Chapter 19 BEHAVIORAL MODIFICATION AND CONSERVATIVE MANAGEMENT OF OVERACTIVE BLADDER

Millions of people throughout the world are affected by overactive bladder (OAB) syndrome, a serious condition that can have dramatic personal and social costs. Symptoms of OAB increase with age and are slightly more common in women. The median prevalence of incontinence in women has been reported as varying from 14% to 40.5%; using the definition of the International Continence Society (ICS), it is 23.5%. In women, urge and mixed incontinence accounted for a median relative share of 51% of cases.

These estimates have varied based on the differing methodologies of the studies and the previously uncertain definition of OAB. OAB is characterized by the ICS as a syndrome encompassing urgency (with or without urge incontinence), usually with frequency and nocturia.¹ OAB syndrome is a well-recognized complex of symptoms that is usually suggestive of detrusor overactivity but can also be caused by urethrovesical dysfunction of another type.

According to the ICS,¹ urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as OAB syndrome, urge syndrome, or urgency-frequency syndrome. Lower urinary tract symptoms are the subjective indicator of a disease or change in condition as perceived by the patient, caregiver, or partner. In this context, urgency is the complaint of a sudden compelling desire to pass urine that is difficult to defer, increased daytime frequency is the complaint of voiding more than to seven times a day, and nocturia is the complaint of awakening one or more times at night to void. Urge incontinence is characterized by a strong desire to void coupled with an involuntary loss of urine.² OAB patients are likely to require long-term or even lifelong therapy to control their symptoms. Patients with OAB symptoms are at elevated risk for other conditions that increase their use of health care resources. Common patient reactions to OAB symptoms and incontinence are embarrassment, frustration, anxiety, depression, and fear of odor from urine leakage.²

Nonpharmacologic approaches include education and explanation of normal lower urinary tract structure and function, lifestyle changes, toileting programs, bladder retraining, and pelvic muscle training or rehabilitation. Behavior modification, which involves learning new skills and strategies for preventing urine loss and other symptoms, has a growing body of clinical research.

LIFESTYLE INTERVENTIONS

Behavior modification is a treatment option for persons with urinary incontinence (UI) and OAB. Changing a patient’s behavior, environment, or lifestyle can mitigate or reduce symptoms (urine leakage or incontinence, urgency, frequency, and nocturia).

The interventions include lifestyle changes: cessation of smoking, weight reduction, elimination of dietary bladder irritants, adequate fluid intake, bowel regulation, moderation of physical activities, and exercises. Lifestyle changes and behavior modification are integral to clinical management of UI and OAB. In the United States, therapies have been combined to include interventions called behavioral treatments.

Behavioral interventions are a group of therapies used to modify stress, urge, or mixed UI by changing the patient’s bladder habits or by teaching new skills. The interventions include lifestyle changes, toileting programs (e.g., habit training, prompted voiding), bladder retraining, and pelvic muscle training or rehabilitation (using methods such as biofeedback, vaginal weights, and electrical stimulation). Although research showing the effectiveness of changes in certain lifestyle behaviors on UI, urgency, and frequency may not be conclusive, many health care providers frequently recommend alterations in lifestyle and behavior.

Smoking

Increased intra-abdominal pressure may promote the development of UI and urinary urgency, particularly in women. This increased pressure exists with conditions that include pulmonary diseases such as asthma, emphysema, and chronic coughing such as seen in smokers.³ Smoking, in particular, increases the risk of developing all forms of UI, and especially stress urinary incontinence (SUI); the level of risk depends on the number of cigarettes smoked. There may be several causes of the increased risk of SUI in smokers. Compared with nonsmokers, smokers have stronger, more frequent, and more violent coughing, which may lead to earlier development of damage to the urethral sphincteric mechanism and vaginal supports.⁴ Violent and frequent prolonged coughing can increase downward pressure on the pelvic floor, causing repeated stretch injury to the pudendal and pelvic nerves. In addition, elements of tobacco products may have antiestrogenic hormonal effects, which may influence collagen synthesis. Nicotine contributes to large phasic bladder contractions, as shown in animal studies through the activation of purinergic receptors; nicotine seems to affect the human bladder similarly.⁵ There may also be an association between nicotine and increased detrusor contractions. Bump and McClish⁶ showed that women who previously smoked had a 2.2-fold increased incidence, and those who currently smoked had a 2.5-fold increased incidence of SUI. The risk of UI in women caused by cigarette smoking was estimated to be 28%. This study indicated that the risk of genuine SUI is positively correlated with both the current intensity of cigarette consumption and the degree of lifetime exposure to cigarette smoking. The increased prevalence of SUI in smokers is independent of other risk factors such as older age, parity, obesity, and hypoestrogenism. Smoking habits indicate that smoking can cause symptoms of urge incontinence and urgency and frequency.³ Nuotio and colleagues⁷ showed a correlation between smoking and urinary urgency in a population-based survey of 1059 women and men aged 60 to 89 years. Smokers were more likely to report incontinence than nonsmokers. In a survey of 2128 middle-aged and elderly men who smoked or formerly smoked, Koskimaki and colleagues showed an increased risk of lower urinary tract symptoms.⁸

