Behaviour Retraining

“Multicomponent behaviour retraining is about learning a new response to urgency based on the use of Pelvic Floor Muscle contraction as a critical component to suppress urgency, control incontinence and restore a normal voiding interval.”

“It involves not rushing to the bathroom in response to urgency, and instead use Pelvic Floor Muscle contractions to suppress bladder contraction and delay voiding.” – International Journal of Clinical Practice 

Aims:

1. Reduce incontinence episodes associated with symptomatic urinary urgency (i.e. eliminate Urge Urinary Incontinence)
2. Use strategies to reduce the sensation of Urgency when Urgency episodes occur
3. Improve confidence to regain control of bladder function and freedom from fear of leakage

Theory: 

The instinctive response to a sudden sensation of urinary urgency (detrusor overactivity) is to begin rushing to the toilet (usually running or walking very fast!). 

Issues:

• Detrusor overactivity = high intravesical pressure
• Rushing to the toilet causes increased pressure on the bladder which can lead to an increased chance of incontinence 
• Increased anxiety brought on by ‘rushing’ can exacerbate detrusor overactivity – the more you rush, the stronger the urge!

Breaking the Cycle:

• It is important to understand that sudden episodes of urgency/ detrusor overactivity are usually only temporary 
• If you are able to wait, the sudden intense urge is likely to pass and settle to a more comfortable sensation
• This allows you to still choose when to go to the toilet but at a time of lower risk of incontinence 
• This method will also reduce urinary frequency by consciously delaying voiding until a later time

Urge Suppression Reflexes:

1. Pressure on Dorsal Clitoral Nerve of Perineum

• A reflex that inhibits urination during sexual intercourse
• Apply pressure to the perineum using hand, corner of the table, the edge of a chair, etc.

2. Activation of Posterior Tibial Nerve

• Contract your calf muscles or curl your toes

3. Activation of Pelvic Floor Muscles

• During the normal bladder storage phase, the detrusor relaxes and the Pelvic Floor contracts while the opposite is true for the voiding phase
• Pelvic floor contraction thought to inhibit detrusor contractility (“Guarding reflex”)
• Contract and hold a strong Pelvic Floor Contraction for 10 seconds and repeat if necessary until the urge passes. DO NOT HOLD YOUR BREATH!
• NB. Need to be careful not to trigger an urge with this technique (i.e. 

4. Facilitation of Frontal Lobe

• Use distraction techniques such as relaxed breathing, counting backwards or recalling a shopping list. 

The goal of Behaviour Retraining is very much to reduce and manage the Urge Incontinence associated with sudden Urgency. But it doesn’t necessarily stop the Urgency from occurring in the first place.

Trigger Retraining

The body can set up abnormal excitatory reflexes where certain triggers can cause detrusor overactivity contractions and urgency. – ICS (2002)

To overcome this issue, we need to unwire certain triggers from causing detrusor overactivity. This involves breaking cortical – bladder neuronal associations and needs deliberate practice daily!

Step 1: Identify trigger (e.g. putting keys in the door, running water, walking past the toilet)

Step 2: Implement reflexes just prior to trigger (i.e. “the knack”, perineal pressure, calf squeeze)

Step 3: Deliberate practice (i.e. going less frequently at the gym, in the shower, hand washing)

Step 4: Form a new habit

Step 5: Monitor success

Bladder Retraining

If your Urgency is spontaneous and/or not related to a trigger we need to incorporate a Bladder Drill Plan with scheduled voids of increasing intervals over time. 

How it works:

Step 1: Complete a bladder diary.

Step 2: Decide on an initial timed voiding frequency that is less than the shortest interval that creates urgency (i.e. urge 4).

Step 3: Urinate when you first wake up in the morning (use suppression techniques before you get out of bed if you usually don’t make it to the toilet without leaking).

Step 4: Empty your bladder completely and check-off that you did (if you did not, leave it blank).

Step 5: Set a timer for your next scheduled void.

Step 6: When the timer goes off, go to the toilet even if you do not feel the need to and attempt to empty your bladder (if you do, check it off – if not, leave it blank).

Step 7: Reset the timer and continue the same pattern throughout the day until you go to bed.

Step 8: If you can complete 3 days in a row without any urgency (grade 4), you can increase the interval time by 15 minutes. Continue to do this up until you are able to go 3-4 hours without any urgency.

NB. If you feel the need to urinate before the timer sounds, practice the distraction and relaxation techniques you have been taught to control the urge until it passes. If you cannot hold until the scheduled void time you may go to the toilet and try again next time. It is perfectly normal for this to happen when retraining the bladder and will take some time to resolve.

Kayla Lee Physio