Bladder training

Bladder Capacity, Voided Volume, and Emptying Efficiency

For young infants it can be expressed as follows (Holmdahl et al, 1996): Bladder capacity (mL)=38+ 2.5 Age (mo) For older children, the most widely accepted formula includes Koff's formula (Koff, 1983 ): Bladder capacity (mL)=[Age (yr)+ 2] 30 Or similarly, Hjalmas' formula (1988): Bladder capacity (mL)=30+ [Age (yr) 30]

Bladder Training/Timed Voiding The term scheduled voiding is the generic term preferred for describing voiding regimens used for homedwelling cognitively intact patients as opposed to prompted voiding or toileting, terms properly applied to institutionalized or otherwise dependent patients.

The most commonly used technique for patients with OAB and UUI is bladder training (bladder drill, bladder retraining). Bladder training starts a patient voiding on a fixed time interval schedule with the idea that, most of the time, the patient will urinate before experiencing urgency and incontinence. The interval is gradually increased with clinical improvement.

Early practitioners of bladder training first established the effectiveness of intensive inpatient bladder training temporarily supplemented by medications ( Frewen, 1978 ). Next, outpatient treatment was proven to be effective ( Elder and Stephenson, 1980 ; Frewen, 1980 ). Finally, the durability of response, with 85% initial and 48% three-year response rates was reported ( Table 63-2 ) ( Holmes et al, 1983 ).

Bladder training should always be combined with urge inhibition techniques and is often combined with anticholinergic medical therapy, particularly for more severe cases and for patients with neurogenic bladder. In contrast, timed voiding involves having a patient void on a fixed schedule, typically every 2 to 3 hours, and is intended to normalize frequency in a patient with infrequent voiding and/or diminished bladder sensation. This technique can be employed for patients with SUI with the idea that leakage will be less if the bladder is less full when physical stress occurs. It can also be used in a variety of patients with UUI who have a good bladder capacity (the classic example is that of patients with diabetic neurogenic bladder; they do not have proper bladder sensation and thus delay voiding inappropriately).

Bladder Training Bladder training (BT) requires patients to resist the sensation of urgency, to postpone voiding, and to urinate by the clock rather than in response to an urge. Mechanisms of action are not well understood, but it is felt that bladder retraining improves cortical inhibition over detrusor contractions, facilitates cortical ability over urethral closure during bladder filling, strengthens pelvic striated muscles, and alters behaviors that affect continence (e.g., frequent response to urgency).

The goals of a BT program are to: Improve bladder overactivity by controlling urgency and decreasing frequency Increase bladder capacity Reduce urge incontinence episodes

Jeffcoate and Francis originally introduced bladder training that was called bladder drill by implementing the program in hospitalized patients with bladder dysfunction secondary to psychological disorders. At that time, it was prescribed for functional disorders of the bladder for which surgical intervention was not expected to be successful.

The management regimen included education followed by a strict schedule of voluntary voiding with specific instructions to avoid responding prematurely to urinary urgency. This type of bladder training was the basis of a randomized controlled clinical trial of 123 women with detrusor instability, stress, and mixed UI. Results on the group taught BT reduced number of incontinent episodes by 57% and quantity of urine loss was reduced by 54% (61).

In addition, BT significantly improved the quality of life, specifically in the ability to carry out activities and relationships, to tolerate and control symptoms and in improved ability to cope. In the behavioral intervention research that focuses on persons with urge or mixed incontinence, BT is an integral component. The Cochrane database includes a systematic review of bladder training.

BT is most appropriate for patients who have: Stress, urge, or mixed incontinence Cognition; are mentally intact Ability to sense the urinary urge sensation Comprehension; can read and follow instructions Motivation; willing to comply with a structured education program

Prior to beginning a BT program, the patient should be educated about the lower urinary tract, causes of urinary incontinence, and concepts of bladder urgency using easy-tounderstand visual aids such as the urinary urge (see Patient Guide #3). Education should include the fact that continence is a learned behavior and the importance of the brains control over lower urinary tract function. The clinician initiates the program by assigning a voluntary voiding schedule, which includes voiding every 3060 min (64).