Obesity

Obesity is an independent risk factor for the development of SUI and mixed UI in women.^9,¹⁰ Excessive body weight, specifically measured by sagittal abdominal diameter, affects bladder pressure. The SUI that occurs with obesity may be secondary to increases in intra-abdominal pressure on the bladder and greater urethral mobility. Also, obesity may impair blood flow or nerve innervation to the bladder. A woman with a body mass index (BMI) of 29 or less is considered to be of normal or low weight; a woman with a BMI of 30 or greater is obese.³ Elia and associates⁹ reported on 540 women who responded to a questionnaire and whose BMI status was obtained. The association between BMI and UI was statistically significant. Poor personal hygiene in obese women may lead to an infectious process. Mommsen and Foldspang found a relationship between SUI and an increased BMI.¹¹ Roe and Doll¹² reported on 6139 (53% response rate) respondents to a postal survey on incontinence status. Significantly more respondents with UI had a higher mean BMI when compared with continent respondents. This association was more prevalent in women than men. Brown and colleagues¹³ studied 2763 women who completed questionnaires about prevalence and type of incontinence as part of a randomized trial of hormone therapy. A higher BMI and higher waist-to-hip ratio were found to be predictors of SUI and also of mixed UI when the major component was stress. This study found that the prevalence of at least weekly SUI increased by 10% for every 5 units of increased BMI. At this time, there is little information on whether weight loss resolves incontinence in women who are moderately obese. Obese women should lose weight before surgery to improve the technical ease, increase the durability, and decrease the failure rate of the surgery.¹⁴ Maintaining normal weight through adulthood may be an important factor in the prevention of UI. Given the high prevalence of both incontinence and obesity in women, weight reduction should be recommended as part of the conservative management and behavior modification for obese women with UI.³

Dietary Habits

Fluid Management

Patients with UI and OAB symptoms may subscribe to either restrictive or excessive fluid intake behaviors. It is important to teach the patient that adequate fluid intake is necessary to eliminate irritants from the bladder and prevent UI.³ Surveys of community-residing elders report self-care practices that include the self-imposed restrictions of fluid intake because of fears of UI, urinary urgency, and urinary frequency.¹⁵ Adequate fluid intake is very important for older adults, who already have a decrease in their total body weight and are at increased risk for dehydration. Institutionalized patients are chronically dehydrated, because most require assistance to eat and drink. Although drinking less liquid does result in less urine in the bladder, the smaller amount of urine may be more highly concentrated and irritating to the bladder mucosa. In addition, inadequate fluid intake is a risk factor for constipation, another problem common in older adults. Nygaard and Linder¹⁶ surveyed teachers and questioned their voiding habits at work, allotted breaks, and bladder complaints including urinary tract infections and incontinence. Teachers who drank less while working to decrease their voiding frequency had a twofold higher risk of urinary tract infection than those who did not report self-imposed fluid restriction. There was no association between urinary tract infection and either voiding infrequently at work or mean number of voids at work. Fitzgerald and colleagues¹⁷ surveyed women who worked for a large academic center. Of the 1113 women surveyed, 232 (21%) reported UI at least monthly.

