Behavioral treatment consists of a group of interventions that actively engage the patient to change her habits or learn new skills to improve pelvic floor function. These interventions have been used for several decades to treat urinary and fecal incontinence, other lower urinary tract symptoms, and defecatory dysfunction. They have been integrated into several disciplines and are implemented in many different ways. The spectrum of behavioral treatments includes those that train pelvic floor muscles in order to improve strength and control, as well as those that modify voiding habits and life style.

In clinical practice, behavioral intervention programs should be individualized according to the needs of the patient and her unique situation, which usually involves the use of multiple components. Behavioral programs are generally built around one of two fundamental approaches. One approach focuses on the bladder outlet, teaching skills for improving pelvic floor muscle strength, control and techniques for urge suppression. Another approach focuses on controlling bladder or bowel function by changing voiding and bowel habits, such as with bladder and bowel training and delayed voiding. Components of behavioral intervention can include self-monitoring (bladder or bowel diary), pelvic floor muscle training and exercise, active use of pelvic floor muscles for urethral occlusion (“stress strategies”), urge prevention and suppression techniques (urge strategies), urge control techniques (distraction, self-assertions), biofeedback, scheduled voiding, delayed voiding, fluid management, dietary changes, weight loss, and teaching normal voiding and defecation techniques.

All of these behavioral techniques require the active participation of the patient and time and effort from the clinician. Most patients are not cured through behavioral intervention, but there is evidence that most patients experience significant reduction in symptoms and improved quality of life with little risk of adverse side effects. Behavioral treatments should be a mainstay in the care of women of all ages with incontinence or other pelvic floor dysfunction.

Behavioral interventions are well established for treating stress and urgency incontinence, fecal incontinence, and overactive bladder. Although less research has been done on voiding dysfunction and defecatory dysfunction, behavioral interventions are also appropriate conservative treatments. Most patients who are motivated and cooperative with behavioral treatment experience some degree of improvement, but there is wide variation in outcomes and little is known of the characteristics of patients who respond best to behavioral treatment. Even women with dementia can benefit from the appropriate combination of behavioral treatment components such as caffeine reduction and timed voiding.

Most of the literature on predictors of outcome has been conducted in the treatment of urinary incontinence. Most studies have shown that outcomes are not related to the type of incontinence or urodynamic diagnosis.^1-5 Patients with more severe incontinence have greater improvement following behavioral treatment than those with lesser incontinence.^2,6 Other studies have shown that patients with more severe incontinence have poorer outcomes,^5-7 or no relationship between severity and outcome.^3,4,8,9 Studies are also inconsistent with regard to the effect of age on the outcome of behavioral therapy.^2,7,8,9

Behavioral treatment outcomes do not seem to be affected by the patient’s race, parity, body mass index, presence of cystocele, uterine prolapse, hysterectomy, hormone therapy, use of diuretics, or urodynamic parameters.⁵ Thus, the current evidence does not allow us to predict treatment response based on the type of incontinence, the patient’s medical or obstetrical history, the results of her pelvic or rectal examination, or the findings of her urodynamic testing. Aside from the baseline frequency of incontinence, there is little information on the usual clinical evaluation of a patient with incontinence that would indicate the likelihood of her success or failure with behavioral treatment. Since behavioral therapy involves minimal risk or discomfort, and most motivated patients see improvement with behavioral treatment, there is no reason to discourage a woman who is willing and motivated to participate in behavioral treatment and every reason for an initial trial of behavioral treatment for the majority of patients who present with pelvic floor dysfunction.

Patient Education

An important first step in any behavioral program is to provide basic patient education to a patient so that she can understand the treatment process and the therapeutic goals. This includes an explanation of the anatomy of the bladder and pelvic floor, how they function, and the causes and mechanisms of urinary incontinence and other lower urinary tract symptoms. It is essential for women to understand that their behavioral program is based on changing their habits and learning new skills, and that improvement is often gradual. Further, understanding that their results will depend on active participation and daily practice facilitates adherence and realistic expectations about therapeutic outcomes.

