cancer control fall prevention health consumerism mental fitness mental health nutrition physical fitness weight control wellness center

andropause incontinence kegel exercises men's sexuality prostate health women's sexuality find a pelvic health specialist

addison's disease arthritis diabetes center eating disorders gout center heart disease caregiving

bookstore ebooks wellness store underwear buying guide product catalogs

overview causes of acute incontinence causes of chronic incontinence treatments managing overactive bladder pelvic pain & vulvodynia pelvic pain & vulvodynia forum bladder disorders in children children and bedwetting bladder problems in men prostate cancer incontinence and fall risk tip sheets for patients ask an incontinence nurse resources

overview electrical stimulation pelvic floor muscle rehabilitation lifestyle changes and behavioral therapy toileting programs bladder retraining biofeedback kegel exercises medications surgery children's treatments

behavioral therapy controlling symptoms patient education bladder record

home pelvic health incontinence treatments lifestyle changes and behavioral therapy behavioral therapy

behavioral therapy for incontinence

by Diane K. Newman, RNC, MSN, CRNP, FAAN

Dietary Habits

Fluid management, restriction of bladder irritants and bowel regulation through dietary changes and habits can help people control or decrease urinary urgency and frequency.

Symptoms of UI and overactive bladder will worsen with too little fluid or too much fluid. In all cases, adequate fluid intake is necessary to eliminate irritants from the bladder and control symptoms. An insufficient intake of fluids on a continuous basis can lead to urinary tract infections and a decrease in bladder capacity.

The elderly are especially at risk for dehydration although many older people mistakenly believe that restricting fluid intake will prevent urinary frequency and urgency. Lowering the fluid intake causes the urine to become more concentrated and to irritate the lining of the bladder. Dark yellow or strong-smelling, concentrated urine may actually cause urinary urgency and frequency. Furthermore, decreased fluid intake can lead to constipation. The timing of fluid intake may also be important, especially in the elderly. Avoiding fluids in the evening can reduce the amount and frequency of trips to the bathroom.

In several studies, increasing fluid intake has correlated with a decrease in UI episodes. The current recommended intake of fluid daily is 1500 ml (about 6 ½ cups), but many people feel that 1800-2400 ml (about 7 to 10 cups) per day is more appropriate. Older people should try to consumer 6- 9 cups of liquids per day in order to be well hydrated.

A formula for calculating proper fluid intake (in the absence of fluid restriction, and with normal physical activity and moderate temperatures) based on body weight can be calculated in three steps. Before doing the calculation, body weight must be expressed in kilograms (2.2 lbs equals 1 kilogram):

1. For the first 10 kg, the fluid requirement is 100ml/kg or 1000ml (4.23 cups)
2. For the second 10 kg, the fluid requirement is 50ml/kg or 500ml (2.11 cups)
3. For weight over 20 kg, the fluid requirement is 20ml/kg (20 ml = .08 cups)

Many women, especially those who are dieting, consume in excess of 4000 ml of fluids per day. If they are having symptoms of UI, they should decrease this amount.

People who have problems with voiding too often at night (nocturia) should take care to time their intake of fluids. Aging can cause nocturia on its own, but restricting fluid intake in the evening may be helpful. Certain chronic medical conditions, including congestive heart failure, venous stasis with peripheral edema, hypoglycemia with excess urine output, and obstructive sleep apnea, as well as the use of diuretics can increase the amount of urine created in the night. People with these problems should not decrease the total volume of liquids consumed but should shift their intake to morning and afternoon hours.

Influence of Bladder Irritants

Different fluids have a different impact on the bladder and on UI symptoms. For example, caffeine is a natural diuretic and bladder irritant and can cause urinary urgency and frequency. Over 80 percent of the US population consumes some form of caffeine daily in the form of coffee, tea, or soft drinks. Sodas that contain caffeine include Mountain Dew, Pepsi, and Coca-cola, energy drinks such as Red Bull, and all foods made from chocolate contain caffeine. Furthermore, more than 1000 over-the-counter drugs, such as Excedrin and Anacin, include caffeine in their formulas, which must be printed on their labels. Alcohol is also considered by some to have diuretic properties as may artificial sweeteners (aspartame), highly spiced foods, citrus juices and tomato-based products.

Studies show that decreasing caffeine intake may reduce UI symptoms. People with UI or OAB should switch to caffeine-free foods and beverages to see if their symptoms change or improve. Caffeine should be restricted to no more than 200 mg/day (two cups of coffee or tea) and the decrease in caffeine should occur gradually over time to reduce the chance of withdrawal headache, nervousness, nausea or muscle tension.