Incontinent women were significantly older and had a higher BMI than continent women. The strategies used by women in this study to avoid urinary symptoms included limiting fluids and avoiding caffeinated beverages. The recommended daily fluid intake is 1500 mL, but many believe that a more appropriate intake is 1800 mL to 2400 mL per day.³ To be adequately hydrated, older patients must consume at least 1500 to 2000 mL per day of liquids.¹⁸ It is suggesting by the renal physicians, that a total fluid intake of 24 mL/kg/day in a temperature climate is appropriate to normal requirements, and of course there are variations depending on factors such as amount of exercise or presence of air-conditioning at home.¹⁹

Influence of Bladder Irritants

The type of fluid or food is important. Caffeine is a xanthine derivative, a natural diuretic and bladder irritant. It acts similarly to thiazide diuretics. Caffeine is a central nervous system stimulant that reaches peak blood concentrations within 30 to 60 minutes after ingestion and has an average half-life of 4 to 6 hours.³ Caffeine can cause a significant rise in detrusor pressure, leading to urinary urgency and frequency after caffeine ingestion.²⁰ Caffeine has an excitatory effect on the detrusor muscles.²¹ Caffeine is found in liquids such as sodas (e.g., Pepsi, Coca-cola) and foods and candy that contain milk chocolate (e.g., 7 mg in 10 ounces of milk chocolate). Carbonated drinks that are identified as “caffeinated colas” have been associated with an increased risk of SUI.²²

Alcohol also has a diuretic effect. Alcohol causes a release of antidiuretic hormone from the posterior pituitary.²⁰ Anecdotal evidence suggests that elimination of dietary factors such as artificial sweeteners (aspartame) and certain foods (e.g., highly spiced foods, citrus juices, tomato-based products) may promote continence.^3,^23,²⁴ Arya and colleagues²⁵ found that women (n = 20) with higher caffeine intake (361 to 607 mg per day) had a 2.4-fold increased risk for detrusor instability than women (n =10) with a low caffeine intake (110 to 278 mg per day). There was also a correlation between current smoking and caffeine intake.

Bryant and coworkers ²⁶ conducted a prospective randomized trial of persons with symptoms of urgency, frequency, and urge UI who routinely ingested 100 mg or more of caffeine per day. Both groups were taught bladder training, but the intervention group was also instructed to reduce caffeine intake to less than 100 mg/day. Significant improvement in urgency (61% decrease), in voiding frequency (35% decrease), and in urine leakage (55% decrease) was seen in the treatment group compared to baseline. Even though current research is not conclusive, patients with UI and OAB should be assessed for amount of caffeine intake. They should be advised about the possible adverse effects caffeine may have on the detrusor muscle and the possible benefits of reduction of caffeine intake.^3,²⁷ They also should be instructed to switch to caffeine-free beverages and foods or to eliminate them and see if urinary urgency and frequency decrease. If they continue to consume caffeine, clients with incontinence and OAB should take no more than 100 mg/day to decrease urgency and frequency.

Nutrient Composition of the Diet

Storage symptoms can affect quality of life and activities of daily living and have large resource implications for both the individual and the health service. Clinically, a number of foods and drinks are thought to have adverse or beneficial effects on certain urinary symptoms. However, little scientific evidence exists, and no studies have investigated the association between nutrient intake and urinary storage symptoms. The origin of detrusor overactivity may be neurogenic, with a variety of neurologic causes ²⁸; some of these may be related to diet, such as neuropathies resulting from vitamin B₁₂ deficiency.^29,³⁰ Another proposed pathologic mechanism is myogenic bladder overactivity,³¹ possibly due to ischemia. Associations with diseases such as stroke and diabetes³² suggest that OAB may be linked to a number of systemic conditions related to nutrition. In an earlier publication, Dallosso and colleagues³³ reported possible dietary associations with OAB in terms of food groups and individual food items and showed that lower intakes of three food groups (vegetables, P < .02; chicken, P < .005; breads, P < .001) were independently associated with increased risks of OAB onset. A higher intake of vitamin D was significantly associated with reduced risk of OAB onset (P = .008). There was some evidence of a trend toward decreased risk of onset with increasing vitamin D intake: those in the 4th quintile were 0.51 times less likely to experience OAB onset, compared with the lowest intake quintile (95% confidence interval: 0.34 to 0.78).