Most women with urinary symptoms believe that they have no control over their condition. As they implement the components of behavioral treatment, they are often empowered to discover increasing control over their symptoms and improvements in their quality of life.

The Bladder Diary

Self-monitoring with a diary is a standard first step in any behavioral program. When treating bladder or pelvic floor symptoms, it is useful to have the patient complete a diary for five to seven days.¹⁰ The diary is a valuable clinical tool for the patient, as well as the clinician. In the evaluation phase, the diary provides information on the type and frequency of symptoms, such as incontinence episodes, frequency of urination, and other symptoms, which helps the clinician plan appropriate components of behavioral intervention. During the course of treatment, the bladder diary can be used to monitor symptoms and to track the efficacy of various treatment components and guide the intervention.

Patients are asked to record the time of each void and incontinent episode, the urgency associated with each, and the circumstances or reasons for incontinence episodes. In bladder training programs, having patients record the times that they void provides a foundation for determining voiding intervals. Voided volumes are more burdensome to document and are usually recorded for only 24 to 48 hours, but they provide a practical estimate of the patient’s functional bladder capacity in their daily lives. A sample bladder diary is presented in Figure 21-1. Columns could be added for voiding volume, and type and volume of fluid intake.

In addition to guiding the clinician, the self-monitoring effect of completing a diary can enhance the patient’s awareness of voiding habits and helps them recognize how their incontinence may be related to their activities. By reviewing the bladder diary with the clinician, patients can identify times when they are at increased risk of an incontinence episode and activities that can trigger incontinence. In particular, identifying the circumstances that precipitate incontinence episodes helps to prepare patients to implement the continence skills they are about to learn.

Behavioral Treatment for Stress Incontinence

Pelvic Floor Muscle Training and Exercise

Pelvic floor muscle training and exercise is a cornerstone of behavioral treatment for both urinary and fecal incontinence. It was originally designed to teach patients how to control and exercise periurethral muscles with the goal of strengthening the muscles and reducing stress incontinence. It was first popularized by Kegel, a gynecologist who proposed that stress incontinence was due to a lack of awareness of function and coordination of pelvic floor muscles,¹¹ and who also demonstrated that women could reduce their stress incontinence through pelvic floor muscle training and exercise.^11,12 Over time, this intervention has evolved both as a behavior treatment and as a physical therapy, combining principles from both fields into a widely accepted conservative treatment for stress, as well as urgency incontinence and fecal incontinence.

Teaching Pelvic Floor Muscle Control

The first step in training is to assist the woman to identify the pelvic floor muscles and to contract and relax them selectively, without increasing pressure on the bladder or pelvic floor. Confirming that patients have identified and isolated the correct muscles is essential and often overlooked. Failure to find the pelvic floor muscles or to exercise them correctly is perhaps the most common reason for failure with this treatment modality. While it is easy for a clinician to give a patient a pamphlet or brief verbal instructions to “lift the pelvic floor,” to hold back the passage of flatus, or to interrupt the urinary stream, this approach does not ensure that the correct muscles are used when she begins her exercises at home. Several techniques can be used to help patients learn to exercise correctly, including verbal feedback based on vaginal or anal palpation,^13-17 biofeedback,^14-24 or electrical stimulation.^21-25 Some clinicians recommend the use of a resistive device or weighted vaginal cones to improve the effects of pelvic floor muscle exercise, but there is little research to support these modalities.²⁶

One problem commonly encountered in learning to control the pelvic floor muscles is that patients tend to recruit other muscles, such as the rectus abdominis muscles or gluteal muscles. Contracting certain abdominal muscles can be counterproductive when it increases pressure on the bladder, bowel, or pelvic floor. Therefore, it is important to observe for this Valsalva maneuver and to help patients to exercise pelvic floor muscles selectively while relaxing these abdominal muscles. Instructing the patient not to hold her breath or to count out loud can be helpful to avoid the Valsalva maneuver.

