept
patients who are unable to toilet themselves independently, or those with non-compliant
following pelvic radiation. To ensure success, it is essential that:

Patients are assessed appropriately;

Organic causes for symptoms are excluded;
Clinicians and patients are willing to invest the necessary time;
Adequate support and encouragement are given to ensure concordance.

Behaviour change

Although there is evidence to support the efficacy and safety of bladder retraining, it is po
understood and there is a lack of consensus over other interventions such as:

Types of fluid recommended;

Fluid manipulation;
Reducing caffeine;
Smoking cessation;
Weight loss.

Weight and smoking. Weight loss and smoking cessation as treatment approaches for OA
relatively recent developments. However, the evidence base to support either of these is l
and contradictory. While Milne (2008) and Dallosso et al (2003) suggested weight loss an
cessation do improve continence, Hashim and Munsa (2009) argued that the evidence ba
It is my opinion that weight loss and smoking cessation should be encouraged, not only to
continence, but also for the other potential health benefits. It is also logical to assume th
loss will reduce abdominal pressure and pelvic floor strain, and that smoking may contrib
chronic cough, which is a recognised risk factor in developing incontinence.

Caffeine. Caffeine is considered the most commonly used psychoactive drug in the world
present in tea, coffee, carbonated drinks, energy drinks, chocolate and many non-prescrip
analgesics. It is suggested that caffeine consumption can adversely affect continence by
diuresis, cause early and increased urgency and frequency of micturition, worsen nocturna
symptoms (Bryant et al, 2000), cause an increase in detrusor pressure, and increase detru
excitability (Lohsiriwat et al, 2011). These findings are claimed to have been reported afte
of caffeine on urodynamic testing in adults and replicated in animal models including rab
We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to

rats.

learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can
be found in the cookie policy. By using our site, you agree to our use of cookies.

However,
Accept other empirical studies do not always support this finding. NICE (2006) found co
reports on the effects of caffeine on the bladder and its impact on incontinence: some stu
reported no difference in symptoms following reduced caffeine intake, some showed no s
difference, and some showed improvement after caffeine reduction. Other studies sugges
artificial sweeteners, high sugar levels, chemicals, and acidity of the fluid consumed rathe
presence of caffeine may irritate the bladder (Dasgupta et al, 2006).

It is also interesting to note that neither NICE (2006) nor the European Association of Uro
(Thuroff et al, 2011) specifically mentioned caffeine reduction in their guidance. SIGN (200
suggested that, although larger cross-sectional studies of caffeine reduction showed no a
with increased incontinence, smaller clinical trials did suggest that caffeine restriction im
continence.

In my experience, caffeine moderation has proved beneficial in the clinical setting in impr
incontinence and frequency and, when replaced by water-based fluid, has had a positive e
constipation, acidity and concentration of urine, and increasing intervals between voids a
capacity. This improvement could be attributed to having a diluting effect on urine concen
thereby causing less irritation. However, it is difficult to find empirical research to support
and study results are conflicting. NICE (2006) found there was either no improvement in s
or a significant increase in symptoms of urgency following an increase in bland fluid intak
water and diluted juice, while Griffiths et al (1993) and Beetz (2003) found significant
improvements in urinary urgency and reduction in urinary tract infection rates.

The confusion over how to approach caffeine intake is further compounded by commercia
on packages of tea that claim it is as hydrating as water, or beverages that claim to be caf
and are then wrongly promoted by health professionals as a suitable alternative (Addison
may be more useful to approach caffeine reduction in terms of low, moderate and high in
suggest that patients who have moderate or high levels try to consume less and reduce th
slowly to prevent the occurrence of withdrawal symptoms (Addison, 2000).

Another controversial area is the amount of fluid that should be consumed. It is often
recommended that adults have 6-8 cups or glasses of fluid per day; however, this advice c
to wide variations in the amount of fluid consumed, simply depending on the size of glas
We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to
used. An You
learn more. effort toof some
can opt out standardise
cookies by adjustingthe amount
your browser ofinformation
settings. More fluidonconsumed
how to do this can was hypothesised by the flu
be found in the cookie policy. By using our site, you agree to our use of cookies.

(Abrams
Accept and Klevmark, 1996), which proposed that fluid consumption should be based on
patient’s weight. This advice could be dangerous and must be interpreted on an individua
taking account of any comorbidities such as heart failure and renal impairment. Also inte
note is that there is no advice within this matrix for patients who weigh more than 100kg
stone).

Guidance needed

There is a real need for a consensus of opinion to be collated and standardised at a nation
health professionals can give clear, correct and appropriate advice to patients. It is unprof
to expect patients to adhere to advice that is conflicting and not evidence based. Patient
and understanding is paramount to the success of behavioural programmes (Wyman et a
so all health professionals should provide the same advice, where possible, based on an e
base or clinical judgement based on outcome measures.

Conclusion

Behavioural interventions aim to improve quality of life of patients with OAB and empow
control their symptoms on a long-term basis; both patients and clinicians need to invest t
successful in this.

Practitioners must assess patients individually; where it is appropriate to recommend som

interventions that are not well supported in the literature, such as caffeine reduction, the
be guided by their own clinical judgement and previous clinical outcomes. They should als
time to explain to patients the rationale behind the suggested intervention, but ultimate
reassured that these interventions will not cause harm.

While nurses are best placed to provide behavioural therapies for patients with OAB, they
demonstrate the positive impact these therapies have more robustly through outcome m
quality indicators and further research, which could lead to a standardised and unified ap
a common and distressing condition. 