Evidence for an association between diet and the OAB symptom syndrome would be valuable in understanding its etiology. In a very recent study, Dallosso and associates ³⁴ investigated prospectively the association between the nutrient composition of the diet and the onset of OAB. A random sample of community-dwelling women aged 40 years or older was studied. Baseline data on urinary symptoms and diet were collected from 6371 women using a postal questionnaire and food frequency questionnaire. Follow-up data on urinary symptoms were collected from 5816 of the women in a postal survey 1 year later. Logistic regression was used to investigate the association of diet (daily intakes of energy, macronutrients, and micronutrients) with 1-year incidence of OAB. There was evidence that three nutrients may be associated with OAB onset. Higher intakes of vitamin D (P = .008), protein (P = .03), and potassium (P = .05) were significantly associated with decreased risks of onset. Although overall the associations with vitamin B₆ and niacin were not significant (P = .08 and P = .13, respectively), there was some evidence of a decreased risk of onset with higher intakes. This study was the first to consider an association between the nutrient composition of the diet and OAB onset, and it provided some evidence that lower intakes of a number of nutrients may be associated with an increased risk of OAB onset. The association was strongest for vitamin D. Further studies are needed using additional validated indicators of OAB status and diet to confirm the associations found.

The observed associations of a number of nutrients with OAB onset present an overall pattern of low intake levels associated with increased risk of onset, possibly suggesting that general inadequacy of the diet may be an important factor. Although clinical deficiencies of protein and vitamins are very uncommon in Western countries, suboptimal levels of intake may be important.³⁵ Comparisons with the literature are difficult, because the only published work on diet and urinary symptoms comes from studies looking at prostatic enlargement in men, defined either clinically^36,³⁷ or by reporting of symptoms.³⁸

The Dallosso study ³⁴ results suggested that low intake levels of certain micronutrients may be associated with increased risk of OAB onset, the most significant association being with vitamin D. Vitamin D and its metabolites are steroid hormones and have many important functions. Low vitamin D status is involved in the pathogenesis of several chronic diseases. Muscle wasting is a symptom of osteomalacia, the clinical condition resulting from vitamin D deficiency in adults, and muscle atrophy has been described histopathologically in type II fibers. The potential role of vitamin D in the function of the detrusor muscle needs to be considered. Because it is produced phytochemically in the skin by exposure to ultraviolet light, the level of dietary intake is not usually very important. Apart from the elderly and other at-risk groups, there is no recommended level of vitamin D intake in the United Kingdom.

This study ³⁴ also provided some evidence that lower intake levels of the B vitamins niacin and B₆ may be associated with OAB onset. Bread and chicken are sizeable sources of niacin in the diet,³⁹ and lower intake levels of both of these food groups showed an association with greater onset of OAB in our earlier analysis.³³ Niacin is involved in energy metabolism and is essential for normal functioning of various systems of the body, including the central nervous system. However, the literature also reports strong associations with folate and vitamin B₁₂; this suggests that the B₆ association with homocysteine may be due to the fact that the three vitamins share the same food sources.⁴⁰ Potassium is very widespread in the diet, and a low intake is rare, sometimes occurring in people with bizarre or extremely low energy intakes. Potassium depletion in the body never results solely from an inadequate intake and is always associated with abnormal losses from the body. The largest sources in the diet are fruit and vegetables (30%) and refined grains (21%)⁴¹; in our earlier analysis, high intakes of vegetables and breads were associated with a reduced risk of OAB onset. A high potassium intake is generally considered an indicator of a “good quality diet,” mainly because of its association with high fruit and vegetable content. The associated reduced risk of OAB onset could therefore be related to some aspect of a “healthy diet.”

