Simple and it works: bladder retraining aids detrusor overactivity

OB/GYN News, March 15, 2004 by Betsy Bates

UNIVERSAL CITY, CALIF. -- What patient wouldn't opt for stress and urgency incontinence therapy that is simple, noninvasive, inexpensive, and uncomplicated by side effects?

Such an alternative exists in the form of bladder retraining, but few patients--and unfortunately, few physicians--have the motivation and determination to make it work, Dr. Alfred Bent said at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

Bladder retraining involves written, visual, and verbal instruction and regular reinforcement through follow-up visits.

It can generally be employed after a simple evaluation that includes a thorough history and physical examination (including a local neurologic examination), completion of a voiding diary, urinalysis and culture, and residual urine determination through ultrasound.

To save time, Dr. Bent's office sends patients instructions to complete the voiding diary before his examination. (See box.)

After examining the patient's 24-hour record of voiding times, amounts, and symptoms, the physician establishes an individualized voiding schedule for the patient. For example, if she voids every 2 hours but is wet in between, she is instructed to begin voiding every hour. When that step successfully keeps her dry, the voiding schedule is extended to 1 hour, 15 minutes, and gradually increased until she is dry virtually all of the time.

Like other incontinence therapies, bladder retraining should be used in conjunction with fluid management and restriction of bladder irritants such as coffee. And it is rarely 100% successful, although incontinent episodes can be reduced by 60% or more, said Dr. Bent, who chairs the department of gynecology at the Greater Baltimore Medical Center.

"A lot of this isn't an 'I'm going to be absolutely dry' condition," he said. "It's an 'I'm going to be a lot better' condition."

In his office, Dr. Bent relies on a nurse incontinence specialist to do weekly follow-up visits with patients who opt for bladder retraining. In addition to adjusting the voiding schedule, she helps patients manage their fluid balance and trains them in Kegel exercises, he said.

Positive reinforcement is critical, whether that reinforcement comes from a physician dedicated to the patient's success, or from an auxiliary member of the professional office staff. The patient also needs to commit to following the program.

"The retraining process is more for the bladder than for the patient, but she has to apply it to her bladder. It is not effective in an unwilling patient," said Dr. Bent.

Because bladder retraining requires no high-tech equipment or drugs, it is significantly less expensive than most other options for treating detrusor overactivity.

Another advantage is that it is effective in virtually any patient who is physically and cognitively able to manage a change in her voiding habits.

With proper follow-up, it is also a long-lasting solution to a condition that is both embarrassing and inconvenient.

"People on medications always want to get off the medications. This lasts," said Dr. Bent.

Sample Patient Voiding Diary

Time        Voided (mL)  Leak?  Urge?  Activity          Intake

 6:30 a.m.    100        Yes    Yes    Arising
 7:00 a.m.     50               Yes    Brushing teeth    2 oz juice
 7:30 a.m.     30               No     Out of shower
 8:00 a.m.                                               8 oz coffee
                                                         8 oz milk
 8:30 a.m.    120        Yes    Yes    Leaving for work
10:00 a.m.    150        No     Yes    Typing            8 oz coffee

Source: Dr. Alfred Bent

BY BETSY BATES

Los Angeles Bureau