Coordinated training of transversus abdominis muscles has also been recommended, because it is believed that these muscles facilitate pelvic floor muscle contraction. This approach remains controversial, however, and a recent review article noted an absence of evidence for this type of training.²⁷

Daily Pelvic Floor Muscle Exercise

Once patients demonstrate the ability to properly contract and relax the pelvic floor muscles in the clinic, a regimen of daily practice and exercise is recommended. The purpose of daily exercise is not only to increase muscle strength but also to enhance motor skills through practice. Pelvic floor muscle exercise regimens vary considerably in frequency and intensity, and the optimal exercise regimen has not been determined. However, good results have been achieved in several trials using 45 to 50 paired contractions and relaxations per day.²⁸ It is usually recommended that patients space the exercises across the day, typically in two to five sessions per day to avoid muscle fatigue. Exercising while in the prone position is often recommended at first, because it is the least challenging. However, it is important for patients to progress to sitting or standing positions with time, so that they become comfortable and skilled using their muscles to avoid incontinence in any position.

To improve muscle strength, contractions should be sustained for two to ten seconds, depending on the patient’s initial ability. Exercise regimens should be individualized so that patients begin with a comfortable and achievable duration and gradually progress to ten seconds. Each exercise consists of muscle contraction followed by a period of relaxation using a 1:1 or 1:2 ratio.²⁹ This allows the muscles to recover between contractions, and facilitates optimal strength building.

Strategies to Prevent Stress Incontinence

The goal of behavioral treatment for stress incontinence is to teach patients how to improve urethral closure by consciously contracting pelvic floor muscles during coughing, sneezing, lifting, or any other physical activities that precipitate urine leakage. Although exercise alone can improve urethral pressure and structural support and reduce incontinence,³⁰ in recent years, more emphasis has been placed on teaching patients to contract the pelvic floor muscles to occlude the urethra during physical activities that cause stress incontinence.^25,31 This skill has been referred to as the “stress strategy,”²⁵ “counterbracing,” “perineal co-contraction,” “the Knack,”³¹ and “the perineal blockage before stress technique.”³² Patient instructions for using the stress strategy are presented in Figure 21-2. As with any new skill, this requires vigilance and a conscious effort initially on the part of the patient. With time and consistent practice, patients can develop the habit of using muscles to increase urethral closure until these maneuvers eventually become automatic.

Although it is ideal for a woman to have strong pelvic floor muscles, even those with weak muscles can benefit from simply learning how to control their muscles and use them actively to prevent incontinence. Others will need a more comprehensive program of pelvic floor muscle rehabilitation to increase strength in addition to skill.

The literature on pelvic floor muscle training and exercise has demonstrated that it is effective for reducing stress, urgency, and mixed urinary incontinence in most outpatients who cooperate with training. Systematic reviews and the International Consultation on Incontinence concluded that there is grade A evidence for pelvic floor muscle training and that it should be offered as first-line treatment to women with stress, urgency, or mixed incontinence.^28,33,34 A sample behavioral treatment program for stress incontinence is presented in Table 21-1.

Behavioral Treatment for Urgency, Frequency, and Urgency Incontinence

Urge Suppression Strategies

Historically, pelvic floor muscle training and exercise was used almost exclusively for the treatment of stress incontinence. In the 1980s, it became evident that voluntary pelvic floor muscle contraction can also be used to suppress detrusor contraction.¹⁹ This technique can be learned by most patients and has become a central element in the treatment of urgency incontinence and overactive bladder.³⁵ Pelvic floor muscle control and exercise is taught in the same manner as it is for women with stress incontinence. What differs is how women with urgency incontinence are taught to use their muscles to deal with urgency and prevent urine loss. Not only can women use an active muscle contraction to occlude the urethra during detrusor contraction, but, more importantly, they also learn to use volitional pelvic floor muscle contractions to inhibit or suppress the detrusor contraction.