Dietary Changes with Improvement of Defecation

Lubowski and colleagues ⁴² reported that denervation of the external anal sphincter and pelvic floor muscles (PFMs) may occur in association with a history of excessive straining on defecation. Many believe that, if these are lifetime habits, they may have a cumulative effect on pelvic floor and bladder function. There is very little research that assesses the effect of regulating bowel function on incontinence and OAB. Spence-Jones and colleagues ⁴³ found that straining excessively at stool was significantly more common in women with SUI and in women with prolapse than in women who experienced neither condition. Moller and coworkers⁴⁴ reported an almost uniform positive association between straining at stool and constipation and lower urinary tract symptoms in women (N = 487) 40 to 60 years of age. Moller believed that chronic constipation and repeated straining efforts induce progressive neuropathy in the pelvic floor. Because research suggests that chronic constipation and straining may be risk factors for the development of incontinence and OAB, self-care practices that promote bowel regularity should be an integral part of any treatment program.³

Treatment of elderly patients can significantly improve lower urinary tract symptoms, which include urgency and frequency.⁴⁵ Suggestions to reduce constipation include the addition of fiber to the diet, increased fluid intake, regular exercise, external stimulation, and establishment of a routine defecation schedule. Improved bowel function can also be achieved by determining a schedule for bowel evacuation so that the client can take advantage of the “call to stool,” or the urge to defecate. The schedule should be determined by the client’s bowel elimination pattern and previous time pattern for defecation. Dougherty and colleagues⁴⁶ conducted a randomized, controlled trial that incorporated reduction of caffeine consumption, adjustments in the amount and timing of intake of fluids, and dietary changes to promote bowel regularity, which were termed “self-monitoring activities.” Women in the intervention group also received bladder training and biofeedback-assisted pelvic muscle exercises. A total of 218 women with stress, urge, or mixed UI were randomized, and 178 completed one or more follow-ups. At 2 years, the intervention group’s UI severity had decreased by 61%. Self-monitoring and bladder training accounted for most of the improvement.

Epidemiologic research has revealed several factors associated with UI in women, the most commonly reported being age, pregnancy, and childbirth. Risk factors that may be modifiable have not been investigated to the same extent. Inadequate control for confounding factors is a weakness of several studies, and many investigations have been performed in selected populations. The aim of one large population-based study ⁴⁷ was to evaluate the role of smoking and other modifiable lifestyle factors potentially associated with UI in women. A total of 27,936 women completed the incontinence part of the questionnaire. For the 6876 incontinent women (24.6 %), a severity index was calculated based on the answers regarding frequency and amount of leakage, and the incontinence was categorized as slight, moderate, or severe. The incontinence was also classified into three different subtypes: stress, urge, and mixed UI. The participating women answered additional questions about many other topics, including smoking habits; intake of alcohol, tea, and coffee; and amount of physical activity. BMI was derived from the measurements of height and weight (kg/m²) at the screening station. Proportions were used to describe the univariate relationship between UI and the ordered variables. Where relevant, possible interaction or confounding was evaluated by stratified table analyses and logistic regression. Logistic regression analyses were used to adjust for confounding and to establish the factors independently associated with the outcome, and odds ratios (ORs) were the effect measure.

Effects were denoted as strong if the ORs were 1.8 or greater and weak if they were between 1.2 and 1.7. In all logistic regression analyses, women without incontinence served as the reference group. All analyses were performed separately for each of the different outcomes under investigation: any incontinence (all incontinent women), severe incontinence, and the different subtypes. The crude analyses showed that the prevalence of any UI increased with increasing age and increasing BMI. Former smokers reported incontinence more frequently than did current or never smokers. An increasing intake of tea and coffee seemed to be associated with a higher prevalence of incontinence, whereas the inverse relationship was true for intake of alcoholic beverages. The crude prevalences also suggested an association between physical activity and any incontinence.

The prevalence of severe incontinence and of the different subtypes of incontinence varied in a pattern parallel to that for any incontinence, according to the factor in question. When smoking status was explored, there was no association between any incontinence and former or current smoking of less than 20 cigarettes a day, but there was an increased and significant OR for both former and current smoking of 20 cigarettes or more daily. The effect was stronger for severe incontinence. For the different subtypes of incontinence, smoking status showed an weak and significant association only with mixed incontinence. Increasing BMI was strongly associated with any UI, with severe symptoms and with all subtypes An increasing amount of low-intensity physical activity was related to slightly lowered odds for any incontinence, severe incontinence, and both SUI and mixed types of incontinence. High-intensity physical activity showed only weak and insignificant associations to either of the outcomes. Daily tea drinkers had an increased risk for incontinence. The intake of tea was weakly associated with all three types, although not significantly for the urge type. Coffee had no effect on any incontinence and a weak but significant negative effect on severe incontinence and severe mixed type. The intake of alcohol showed no association with any of the outcomes under analysis.

