The Path to Bladder Confidence: Understanding the Benefits of Bladder Training and Urge Suppression - Diane Newman

July 17, 2023

Diane Newman delivers an informative presentation on bladder training and urge suppression techniques as methods to manage lower urinary tract symptoms, particularly storage symptoms. She discusses the origins and principles of bladder training, explaining how it aims to improve bladder function by lengthening voiding intervals, thereby increasing bladder capacity and reducing overactivity. Urgency, often accompanied by incontinence, is a significant focus. Dr. Newman outlines various practical techniques to suppress urgency and delay voiding, including deep breathing, pelvic floor exercises, mind games, and self-affirmations. Notably, she emphasizes patient education and tailoring techniques to each patient's context and comfort. Acknowledging the process can be slow and stressful situations can exacerbate symptoms, she recommends starting in a relaxed, controlled environment. Backed by evidence from research, Dr. Newman promotes bladder training as a first-line treatment for managing urinary urgency and frequency, and, combined with pelvic floor muscle training, incontinence.


Diane K. Newman, DNP, ANP-BC, BCB-PMD, FAAN, Adjunct Professor of Urology in Surgery, Research Investigator Senior, Perelman School of Medicine, University of Pennsylvania, and Former Co-Director of the Penn Center for Continence and Pelvic Health, Philadelphia, PA

Read the Full Video Transcript

Diane Newman: Welcome. I'm Diane Newman. I'm a nurse practitioner who specializes in lower urinary tract dysfunction. I'm a continent nurse specialist and I've been providing behavioral treatments, non-surgical management of lower urinary tract symptoms for now over 35 years. This is just one in a series of presentations on behavioral therapies and all you wanna know about lower urinary tract symptoms. So I hope that you have finding these helpful. We're gonna talk now about bladder training and urge suppression techniques. These are part of behavioral therapies and I wanna go methodically through what you can do and really it's an education program. Where we utilize bladder training is for all these lower urinary tract symptoms, especially storage symptoms. Okay? As far as, because where bladder training really helps as far as urgency and frequency and also preventing urge urgency incontinence. We don't use it as much with stress incontinence, but we can.

So I wanna talk to you about intervention for these symptoms. So what is bladder training? Well, let's start with the symptoms. Urinary urgency. What patients will say is, honey, when I gotta go, I gotta go. You don't understand, I can't make it there, I have to rush there. Okay? And what happens is they develop really what I call obsessive toileting habits where they start to go more and more frequently. You know, I have patients that go every hour, which I don't know how they can work and go every hour. They literally live next to a bathroom or they only go places where they know where the bathroom is, which is called toilet mapping. So what is urinary urgency? It's sudden, it's uncomfortable, it comes on. You're not, no, not prepared for it. You don't know when it's gonna happen. Usually you lose urine as you walk to the bathroom and you have urgency incontinence.

When you urinate, it's usually small amounts because you're going so frequently and people will go over eight times a day and basically you may also get up at night to urinate. So that's urinary urgency. Bladder training has been shown to be very effective in this population. It's been around since the 1960s. It's actually the original research was done in a UK hospital where they called, did something called bladder drill, where they took the individual hospitalized patients to the bathroom every two hours to keep them continent so they didn't leak urine. And actually that's where the every two hours came from in nursing home. So that was what we call timed voiding, but it's been around a long time. But basically bladder training is like a bladder retraining. It's to improve bladder function by focusing on voiding habits. So you wanna find out when that individual goes to the bathroom and increase the times between voids. So that's what bladder training is. Hopefully over time, if they're avoiding frequently, you're gonna increase the times, which means that bladder capacity is going to increase and that bladder will decrease the overactivity that might be occurring, that urgency and that urgency incontinence.

Now these are a group of strategies. It is an educational program. So one of the most important things is the learning capability of the patient. If you have someone with a cognitive impairment may not remember these instructions, that may not be helpful. So basically you teach 'em what urinary urgency is. What urgency incontinence is usually follows your near urgency and how you can, the goal is to suppress that urgency before you walk to the bathroom. So you get rid of that really strong pressure before you walk to the bathroom. If you can do that, you are apt not to leak urine on the way. Now how does this work? And there's actually some research on why this works. And basically it improves the bladder's capability to inhibit bladder contractions. It improves the brain's facilitation over urethral closure as it starts to fill with urine. It improves central modulation of the afarrent and sensory impulses. Remember, urgency is a sensory impulse from the nervous system and it increases the person's awareness and changes behavior related to the circumstances that lead to bladder symptoms.

So that's why we see that this does work well. So what do we start with? Well, the goal is to first find out what is the person's pattern and how do you do that? From a bladder diary. I talked about that in one of the other presentations as part of UI assessment. So how often are they going? And then what you do is you slowly increase the interval. So if they're going say every hour, I want you now to start not going for every maybe hour and a half and what do you do in the interim? So the goal is to try to expand the times between voiding. That's called increasing inter void intervals. Okay? and this is a slow process. So you give them like try for three days. You don't want them to have incontinence, but what do they do? Because you may not want them to do this at work because if they're fearful or stressed or anxious that something's gonna happen.

