behavioral therapy as a treatment for urinary incontinence

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

Changes in personal behavior can help many people to prevent urinary incontinence or reduce the troubling symptoms of urgency and frequency.

Dietary habits can affect urinary incontinence symptoms

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 urinary incontinence 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 urinary incontinence 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 during the night.

In several studies, increasing fluid intake has correlated with a decrease in urinary incontinence 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 consume 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 urinary incontinence, 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 (caffeine and alcohol) on urinary incontinence symptoms

Different fluids have a different impact on the bladder and on urinary incontinence 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 urinary incontinence symptoms. People with urinary incontinence or overactive bladder 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. Keep a 3 day bladder record and take it with you to show your doctor. Both the type and amount of fluid intake is recorded along with each episode of urinary incontinence. After a short period of time, patterns will emerge that can provide evidence of the effectiveness of any changes made.

Bowel regularity may affect urinary incontinence symptoms

Chronic constipation (strictly defined as fewer that three bowel movements per week) and straining when having a bowel movement can contribute to urinary incontinence 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 urinary 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 can have an impact on urinary incontinence symptoms

Urinary 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 urinary incontinence. 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 urinary 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 urinary 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 urinary incontinence, urgency and frequency as well as pelvic organ prolapse.

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Posted October 2006
Last update August 2009

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