Hannestad and colleagues ⁴⁷ found that former and current smoking was associated with incontinence only for those who smoked more than 20 cigarettes per day. Severe incontinence was weakly associated with smoking regardless of number of cigarettes. The association between increasing BMI and incontinence was strong and was present for all subtypes. Increasing amounts of low-intensity physical activity had a weak and negative association with incontinence. Tea drinkers had raised risk for all types of incontinence. No important effects of high-intensity activity or of intake of alcohol or coffee were found. This study was designed to describe associations, and accordingly no conclusions could be drawn regarding causality. It remains for future research to establish whether modification of associated lifestyle factors alters the prevalence of incontinence. Nevertheless, strategies to discourage women from smoking should be implemented. At the very least, women should be educated on the relationship between smoking, UI, and OAB.³

Physical and Occupational Stressors: Sports and Fitness Activities

Another lifestyle behavior associated with triggering of SUI in young, healthy women is physical exertion. This is more common than health care professionals estimated, and it is one of the chief complaints in the younger female population. Physically active women are more likely than sedentary women to experience incontinence, and the problem is most common in high-impact sports, such as running and basketball, because repetitive bouncing can increase abdominal pressure and transmit the impact to the bladder. Because SUI occurs during physical exertion, we could say that this condition represents a major problem for females participating in fitness programs or sports activities.

Regarding the problem of PFMs, there are two contradicting theories about female athletes and the strength of their PFM.⁴⁸ The first theory is to consider that general physical activities strengthen all the body muscles, including the pelvic floor, and female athletes could have a strong pelvic musculature. The second theory is that heavy activities with repetitive pressure on the pelvic floor support may overload the pelvic floor and weaken these muscles over time. The PFMs play a major role in the continence control system. The speed and strength of PFM contractions may be one of the main causes.⁴⁹ During stressful situations (physical exertion, strain), the levator ani muscles pull the vesical neck upward, and the urethra is compressed against a supportive layer composed of the endopelvic fascia and the anterior vaginal wall. The theory of Petros and Ulstem, with their prediction that defects of the vagina or its supporting ligaments adversely affect the dynamics of the pelvic floor and the ability of interacting forces to coordinate closing of the urethra, is another explanation of the SUI associated with physical activities.⁵⁰ The high intra-abdominal pressure and/or weakness or nonfunctioning of the levator ani leads to loss of support of the bladder neck and urethra. These two parameters represent the mechanical hypothesis in the pathophysiology of SUI related to sports. Because of the rigidity of the abdominal wall, the pelvic diaphragm cannot play its role of “shock absorber.” Prevalence of SUI in young female athletes and women who exercise ranges from 8% to 47%.

Nygard and associates ⁵¹ studied the relationship between exercise and incontinence. A self-administered questionnaire assessed the prevalence of both exercise and incontinence in 326 regularly exercising women (mean age, 38.5 years) attending private gynecologic offices. Eighty-nine percent exercised at least once a week, with an average practice of three times per week for 30 to 60 minutes per session. Researchers found that 47% of regularly exercising women reported some degree of incontinence. In another study⁵² involved a group of 156 nulliparous, elite college varsity female athletes (mean age, 19.9 years), who were asked to fill out a questionnaire about the occurrence of UI during participation in their sport and during activities of daily life. Overall, 40 athletes (28 %) reported urine loss while participating in their sport. Activities most likely to provoke incontinence included jumping (basketball), running, and making impact on the floor as gymnasts do with dismounting or after flips.

Bourcier and Juras ⁵³ studied SUI in sports and fitness activities in 59 women, whom they divided into two groups: group I (n = 28) represented female athletes, and group II (n = 31) represented women who practiced sports on a regular basis. In group I, the mean age was 25.5 years (range, 21 to 29) and mean parity was 0.5 (range, 0 to 1); in group II, mean age was 28 years (range, 23 to 32), and mean parity was 1 (range, 0 to 2). The degree of SUI was defined as severe (dripping incontinence on exercising), moderate (incontinence with heavy lifting, running), or mild (incontinence in jumping). In the athlete group, the prevalence of SUI symptoms was 7% for severe, 24% for moderate, and 33% for mild incontinence. Bourcier and coworkers⁴⁸ studied the relationship between physical activity and incontinence. A self-administered questionnaire assessed the prevalence of both exercise and incontinence in two groups of patients; 480 women (group I; mean age, 48.5 years) with no regular practice of sports and 120 women (group II; mean age, 28 years) who practiced sports on regular basis (>5 hr/wk) were investigated. The investigators reported that urine loss in group I was related to sneezing or coughing in 87% of the women; in group II, urine loss was related to running or tennis in 38% and aerobics in 35%.