In order to better track the effect of changes in the type and timing of fluid intake, it may be very helpful to keep a Bladder Record or Voiding Diary (See Figure 1.) Keep a 3 day bladr record and take it with oyu to show your doctor. Both the type and amount of fluid intake is recorded along with each episode of incontinence. After a short period of time, patterns will emerge that can provide evidence of the effectiveness of any changes made.

Bowel Regularity

Chronic constipation (strictly defined as fewer that three bowel movements per week) and straining when having a bowel movement can contribute to UI symptoms and to pelvic organ prolapse (dropped badder, uterus or rectum). For the person who feels constipated, however, the definition may also include painful defecation, dry hard stools, small stools, and incomplete or infrequent stool evacuation. Since there appears to be a relationship between chronic constipation and incontinence, it makes sense for the affected person to change lifestyle habits to encourage bowel regularity. These might include increasing the amount of fiber in the diet, increasing daily fluid intake, regular exercise, and the establishment of a daily routine around bowel habits.

It is important to never ignore the urge to defecate but the ideal time for defecation is in the morning after breakfast. The schedule should also allow adequate, undisturbed time for the pelvic floor muscle to become relaxed. Avoiding constipation may be easier if fluids and bladder irritants are being managed at the same time as an attempt to regulate daily bowel habits.

A good way to increase fiber in the diet is by using a “special bran recipe”. Mix together: 1 cup applesauce, 1 cup coarse unprocessed wheat bran and ¾ cup prune juice. Refrigerate mixture and take 2 tablespoons of the mixture every day. Take the mixture in the evening for a morning bowel movement. Increase the bran mixture by two tablespoons each week until bowel movements are regular. Always drink one large glass of water with the mixture.

Physical and Occupational Stressors

Incontinence in young, healthy women has been associated with physical exercise and is common among female athletes, women in the military, and among professional dancers. Any high impact physical exertion (when both feet are off the ground at the same time) will cause downward pressure on the pelvic floor muscle and may result in stress UI. Sports such as basketball and gymnastics can create sudden increases in intra-abdominal pressure that result in urine leakage. Jumping and running are the activities most associated with this type of incontinence and women who experience this form of stress UI can use an absorbent pad or panty shield to manage the slight amounts of urine lost.

Another cause of incontinence in women can be blue collar, factory, and sales jobs that require long periods of standing and few bathroom breaks. This type of job may also require heavy lifting and bending or long periods of walking and standing, all of which may increase risk for UI, urgency and frequency as well as pelvic organ prolapse.