Urge suppression skills are an essential component in teaching patients a new and more adaptive way of responding to the sensation of urgency. Ordinarily, women with OAB or urgency incontinence feel compelled to rush to the nearest bathroom when they feel the urge to void. With behavioral treatment, they learn how this natural response is actually counterproductive, because it increases physical pressure on the bladder, increases the feeling of fullness, exacerbates urgency, exposes patients to visual cues that can trigger incontinence, and increases the risk of an incontinent episode. Although it may seem paradoxical at first, patients are taught not to rush to the bathroom when they feel the urge to void. Instead, they are advised to stay away from the bathroom, so as to avoid exposure to cues that trigger urgency. They are encouraged to pause, sit down if possible, relax the entire body, and contract pelvic floor muscles repeatedly, without relaxing in between contractions, to diminish urgency, inhibit detrusor contraction, and prevent urine loss. Women are taught to focus on inhibiting the urgency sensation, giving it time to pass. Once the sensation subsides, they are then taught to walk at a normal pace to the toilet. Patient instructions for using the urge suppression strategies are presented in Figure 21-3.

In addition to the daily exercise regimen, it is also helpful for patients with urgency incontinence to interrupt or slow the urinary stream during voiding once per day. Not only does this provide practice in occluding the urethra and interrupting detrusor contraction, but also it does so in the presence of the urge sensation, when patients with urgency incontinence or OAB need it most. Some clinicians are concerned that repeated interruption of the urinary stream may lead to incomplete bladder emptying in certain groups of patients. Therefore, caution is recommended when using this technique with patients who may be susceptible to voiding dysfunction.

The effectiveness of behavioral training with urge suppression for urgency incontinence has been established in several clinical series studies^7,8,19 and in controlled trials using intention-to-treat models, in which mean reductions of incontinence range from 60% to 80%.^13,35 In the first randomized controlled trial, behavioral training reduced incontinence episodes significantly more than drug treatment and patient perceptions of improvement and satisfaction with their progress were higher.³⁵ A sample behavioral treatment program for patients with urgency, frequency, and/or urgency incontinence is presented in Table 21-2.

Bladder Training

Women who experience urgency incontinence or severe urgency without leakage tend to void frequently. This response provides immediate relief from the sensation of urge or urgency, but it sets the stage for more and more frequent urination. Once frequent voiding becomes a habit, it can be difficult to change, and may lead to reduced functional bladder capacity, detrusor overactivity, and, in some cases, urgency incontinence. Detrusor overactivity, in turn, produces urgency, completing a cycle of urgency and frequency that is then perpetuated (see Figure 21-4).36 This cycle can be broken by initiating a voiding schedule using bladder training or by using a program of progressive delayed voiding.

The goal of the bladder training is to break the cycle of urgency and frequency using incremental voiding schedules to reduce voiding frequency, increase bladder capacity, and restore normal bladder function. The woman voids at predetermined intervals, rather than in response to urgency. She first completes a voiding diary, to determine how often she voids. After reviewing the diary with the patient, the clinician selects a voiding interval based on the longest time interval between voids that is comfortable for the patient. She is then given instructions to void first thing in the morning, every time the selected interval passes, and before going to bed at night. Over time, the voiding interval is increased at comfortable intervals to a maximum of every three to four hours.

To comply with the voiding schedule, patients must resist the sensation of urgency and postpone urination. Behavioral techniques can help patients to control the urge to urinate while they wait for their voiding interval to pass. The traditional approach has been to suggest various techniques for relaxation or distraction to another activity.^2,3 Patients are encouraged to get their minds off the bladder by engaging in a task that requires mental but not physical effort, such as reading, calling a friend, or making a to-do list. Also helpful are affirming self-statements such as “I am in control of my bladder,” or “I can wait.” More recently, the urge suppression strategy, that is, repeated contractions of the pelvic floor muscles without relaxing them in between, has been used to control urgency and detrusor contractions while the patient postpones urination.