The purpose of the study by Larsen and Yavorek ⁵⁴ was to determine the prevalence of UI and to assess the stages of pelvic support in a population of nulliparous, physically active college students at the United States Military Academy. This was an observational study of 143 female cadets. Cadets in the freshman and sophomore classes were asked to participate in an ongoing study comparing UI and pelvic organ support before and after attending military jump school. The results were as follows. Overall, the group of women were found to be very physically active, with 69.2% (99/143) exercising four or more times per week and 91.6% (131/143) working out three or more times. Additionally, 49.7% (60/131) of those exercising spent 60 minutes or more per session. Running was the most common form of exercise, with 77.6% (111/143) running for at least part of their workout. Of the women examined, 50.3% (72/143) were found to be at pelvic prolapse stage 0 and 49.7% (71/143) at stage I. A total of 18.8% (27/143) women who reported recurrent incontinence, with the largest percentage (44%) being SUI by history. The conclusion of the authors was that 50% of nulliparous cadets had stage I prolapse on standardized pelvic support examination, primarily in the anterior compartment. A small percentage admitted to incontinence at the time of examination. This study indicates that trauma from physical activity might cause pelvic support defects that could predispose women to incontinence problems later in life.

Because the percentage of women who exercise and participate in sports is increasing, it is important to determine what effect this increase has on pelvic support. Jorgensen and coworkers ⁵⁵ reported that Danish nursing assistants, who are exposed to frequent heavy lifting, were 1.6-fold more likely to undergo surgery for pelvic organ prolapse or UI than women in the general population. Fitzgerald and colleagues¹⁷ surveyed women who worked for a large academic center. Of the 1113 women surveyed, 21% (n = 232) reported UI at least monthly. Incontinent women were significantly older and had a higher BMI than continent women. Women in this study used self-care practices such as using absorbent products or limiting fluids.

Several studies have reported on the relationship between UI and military training and activities. Women in the military have physically demanding roles, and the presence of UI can interfere with lifestyle as well as ability to perform assigned duties. Sherman and associates ⁵⁶ found that 27% (N = 450) of U.S. female army soldiers (average age, 28.5 years) experienced problematic UI, with 19.9% saying they leaked significantly during training tests. However, only 5.3% felt that urine leakage had a significant impact on their regular duties. This may due to the fact that 30.7% women stated that they took precautions such as voiding before training, wearing “extra-thick” pads, and limiting fluid intake. A very disturbing finding in this study was that 13.3% of women restricted fluid intake while participating in strenuous field training. A third study ⁵⁷ looked at women flying in high-performance combat aircraft. Aircrews who fly in high-gravity aircraft perform an M-1 maneuver, which is a modified Valsalva with an isometric contraction of the lower extremities. This movement may place women pilots at risk for urine loss due to increased intra-abdominal pressure and increased gravity load. Results of a questionnaire of aircrew (N = 274) indicated that 26.3% had experienced urine loss at some time. However, pilots did not have higher UI rates than women in other positions (e.g., navigators, weapon systems operators). In this study, as in others, crew position, history of vaginal delivery, and age were found to be significant risk factors.³

The data from these studies demonstrate that UI is not rare among young women. We think that young incontinent women need an appropriate treatment to prevent the possible worsening of symptoms, and it seems logical to develop strategies for screening those with high risk factors.⁵⁸ We assume that UI is a female disease with much higher prevalence than medical literature has demonstrated and with a surprisingly high prevalence in groups of physically active women.^48,⁵³ Based on our current knowledge of the effect of pelvic floor muscle training (PFMT), we recommend that specific training pelvic programs be proposed as the first choice of treatment. The perineal blockage technique and the Knack technique appear to be effective adjunctive modalities for pelvic floor rehabilitation and can be proposed for active women.^48,⁵³ The impact of carefully instructed pelvic floor exercises on sports incontinence has not been as beneficial as that in a normal female population.