Key points

Overactive bladder (OAB)syndrome is characterised by urinary urgency but not necessarily urgency-associated urinary incont
The prevalence of OAB is higher than other common long-term conditions such as diabetes
We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to

The
learn condition
more. You can opthas a some
out of detrimental effect your
cookies by adjusting on individuals’
browser settings.quality of lifeon how to do this can
More information
be found in the cookie policy. By using our site, you agree to our use of cookies.
The complete aetiology of OAB is not fully understood
Accept
 Management of OAB can be complex and multifaceted

Abrams P et al (2003) The standardisation of terminology in lower urinary tract function:

from the standardisation sub-committee of the International Continence Society. Urology
49.

Abrams P et al (2000) Overactive bladder significantly affects quality of life. American Jou
Managed Care; 6, 580-590.

Abrams P, Klevmark M (1996) Frequency and volume charts: an indispensible part of lowe
tract assessment. Scandinavian Journal of Urology and Nephrology; 179: 45-53.

Addison R (2000) How coffee and caffeine affect continence. Nursing Times; 96: 40, 7-8.

Beetz R (2003) Mild dehydration: a risk factor of urinary tract infection? European Journal
Nutrition; 57: 52-58.

Bryant CM et al (2000) A randomised trial of the effects of caffeine upon frequency, urgen
urge incontinence. Neurourology and Urodynamics; 19: 501-502.

Burgio KL (2004) Behavioural treatment options for urinary incontinence. Gastroenterolog

82-89.

Coyne KS et al (2008) The impact of the overactive bladder, incontinence and other lower
tract symptoms on quality of life, work productivity, sexuality and emotional well being in
women: results from the EPIC study. British Journal of Urology International; 101: 1388-139
Dallosso HM et al (2003) The association of diet and other lifestyle factors with overactive
and stress incontinence: a longitudinal study in women. British Journal of Urology Interna
67-69.

Dasgupta J et al (2006) Enhancement of rat contraction by artificial sweeteners via increa

extracellular calcium influx. Toxicology Applied Pharmacology; 217: 216-224.

Ellsworth PI (2008) Overactive Bladder - Etiology, Diagnosis, and Impact. Medscape.

Griffiths DJ et al (1993) Relationship of fluid intake to voluntary micturition and urinary

incontinence in geriatric patients. Neurourology and Urodynamics; 12: 1-7.

Hashim H, Al Munsa R (2009) Management of fluid intake in patients with overactive bla
Current Urology
We use cookies Reports
to personalize and improve;your
10: 6, 428-433.

experience on our site. Visit our Privacy Policy and Cookie Policy to
learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can

Liberman JN et al (2001) Health-related quality of life among adults with symptoms of ov

be found in the cookie policy. By using our site, you agree to our use of cookies.

Accept
bladder: results from a US community-based survey. Urology; 57: 1044-1050.

Lohsiriwat S et al (2011) Effect of caffeine on bladder function in patients with overactive

symptoms. Urology Annals; 3: 1, 14-16.

Mattiasson A et al (2003) Simplified bladder training augments the effectiveness of tolte

patients with an overactive bladder. British Journal of Urology International; 91: 54-60.

Milne JL (2008) Behavioural therapies for overactive bladder: making sense of the evidenc
of Wound, Ostomy and Continence Nursing; 35: 1, 93-101.

Milsom I (2001) How widespread are the symptoms of an overactive bladder and how are
managed? A population-based prevalence study. British Journal of Urology International;
766.

NICE (2006) Urinary Incontinence - The Management of Urinary Incontinence in Women. L

NICE.

Nuotio M et al (2003) Predictors of institutionalisation in an older population: ten-year ch

their association with mortality. Journal of Gerontological and Biological Science; 58: 756-7
Ong KL et al (2008) Prevalence, treatment and control of diagnosed diabetes in the US. N
Health Nutrition Survey 1999 - 2004. Annals of Epidemiology; 18: 222-229.

Scottish Intercollegiate Guidelines Network (2004) Management of Urinary Incontinence

Care: A National Clinical Guideline. Edinburgh: SIGN.

Stewart WF et al (2003) Prevalence and burden of overactive bladder in the United States
study). World Journal of Urology; 20: 327-336.

Thuroff JW et al (2011) European guidelines on urinary incontinence. Actas Urológicas Esp

35: 7, 373-388.

Wyman JF (2005) Behavioral interventions for the patient with overactive bladder. Journal
Wound, Ostomy and Continence Nursing; 32: 11-15.

Wyman JF et al (2009) Practical aspects of lifestyle modifications and behavioural interve

the treatment of overactive bladder and urgency urinary incontinence. International Journ
Clinical Practice; 63: 8, 1177-1191.

Yamaguchi O et al (2009) Clinical guidelines for overactive bladder. The Japanese Urologica
We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to
International Journal
learn more. You can opt of Urology
out of some cookies ; 16:
by adjusting your 126-142.
browser settings. More information on how to do this can
be found in the cookie policy. By using our site, you agree to our use of cookies.

Accept
 Related files
Behaviour change to treat overactive bladder syndrome
PDF, SIZE 16.00 KB

EMAP Publishing Limited Company number 7880758 (England & Wales) Registered address: 7th Floor, Vantage London, Great West Road, Brentford, United Kingdom, TW8 9AG

We use cookies to personalize and improve your experience on our site. Visit our Privacy Policy and Cookie Policy to
learn more. You can opt out of some cookies by adjusting your browser settings. More information on how to do this can
be found in the cookie policy. By using our site, you agree to our use of cookies.

Accept