The voiding intervals are based on the baseline micturition frequency as determined by the bladder diary. The initiation of BT with very short voiding intervals is particularly important for patients who are experiencing urgency, as the shorter intervals will decrease or eliminate these symptoms. The goal is for the patient to void before the urge sensation of bladder fullness. Depending on the patients ability to keep the schedule and/or evidence of reduction of incontinence episodes and/or urinary urgency and frequency, the scheduled intervals between voiding is increased by 30 min until the patient can achieve a goal of voiding every 34 hr.

In many cases, patients find this schedule difficult. Therefore the patient should be told to adhere to this schedule at least 75% of the day, and it is not realistic to expect patients to maintain this voiding schedule during the night. The use of reminders such as a kitchen timer or stop watch can be beneficial to helping the patient keep on a schedule (66). Selfmonitoring through the use of bladder diaries is used to evaluate adherence and to determine the next weekly voiding interval. Another essential part of BT patient education focuses on the cortical ability to delay Voiding and strategies for distraction.

Concentration on an attentional task is useful in distracting the individual from the sensation of urgency (65). The patient is taught methods to resist or inhibit the urge sensation so that an expanded voiding interval can be adopted. Improving the ability to suppress the urge sensation and eventually diminish urgency will enable the patient tonadopt a more normal voiding pattern. There are several bladder control strategies or techniques used to inhibit the urge sensation (67). They include: Slow, deep breathing to consciously relax the bladder to combat a stressful rush to the toilet Performing five or six rapid, deliberate, and intense pelvic muscle contractions, or quick flicks which are 23 sec in duration

As with most behavioral interventions, the relationship between the clinician and patient is very important to the success of there training.The clinician must monitor the patients progress And provide praise and encouragement where appropriate. The use of a signed patient agreement or contract with the patient stating personal outcome goals can be helpful in motivating the patient to adhere to the program and outlines expectations. It has been shown that women with incontinence have diverse goals for incontinence treatment, which in some cases may be improvement in urine leakage and not continence (68).

It is felt by most experts that combining behavioral interventions with treatments such as drug therapy would increase symptom reduction. Mattiasson et al.(69) reported on a multicenter, single-blind Scandinavian study of 505 subjects, predominantly women (mean age 63) with symptoms of OAB with and without urge incontinence that were either treated with tolterodine 2 mg BID or tolterodine 2 mg BID and bladder retraining (BT).
Subjects in the BT group were provided with a written information sheet that outlined the principles of BT and explained simple techniques that could be used to help improve bladder control.

Both groups received bladder diaries to track outcomes. Seventy-eight percent of subjects completed 24 weeks of treatment. The median percent reduction of voiding frequency for those receiving drug Therapy plus BT was 33% compared with 25% reduction in those subjects on drug therapy alone. There was no significant difference between the groups in relation to reduction in incontinence episodes or urgency. The authorsterm this approach as aminimalistapproach,as there was no physician or other professional. They feel this negates the need for an extensive personal interaction between the patient and clinician; however,this is the only study that has shown this technique. Other such programs have not been successful (70).

Patient Guide #3: Bladder RetrainingControlling Urgency and Frequency

Frequency is voiding often,usually eight times or more in a 24-h period. Frequency can worsen if you get into the habit of voiding just in case, which means that the bladder never fills completely and holds only a small amount of urine. It is better to wait until the bladder is full. Urgency is a sudden need to void immediately that can cause urine leakage on the way to the bathroom. Urgency follows a wave pattern; it starts, grows, peaks and then subsides until it stops.

The key to controlling the urinary urge is not to respond by rushing to the bathroom. Rushing causes movement, which jiggles your bladder, which in turn increases the feeling of urge.

Controlling the urge The goal is for you to be voiding no more than every___hours .If you get the urge to void and it Is not yet your scheduled voiding time, stop all activity and sit down if possible. Then try one or more of the following techniques that may help the urge to subside allowing the bladder to relax and give you more time to get to the bathroom: Take some slow, deep breaths through your mouth, concentrating on your breathing, or Tighten your pelvic muscle quickly and hard several times in a row. Use mental distraction strategies such as concentrating on an activity, such as counting backward from 100 by sevens, or reciting the words of a favorite song or nursery rhyme.