BLADDER RETRAINING AND PELVIC FLOOR MUSCLE EXERCISES

Bladder Retraining

No single treatment modality should be considered the first choice of treatment in the management of either the unstable bladder or the urge syndrome. Bladder retraining, sometimes termed bladder drill, is a noninvasive treatment modality that has been used not only for these two conditions but also for mixed incontinence and even SUI.⁵⁹ It has been widely studied over the last 20 to 25 years, although little scientific work has been published recently. An excellent review of the subject is available in the Cochrane Library.⁶⁰ Bladder retraining is a form of behavioral therapy in which a patient with an intact nervous system “relearns” to inhibit a detrusor contraction or a sensation of urgency. Such behavioral therapies include biofeedback, hypnotherapy, and acupuncture. There are good reasons why behavioral methods or therapies may be of value in idiopathic urge syndromes. Although these have been a subject of review,^59,⁶¹ they can be summarized as follows:

A strong emotive event in a patient’ life may be the initial trigger for urinary symptoms.

Patients with detrusor instability have a higher neuroticism score on formal testing than do patients with genuine SUI.

There is relationship between detrusor instability and hysterical personality trait.

Patients with detrusor instability are more likely to have psychosexual problems than patients with genuine SUI.

Other behavioral forms of therapy, such as hypnosis, are effective methods of treatment.

Treatment is itself associated with a strong placebo effect, which has been estimated at between 4% and 47% in clinical trials.

A frequently used treatment regimen ⁵⁹ can be broken into the following components:

Exclude pathology.

Explain the condition to the patient.

Explain the treatment and its rationale to the patient.

Instruct the patient to void at set times during the day, for instance, every hour. The patient must not void between these times; she must wait or be incontinent.

The voiding interval is increased by increments (of perhaps 30 minutes) after the initial goal is achieved, and the process is then repeated.

The patient should have a normal fluid intake.

The patient should keep her own input and output chart. The increasing volumes of urinary output at increasing intervals act as a reinforcement reward.

The patient should receive praise and encouragement on reaching her daily targets.

Typical results note that up to 90% of patients become continent, although there is a relapse rate up to 40% within 3 years of treatment. Such relapses could be treated by reinstitution of a retraining program.

Most patients with a urodynamically demonstrable unstable bladder who were rendered symptom free also became stable on urodynamic assessment.⁵⁹ Several studies have compared bladder retraining regimens with pharmacologic treatment. Further studies have addressed the issue of supplementing bladder retraining with drug treatment. Although the data from such studies are currently limited, there is no evidence so far that supplemental drug therapy is superior to bladder retraining alone.^59,⁶¹ Therefore, bladder retraining appears to be equal or superior to drug treatment and may have greater long-term benefits.

There are numerous areas for future study. There is a lack of consistency in bladder retraining programs. There is a need not only to evaluate an optimal program but also, most importantly, to identify the optimal increment in both the voiding interval and the rate at which the voiding interval is iterated after attainment of each stage of the regimen. A shorter initial voiding interval, for instance, may be necessary for women with more intense frequency or with less confidence. There is clearly a popular benefit from widespread treatment in a community as opposed to treatment of a small number of patients in hospital, but there is a need to determine the optimal supervision in the community. There is a need for comparison between bladder retraining and other physical interventions. There are limited data, for instance, comparing bladder retraining with PFMT, estrogen replacement, and electrical stimulation. Bladder retraining is an effective treatment for women with urge, stress, or mixed UI. It is not yet clear whether the urodynamic diagnosis specifically affects the likelihood of success. There is a lack of consistency in bladder retraining programs, and an optimal regimen needs to be identified. However, it is possible that regimens will need to be tailored to the individual patient.⁵⁹ Bladder retraining appears to have benefits similar to those of drug treatment; it does not appear to be benefited by supplementary drug treatment; and it may have greater long-term benefits than drug therapy. Bladder retraining appears to be largely free of adverse effects and is acceptable to patients.⁵⁹