This article originally appeared in the August 2004 Harvard Women’s Health Watch and is provided courtesy of Harvard Health Publications.

Bladder control training for urinary incontinence

You may be able to teach your bladder to behave itself.

Urinary incontinence — the involuntary loss of urine — can happen to anyone, but it occurs more often in women. One of the major causes is pelvic floor or sphincter muscle damage sustained during childbirth. Another possible contributor is the drop in estrogen levels at menopause, which can lead to changes in muscles that support the bladder and in the lining of the bladder and urethra. Other causes include aging, diseases such as diabetes, medications, and nerve damage.

Many women accommodate minor or temporary urinary incontinence by wearing pads. But all too often, urinary control problems take over a woman’s life. She may start to organize her activities around access to a bathroom or give up important pursuits, such as exercise, social events, and travel. If this is happening to you, you should know that in most cases, nonsurgical treatment can cure or markedly reduce urinary incontinence. One strategy that’s often successful is bladder control training.

What’s involved?
In bladder control training, a physician will first try to identify the cause of the incontinence. She or he will perform a physical exam, take a medical history, ask about any medications or supplements you take, and discuss your lifestyle and activities. You may also be asked to keep a 48-hour voiding diary — a record of your fluid intake, the times you urinate, and any leaking episodes.

Medical devices, medications, and surgical procedures have been developed to treat urinary incontinence. Depending upon the type and seriousness of the problem, one or more may be right for you. But many clinicians start by recommending a trial of bladder control training. This includes learning to urinate on a schedule (timed voiding), pelvic muscle exercises (Kegels), and sometimes biofeedback. Your clinician may also suggest taking a medication and limiting fluids to no more than 6–8 cups per day from all sources while you’re learning to control your bladder.

Bladder control training can be especially helpful with urge incontinence — the sudden and overwhelming need to urinate, sometimes accompanied by involuntary loss of urine on the way to the bathroom. During urge incontinence, the muscle surrounding the bladder contracts too soon, telling your brain that you must go, even when your bladder isn’t full. Urinating every time you get the urge only worsens the problem; it teaches the bladder to hold smaller and smaller amounts of urine. Bladder control training helps increase bladder capacity.

Learn to “go” on schedule
The mainstay of bladder control training is timed voiding, which means that you urinate at a set time, not when your bladder tells you to. Here’s what to do:

Determine your pattern. For a day or two, keep track of the times you urinate or leak urine during the day. If you filled out a voiding diary at your clinician’s request, you already have this information.
Choose an interval. Figure out how long you typically wait between urinations during the day. Based on that average interval, choose a starting time that’s 15 minutes longer. For example, if you usually go every hour, your starting interval will be 1 hour, 15 minutes.
Go by the clock. On the day you start, empty your bladder first thing in the morning and not again until after the interval you’ve set. If that time arrives before you feel the urge, go anyway. Remember, you’re training your bladder to keep a schedule. If the urge hits first, do everything you can to hold off going. This can be difficult at first, but usually improves with practice. If the urge is great, try to distract yourself. Practice Kegels (described below), cross your legs, stand still, or breathe slowly in and out for counts of four. Remind yourself that your bladder isn’t really full. If you can’t wait the full 15 minutes, try to manage another 5 minutes before walking slowly to the bathroom.
Increase your interval. Once you’re comfortable with your initial interval and aren’t having any leakage — this may take anywhere from a few days to a few weeks to accomplish — increase the time by another 15 minutes. Continue repeating this process and increasing your time by 15-minute increments. After several weeks or months, you may find that you’re able to wait for 3–4 hours between trips to the bathroom and that the feelings of urgency and episodes of incontinence have greatly diminished.
No training at night. Get up in the night whenever you need to urinate. Your day training should eventually begin to influence your entire voiding pattern, so that you get up less frequently at night.

What goes wrong?
Urinary continence relies on a complex process involving the brain, nerves, and muscles. When the bladder is full, nerves send the brain a message that it’s time to urinate. Normally, the ringlike sphincter muscle surrounding the urethra (the tube that carries urine from the bladder and out of the body) helps hold the urine back until you reach the bathroom. Once you’re there, the brain signals the sphincter to relax (to let the urine out) and tells the muscle surrounding the bladder (the detrusor muscle) to squeeze the urine out.

If any step in this process goes wrong, incontinence can result. For example, if muscles in the pelvic area are too weak to support the bladder and other nearby organs, urine may leak out when you exercise, laugh, cough, sneeze, or otherwise put pressure on the bladder. This is called stress incontinence. Urge incontinence is thought to result from an overactive detrusor muscle that causes the bladder to go into spasm. It’s exacerbated by poor tone in the urethra. Postmenopausal women often have both types — so-called mixed incontinence.

Learn to Kegel
Pelvic floor muscles are the muscles you use to hold back urination and thus are important to urinary continence. Contracting them also signals the detrusor muscle to relax, which allows the bladder to better hold the urine. You can strengthen and condition these muscles with pelvic floor exercises, also known as Kegels (named for Arnold Kegel, the physician who first described them).

To perform Kegels, you first need to find your pelvic floor muscles. Pretend you’re trying to avoid passing gas while simultaneously tightening your vagina around a tampon. You should feel the contraction more in the back than the front. Don’t contract the muscles of your stomach, leg, or buttocks. Once you’ve located the pelvic floor muscles, you need to repeatedly contract and relax them. Practice both short and long contractions and releases.

Short contractions, sometimes called flicks, are quick squeezes and releases. Mastering long contractions will take more practice. Start by holding each contraction for 3–5 seconds, resting for the same number of seconds between contractions. Build up to 10-second contractions with 10 seconds of rest between contractions. Try to do 30–40 long Kegels every day, divided into groups of 10 contractions each. You may want to do 10 before getting out of bed in the morning, 10 standing after lunch, 10 in the evening while sitting, and another 10 before going to sleep.

Women who have very weak pelvic muscles may benefit from biofeedback using a device that can help monitor progress in learning and doing Kegels. Patches placed over the muscles are connected to a video screen that displays the strength of the muscle contractions.

Selected resources
Better Bladder and Bowel Control, a Special Health Report from Harvard Medical School, is available for $16.

 Harvard Health Publications
P.O. Box 421073
Palm Coast, FL 32142-1073
877-649-9457 (toll free)
www.health.harvard.edu/BBBC

 National Association for Continence
800-252-3337 (toll free)
http://www.nafc.org/

 Simon Foundation for Continence
800-237-4666 (toll free)
http://www.simonfoundation.org/