Behavioural Intervention in Urinary Incontinence

Behavioural interventions are the recommended first-line treatment for geriatric urinary incontinence, because they are non-invasive, free of drug side-effects and non-specific — patients with stress and urgency incontinence respond equally well.

They are the only treatment modality applicable to every type of incontinence, and can be combined with drugs or surgery.

The essential classification is into patient-dependent procedures (requiring adequate function, learning capability and motivation, aiming to restore normal voiding and continence) and caregiver-dependent procedures (for functionally disabled patients, aiming to keep the patient and environment dry).

All patient-dependent procedures involve continuous self-monitoring with a bladder record; caregiver-dependent procedures use a staff-completed bladder and bowel record.

Education, modification of fluid and caffeine intake (aim for 1.5–2 litres of non-caffeinated fluid per day), and review of medications, discontinuing diuretics where possible.

Environmental manipulation — accessible toilets, commodes, urinals, adequate lighting, clothing that is easy to remove, walking aids — plus appropriate garments and pads.

Address reversible contributors: constipation and straining, obesity, chronic cough, atrophic vaginitis (long-term vaginal oestrogen where irritative symptoms predominate), delirium, and restricted mobility.

Pelvic floor muscle (Kegel) exercises are the essential component and produce the greatest benefit in treating urinary incontinence. They consist of repetitive contraction and relaxation of the pelvic floor muscles.

Technique: teach by asking the patient to interrupt voiding, or by squeezing the examiner’s fingers on vaginal examination — without a Valsalva manoeuvre, which is the opposite of the intended effect.

A full exercise is a 10-second squeeze and a 10-second relaxation, built up gradually, practised up to 40 times a day, and — crucially — used in real life at moments that provoke leakage (the “knack”: contracting before coughing, standing or hearing running water).

Women over 75 usually require biofeedback (vaginal or rectal pressure or EMG, with or without abdominal EMG) to identify the correct muscles; older men also respond to pelvic muscle and bladder training for overactive bladder and urgency incontinence.

Bladder training combines education, bladder records, pelvic muscle exercises and urge-suppression strategies; it is highly effective in motivated, functional community-dwelling patients.

Bladder retraining progressively lengthens or shortens the inter-voiding interval, with intermittent catheterisation where there is persistent retention — used chiefly after removal of an indwelling catheter or after an overdistension injury.

A bladder retraining protocol after catheter removal: remove the catheter (clamping first is unnecessary), treat any infection, then toilet the patient on waking, 2-hourly by day and evening, before bed and 4-hourly at night, with monitoring of continent voids, incontinent episodes, fluid intake and post-void residual. If difficulty persists beyond 1–2 weeks, seek reversible causes and consider urological referral.

Trigger and emptying techniques — running tap water, stroking the inner thigh, suprapubic tapping to trigger voiding; bending forward, suprapubic pressure and double voiding to complete emptying.

Scheduled (timed) toileting — routine toileting at fixed intervals, usually 2-hourly during the day and 4-hourly at night; usable in cognitive or physical impairment; the goal is to prevent wetting episodes.

Habit training — a variable toileting schedule individualised to the patient’s own voiding pattern as shown by the bladder record.

Prompted voiding — the best studied of these procedures: contact the resident approximately 2-hourly by day, focus attention on voiding by asking whether they are wet or dry, check and give feedback, offer toileting, give social reinforcement for continence and for appropriate requests, and offer fluids routinely.

Up to 25–40% of nursing home residents respond well to prompted voiding during the day, and responders can be identified by a 3-day trial, which improves cost-effectiveness. Night-time toileting should be individualised against sleep disruption and fall risk.

Success of caregiver-dependent programmes depends more on the knowledge and motivation of the staff or caregiver than on the patient’s physical or mental status — so staff training, supervision and quality-improvement methods are integral to the intervention.