References

1. Arya LA, Myers DL, Jackson ND. (2000) Dietary Caffeine intake and the risk for detrusor instability: A case-control study, Obstetrics & Gynecology. July, 96(1): 85-89.
2. Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), Evidence-based clinical practice guideline, Continence for Women. 2000.
3. Brown JS, Grady D, Ouslander JG, Herzog AR, Varner RE, Posner SF, (1999) Prevalence of urinary incontinence and associated risk factors in postmenopausal women, Obstetrics & Gynecology; July, 94(1): 66-70.
4. Brown, JS, Seeley, DG, Fong, J., Black, DM, Ensrud, KE, Grady, D. (1996) Urinary incontinence in older women: who is at risk? Obstet Gynecol;87:715-21.
5. Bump RC, McClish DM. (1992) Cigarette smoking and urinary incontinence. Am J Obstet Gynecol;167(5):1214-1218.
6. Bump RC, McClish DM. (1994) Cigarette smoking and pure genuine stress incontinence of urine. A comparison of risk factors and determinants between smokers and nonsmokers. Am J Obstet Gynecol;170(2):579-82.
7. Bump RC, Sugerman, H., Fantl, JA, McClish DM. (1992) Obesity and lower urinary tract function in women: effect of surgically induced weight loss. Am J Obstet Gynecol;166:392-9.
8. Burgio KL, Matthews KA, Engel BT. (1991) Prevalence, incidence and correlates of urinary incontinence in healthy, middle-aged women. J Urol;146:1255-9.
9. Bryant, CM., Dowell, CJ., Fairbrother, G. (2000) A randomized trial of the effects of caffeine upon frequency, urgency and urge incontinence. Neurourology and Urodynamics. 19: 501-502.
10. Cohen, SM., Johansson, SL. (1992) Epidemiology and etiology of bladder cancer. Urol Clin N America;19:421.
11. Creighton, SM and Stanton, SL. (1990) Caffeine: Does it affect your bladder? British Journal of Urology; 66:613-614.
12. Deitel, M., Stone, E., Kassam, H.A., Wilk, E.J., Sutherland, D.J.A. (1988) Gynecologic-obstetric changes after loss of massive excess weight following bariatric surgery. Journal of the American College of Nutrition. 7 (2): 147-153.
13. Diokno, AC., Brock, BM., Herzog, AR., Bromberg, J.(1990) Medical correlates of urinary incontinence in the elderly. Urology. 36: 129-138.
14. Dougherty, MC, Dwyer, JW, Pendergast, JF, Boyington, AR, Tomlinson, BU, Coward, RT, Duncan, RP, Vogel, B, Rooks, LG. (2002) A randomized trial of behavioral management for Continence with older rural women. Research in Nursing & Health.;25:3-13.
15. Davis, GD., Goodman, M. (1996) Stress urinary incontinence in nulliparous female soldiers in airborne infantry training. Journal of Pelvic Surgery. 2(2): 68-71.
16. Dowd, T.T., Campbell, J.M., Jones, J.A. (1996) Fluid intake and urinary incontinence in older community-dwelling women. Journal of Community Health Nursing. 13(3): 179-186.
17. Dwyer PL, Lee, ETC, Hay. DM. (1988) Obesity and urinary incontinence in women. British Journal Obstet Gynecol;95:91-6.
18. Elia, G., Dye, TD., Scariati, PD. (2001) Body mass index and urinary symptoms in women. Int Urogyncol J; 12:366-69.
19. Engberg, SJ., McDowell, BJ., Burgio, KL., Watson, JE., Belle, S.,( 1995) Self-care behaviors of older women with urinary incontinence. JOGN; 21(8):7-14.
20. Fantl, JA, Newman, DK, Colling, J. et.al. (1996) Urinary Incontinence in Adults: Acute and Chronic Management Clinical Practice Guideline, No 2, Update, Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, AHCPR Publication No. 96-0682. March.
21. Fischer, JR., Berg, PH., (1999) Urinary incontinence in United States air force female aircrew. Obstetrics and Gynecology. 94(4):532-536.
22. Fitzgerald, S., Palmer, MH., Berry, SJ., Hart, K.. (2000) Urinary incontinence: Impact on working women. AAOHN Journal. 48(3), March:112-118.
23. Griffiths, D.J., McCracken, P.N., Harrison G.M., Gormley, E.A. (1993) Relationship of fluid intake to voluntary micturition and urinary incontinence in geriatric patients. Neurourology & Urodynamics. 12: 1-7.
24. Gray M, (2001) Caffeine and Urinary Continence, JWOCN, 28: 66-69.
25. Hojberg K-E, Salvig JD, Winslow NA, Lose G, Secher NJ (1999) Urinary incontinence: prevalence and risk factors at 16 weeks of gestation, British Journal of Obstetrics and Gynaecology, August, 106:842-850.
26. Johnson, TM., Kincade, JE., Bernard, SL., Busby-Whitehead, J., DeFriese, GH. (2000) Self-care practices used by older men and women to manage urinary incontinence: results from the national follow-up survey on self-care and aging, JAGS., 48(8):894-902.
27. Jorgensen S, Heiin HO, Gyntelberg F (1994) Heavy lifting at work and risk of genital prolapse and herniated lumbar disc in assistant nurses, Occup. Med., vol. 44: 47-49.
28. Kayser-Jones J, Schell ES, Porter C, Barbaccia JC, Shaw H. (1999) Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision JAGS 47:1187-1194.