Like if you're a teacher and you're worried about wetting yourself between classes, you would not practice bladder training there. You tell them to PR practice in a relaxed environment, usually, usually at home when the bathroom's nearby. So if they have a problem, they're all controlled situation so that they could be successful. Remember, stress, anxiety worsens bladder problems because the area of the brain that handles emotions handles the bladder. I tell them it's a physiological connection. Okay? So I use actually in this, I use in my practice, I've actually had this urge wave blown up at Kinkos and I laminated it and I teach patients about the urge wave. What does urge mean? Well, the bladder's filling with urine, it gets too peak when you get that urgency and then it goes away. What you're doing when it gets strong is you're rushing to the bathroom. I don't want you doing that. I want you to get rid of the urge or lessen it before you walk to the bathroom. Well, how can I do that? Diane, you don't understand.

There's a lot techniques and I want you to go through all these slides very carefully because it's part of my teaching tool. I give them an educational tool on this and there's a d different techniques that work. And this has been tried and shown the effectiveness in randomized control trials by actually a nurse researcher Gene Wyman back in the 19, late eighties and early nineties where they took middle age women and taught them these techniques to delay void, to decrease that urgency, frequency and incontinence. So what I tell them, and let me walk through, through this, I tell them to sit down, close your eyes when they have urgency, sit down, don't run to the bathroom. So you're gonna sit down, close your eyes and you're gonna do some slow deep breathing in and out of your mouth, concentrate on your breathing, the urge will lessen and then you wait a few minutes and walk to the bathroom.
Now what was I doing there? Well actually you're distracting them. You're having them not concentrating their bladder but concentrate on their breathing. I use the analogy of the nurse. I always tell my patients a story. Okay? The nurse is a nurse in the hospital, she's passing out meds, she's an hour behind. A patient falls outta bed, she gets the urge to pee. What does she do? So those are three messages from the brain, right? Well, what she probably will do would, if she's a good nurse, is oh my goodness, I could let me go help them get the patient off the floor. I'm gonna have to write out an incident report. I'm gonna be so far behind in my meds, what happened to the bladder. Whereas the urine, it didn't fly away. She inhibited subconsciously without even thinking about it, by throwing that message of urge out with the more important things, getting the patient off the floor.

And now I need to do meds. And nurses are notorious going eight hours, not 40 because the urge comes back later and later and she keeps inhibiting because she's probably gonna be behind the whole shift. Another example is a child. Have you ever seen a little child running from the playground holding themselves, wetting themselves? So they kept getting the urge while they're playing and they're having so much fun playing, they won't stop. So where they do, they get to capacity and then they're wet. So these are the distraction methods. You can use a deep breathing. I have found that successful. You can also do a couple quick pelvic floor muscle exercises, which will also be effective. Okay? they show that that actually breaks the reflex arc when you quickly can track the pelvic floor. You can do mind games. One mind game that drives me nuts is subtracting back from a hundred by seven. Becasue I'm not into math. I get to 93, then I have to really concentrate and say, okay, seven from 93 is, what is that? 86? So that's distracting to me. You can do several things and I tell patients there's several things you can do. You can do self affirmations such as I'm not gonna go, I'm gonna wait, I'm gonna wait. I had a man in his forties that did that.

I mean one visit, he came back and said, Diane, he was having problems in meetings. He had just sold his company. He was kept on to try to manage the new group. It was very stressful. He was finding, drinking a lot of coffee, finding he was always having to go to the bathroom. And I worked with him. He said, I know, I just silently in my head say, you can hold it. We're gonna be done in 10 minutes. You can hold it. And that worked for him. So there's a lot of different things. You can play a game or a puzzle on your cell phone. I think those are very distracting. What you want the patient not to do, and this is very important, do not rush to the bathroom. You stop and stay still. You can squeeze the pelvic floor, relax the body, and then what'll happen is the urge will lessen and then they slowly walk to the bathroom.

Now I tell patients, success is not every time. If this works for you once a day, once a week, that's success for me. I just want you to try this. And what patients will say when they come back and remember, I, I teach bladder training to patients with urgency frequency, not with stress incontinence. So this is for urgency, frequency, urgency, incontinence. They'll come back and say, oh, you're right Diane. I tried that. It does work once in a while or I try to really do, you know, sit down and try to relax and yeah, I, and they'll say I have more control. It doesn't seem like I'm rushing as much. Those are the kinds of outcomes that you'll hear patients will say. The efficacy, as I said, was by J.A Fantl, Gene Wyman. This was in 1991. 123 women. You can see reduction in incontinence.

They looked at incontinence and you can see improvement in 50 to 79%. Dry 12%. But you can see that change. So this is really a very effective program. And this is the evidence of bladder training from the international consultation on incontinence. Looking at bladder training by itself. And a recommendation is first line treatments. This works education program, it's counseling. It takes time. But I'm telling you, if you put in the time, you will see success, both whether you're a clinician or a patient when you combine it with pelvic floor muscle training. And I do have a presentation on that or in as a supplement, it does work. So the thing is, is that the evidence is there. You know, let's, I really hope you add bladder training with urge suppression to your practice, because I know it can be effective. So awaken that pelvic floor and get started and let's have you become a bladder whisperer. Thank you.
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