Several studies have demonstrated the efficacy of bladder training for reducing incontinence.^2,37-39 The most definitive study is a randomized clinical trial that demonstrated a mean 57% reduction in frequency of incontinence in older women.² In this trial, bladder training reduced not only urgency incontinence but also stress incontinence. This unexpected finding may be because patients developed a greater awareness of bladder function or that postponing urination increased pelvic floor muscle activity. In another trial that compared bladder training with oxybutynin, 73% of women in bladder training were reported to be “clinically cured.”³⁹

Delayed Voiding

Delayed voiding is another approach to helping patients to expand the interval between voids. It differs from bladder training in that patients are not placed on a predetermined voiding schedule. When first experiencing an urge to void, patients are instructed to use their urge suppression techniques until the urge subsides. However, instead of going to the bathroom immediately after suppressing the urge, they postpone urination by waiting five minutes before voiding.

In patients who have experienced urgency incontinence, even a mild urge to void triggers a trip to bathroom as soon as possible, due to the fear of leakage otherwise. However, most patients can be convinced to try a five-minute delay, particularly in safe circumstances such as when they are at home alone. Often, they are surprised to find that after a brief wait, the urge subsides or disappears altogether. This enhances their sense of control and helps restore confidence so that they can gradually increase the delay time to achieve a normal frequency.

Increasing Voiding Frequency (Timed Voiding)

In some women, the bladder diary reveals a pattern of infrequent voiding (eg, less than five times per 24 hours) accompanied by urgency incontinence. This may be due to lifelong infrequent voiding such as which occurs among teachers or nurses, or can be the result of reduced bladder sensation, or dementia or other cognitive impairment. Often these patients have never considered voiding more frequently because they do not have an urge to void. A timed voiding schedule can allow them to void before their bladder becomes so full that urgency with leakage occurs.

Voiding more frequently should not be recommended to women with normal voiding frequency. This approach may provide immediate relief in the short term; however, the long-term result may be loss of ability to accommodate a full bladder and reduced functional bladder capacity. This starts the cycle of urgency and frequency that is thought to perpetuate overactive bladder and urgency incontinence over time (Figure 21-4).

Fluid Management

Many women attempt to control their incontinence by restricting their overall fluid intake. In some cases, particularly in older women, the resulting fluid intake may be inadequate and places them at risk of dehydration. Although it may seem counterintuitive, it is usually good advice to encourage the patient to consume at least six, 8-oz, glasses of fluid each day.⁴⁰ Some clinicians believe that this will also dilute the urine, making it less irritating to the bladder.

Although overall fluid restriction is not a good strategy, it may be very helpful to restrict fluids at particular times of day when toilet access will be limited, such as before a church service. Avoiding excessive fluid intake in the evening hours may also be helpful for reducing nocturia. Women using temporary fluid restriction should be encouraged to keep their total daily fluid intake optimized, by making up the missed fluids earlier or later.

It is not uncommon to encounter women who increase their fluid intake deliberately in an effort to “flush” their kidneys or lose weight. In other women, it is simply an unconscious habit. For women who consume an unnecessarily high volume of fluid (eg, resulting in >2,100 mL of output per 24 hours), reducing excess fluids can help prevent sudden bladder fullness and resulting urgency or incontinence.⁴¹

Reducing Caffeine and Other Bladder Irritants

Caffeine Reduction

Caffeine is a diuretic. However, it is also a bladder irritant for many women. Urodynamic studies have shown that caffeine increases detrusor pressure⁴² and is a risk factor for detrusor overactivity.^43,44 There is also evidence that reducing caffeine intake can help to reduce both stress and urgency incontinence.^45-47 Women are often reluctant to forgo their caffeinated beverages, particularly their morning coffee. However, if it is presented as a trial period, they may be convinced to try it for three to five days. If they experience relief from their symptoms, they are often more than willing to reduce or eliminate caffeinated beverages from their diet. To avoid symptoms of caffeine withdrawal, most notably headaches and irritability, it is recommended that caffeine reduction be approached gradually and may include mixing caffeinated and decaffeinated beverages incrementally over several weeks (Table 21-3).