29. Koley, B., Koley, J., Saha, JK. (1984) The effects of nicotine on spontaneous contractions of cat urinary bladder in situ. British J Pharmacol. 83:347-55.
30. Koskimaki, J, Hakama M, Huhtala H, Tammela TLJ. (1998) Association of smoking with lower urinary tract symptoms. J Urol 159: 1580-2.
31. Lamarine RJ, (1994) Selected Health and Behavioral Effects Related to the Use of Caffeine, Journal of Community Health, December, 19(6): 449-466.
32. Lee RA, Balick MJ. (2006). Rx: Caffeine. Explore, 2, 55-59.
33. Lee JG, Wein AJ, Levin RM, (1993) The effect of caffeine on the contractile response of the rabbit urinary bladder to field stimulation, General Pharmacology, 24(4): 1007-1011.
34. Lubowski, DZ., Swash, M., Nicholls, R.J.,Henry, MM. Increase in pudendal nerve terminal motor latency with defaecation straining. British Journal of Surgery. 75: 1095-1097, 1988.
35. Moller LA, Lose G, Jorgensen T (2000) Risk factors for lower urinary tract symptoms in women 40 to 60 years of age, Obstetrics & Gynecology, 96(3): 446-451.
36. Mommsen, S; Foldspang, A. (1994) Body mass index and adult female urinary incontinence. World Journal of Urol;19:319-22.
37. Newman, DK. (2002) Managing and treating urinary incontinence. Baltimore: Health Professions Press.
38. Newman, D.K. (1999). 2nd Ed. The Urinary Incontinence Sourcebook, Lowell House, California.
39. Nuotio, M., Jylha, M., Koivisto, AM., Tammela, TLJ., (2001) Association of smoking with urgency in older people. European Urology; 40: 206-212.
40. Nygaard, IE., Thompson, FL., Svengalis, SL., Albright, JP. (1994) Urinary incontinence in elite nulliparous athletes. Obstetrics & Gynecology. 84 (2): 183-187.
41. Nygaard IE., Linder, M. (1997) Thirst at work- an occupational hazard? Int Urogyn and Pelvic Floor Dysfunction; 8(6):340-343.
42. Nygaard IE. (1997) Does prolonged high-impact activity contribute to later urinary incontinence? A retrospective cohort study of female Olympians. Obstet Gynecol; 90(5):718-722.
43. Nygaard, I (1995) Prevention of exercise incontinence with mechanical devices. Journal Reprod Med. 40:89.
44. Palmer, MH., Fitzgerald, S., Berry, SJ., Hart, K.. (1999) Urinary incontinence in working women: an exploratory study. Women and Health. 29(3):67-80.
45. Roe, B., Doll, H., (1999) Lifestyle factors and continence status: comparison of self-report data from a postal survey in England.,.JWOCN: 26(6): 312-319.
46. Ruggieri, MR., Whitmore, KE., Levine, RM. (1990) Bladder purinergic receptors. J Urol: 144:176-81.
47. Sherman, RA., Davis, GD, & Wong, MF. (1997) “Behavioral treatment of exercise-induced urinary incontinence among female soldiers” Military Medicine 162,690-694.
48. Snooks, SJ, Barnes, PRH, Setchell, M., Henry, MM., (1985) Damage to the innervation of pelvic floor musculature in chronic constipation. Gastroenterol :89:977-981.
49. Spence-Jones C, Kamm MA, Henry MM, Hudson CN (1994) Bowel dysfunction: a pathogenic factor in uterovaginal prolapse and urinary stress incontinence, British journal of Obstetrics and Gynaecology, February,101:147-152.
50. Subak LL, Whitcomb E, Shen H, Saxton J, et al: (2005). Weight loss: A novel and effective treatment for urinary incontinence. Journal of Urol, 174, 190-195.
51. Tampakoudis P, Tantanassis T, Grimbizis G, Papeletsos M, and Mantalenakis S. (1995) Cigarette smoking and urinary incontinence in women – a new calculative method of estimating the exposure to smoke. Eur J Obstet Gynecol and Reprod Bio; 63: 17-30.
52. Thomas, AM, Morse, JM., (1991) Managing urinary incontinence with self-care practices. J Gerontological Nurisng;17(6):9-14.
53. Thyssen, HH, Clevin, LS. Olesen, L., Lose, G (2002) Urinary Incontinence in Elite Female Athletes and Dancers. Int Urogynecol J;13: 15-17.
54. Tomlinson, BU, Dougherty, MC, Pendergast, JF, Boyington, AR, Coffman, MA, Pickens, SM. (1999) Dietary caffeine, fluid intake and urinary incontinence in older rural women. International Urogynecolgy 10:22-28.
55. Wells, TJ (1997) Nursing Management in Urinary incontinence., O’Donnell, PD ED., St Louis: Mosby:439-433.
56. Wilson PD, Berghamns, B., Hagen, S., Hay-Smith, J., Moore, K., Nygaard, I., et al. (2005) Adult conservative management. In Abrams P, et al (eds). Incontinence, Proceedings from the 3rd International Consultation on Incontinence. Plymouth, United Kingdom: Health Publications; 855-964.
57. Wyman, J.F., Elswick, R.K., Wilsom, M.S., Fantl, J.A. (1991) Relationship of fluid intake to voluntary micturitions and urinary incontinence in women. Neurourology & Urodynamics.: 463-473.

Posted October 2006

26 South Main Street, PMB #162 . Concord, NH 03301 . Phone: 603 397-0103