Timed Voiding and Fluid Management

Marie Fidela R. Paraiso and George Abate

Timed voiding (also referred to as bladder retraining/training, bladder drill, bladder discipline, and bladder reeducation) is a behavioral exercise used to establish bladder control in adults. Evidence indicating that bladder training is effective in women with urodynamic urge incontinence with or without associated detrusor overactivity, sensory-urgency without incontinence,1 and urodynamic stress incontinence,2 has led to the 1996 Clinical Practice Guideline's recommendation of bladder training as a first-line therapy for urge, stress, and mixed incontinence.3 Urodynamic studies are not required before initiation of behavioral therapy.

The three components of timed voiding are education regarding continence and incontinence mechanisms; scheduled voiding with systemic delay of voiding by implementing distraction and relaxation techniques; and positive reinforcement provided by a caregiver. The specific goals of bladder training include correcting inappropriate habits of frequent urination, improving control of bladder urgency, extending intervals between voids, increasing bladder capacity, reducing incontinence episodes, and building patient self-confidence in bladder control. There is very little understanding of how bladder retraining works. Several hypotheses exist, including improved cortical suppression of sensory stimuli from an uninhibited bladder, improved cortical inhibition of an overactive detrusor muscle, maintenance of bladder pressures lower than the urethral closure pressure during stress, increasing bladder "reserve" volume, and altered patient behavior to avoid incontinence triggers and to gain awareness of the lower urinary tract.

Two randomized trials showed significant improvements in incontinent patients when compared with an untreated control group. Jarvis and Millar4 reported that 90% of the treatment group was continent and 83.3% was symptom free at 6 months; whereas, the control group reported 23.3% continence and lack of symptoms. Fantl et al.2 demonstrated that 12% of the treatment group was continent and 76% were improved at 6 weeks and subsequently maintained at 6 months. They also reported a 55%

improvement of quality of life. One multicentered randomized trial by Wyman et al.5 indicated that bladder retraining and pelvic floor muscle exercises showed similar efficacy in women with urge, stress, and mixed incontinence.

The literature regarding dietary factors and fluid intake and their effect on incontinence is sparse, and there are few poorly powered randomized trials. Caffeine intake increases detrusor pressure on cystometry, and women with detrusor overactivity have a higher mean caffeine intake.6,7 Decrease of caffeine intake decreases urine loss episodes.8 In the only randomized trial by Bryant et al.,9 reduction of daily caffeine intake to less than 100 mg along with bladder exercises, decreased incontinent episodes by 74% versus a 32% reduction in those who continued to take normal caffeine and performed the same bladder exercises. In a multivariable analysis, there was no association between coffee drinking or alcohol consumption and incontinence.10 Griffiths et al.11 showed a strong relationship between evening fluid intake, nocturia, and nocturnal voided volume. However, the relationship was not as strong for diurnal intake, voiding, and voided volume. A modest positive association has been noted between fluid intake and incontinence severity in women older than age 55, whereas no such correlation was seen in women with detrusor overactivity.12 In a small randomized trial of 32 women who were assigned to three different groups of fluid intake, adherence to protocol was so poor that the results were difficult to interpret.13 There is anecdotal evidence that supports elimination of certain dietary irritants. In summary, fluid intake has a minimal effect on incontinence and caffeine intake, and its role in the pathogenesis of incontinence is controversial.

Timed voiding and fluid management go hand in hand as first-line therapy for urinary incontinence. A thorough history and physical, urinalysis, postvoid residual, and urinary diary are the baseline assessment of all incontinent patients before this first-line treatment. Bladder diaries are essential in helping the clinician and patient identify habits that the patient may modify to reduce incontinence.

Voiding and fluid diaries can be used to determine whether decreasing fluids or increasing the voiding interval is appropriate. (Please refer to Chapter 14-1 on bladder diaries for more detail.) Women with excessive fluid intake can decrease incontinence by limiting intake. However, other causes for incontinence, such as diabetes mellitus, diabetes insipidus, and hypercalcemia should be ruled out as causes for polydipsia and polyuria. If a patient complains of urinary frequency and drinks large volumes of fluid per day, we will obtain a fluid diary, and if voided volume is more than 3 to 4L, a urine osmolality (Uosm) is ordered. If the Uosm is 200 or less, a plasma osmolality (Posm) is obtained, if less than 280 mOsm/kg, psychogenic polydipsia is likely and if greater than 290 mOsm/kg, diabetes insipidus is the diagnosis (Figure 12-2.1).14

Patients often are not aware of how much or what types of fluids they drink. With fluid diaries, patients learn to associate bad habits, such as caffeine intake, with worsening incontinence. The recommended daily water intake is 0.5 ounce per pound of body weight, or six to eight glasses a day. However, few scientific data are available to support this recommendation.15 Constipation, which is a common problem that can worsen incontinence, can be lessened by adequate fluid consumption. Caution should be taken when advising patients to decrease fluid intake because this may lead to constipation, urinary tract infections, and dehydration. Adequate fluid intake ensures nonirritating, dilute urine, which reduces incontinence. Only patients with abnormally high fluid intake should be counseled to decrease fluid intake.

Generally, acidic and caffeinated foods and beverages, as well as oxalate-containing foods, are bladder irritants. The following foods are common bladder irritants:

• Alcoholic beverages

• Apples and apple juice

• Aspartame and saccharin

• Cantaloupe

• Carbonated beverages

• Chili and spicy foods

POLYURIA Material in Urine

NaCl

Solute

(Uosm 250-350)

Glucose

1) Renal salt wasting 1) Diabetes diuretics Mellitus

2) Mineralocorticolds

Urea

1) Post obstructive diuresis

2) Protein loading

Water

Central D.I. NephrogenicD.I. Psychogenic Polydipsia

Posm

Central D.I. NephrogenicD.I.

Water Deprvation

Exogenous AVP

Further T Uosm Central D.I.

Figure 12-2.1. Evaluation of polyuria.

• Citrus fruits and juices

• Coffee (including decaffeinated)

Cranberries and cranberry juice

Grapes and grape juice

• Guava peaches

Strawberries

• Vitamin B complex

Oxalate-containing foods include all berries, as well as spinach. The acid-restricted diet is most effective when 64 ounces of water are ingested daily. Low-acid substitutions include apricots, papaya, pears, and watermelon. Coffee drinkers may consume kava. Tea drinkers may substitute noncitrus herbal and sun-brewed teas. Citracal tablets, taken with meals, may reduce urinary excretion of dietary oxalates.

Strict adherence to a nonirritant diet often brings marked improvement in symptoms in just 10 to 15 days. Once a baseline is maintained, then irritants can be individually resumed. If symptoms return, then the most irritating sources are identified. This systematic approach allows patients to not eliminate all irritants, thereby maintaining quality of life. Patients with suspected interstitial cystitis should more closely follow an antiinflam-matory diet. (Please refer to the chapter on interstitial cystitis.)

Voiding diaries can help to elucidate whether patients have a stress or urge-predominant incontinence pattern. The diaries document involuntary leaking episodes, precipitating factors, degree of urgency, timing, and volume of voids. The diaries also confirm that behavioral changes work to prevent incontinence. This allows for estimates of 24-hour urine volume, nocturia, voiding frequency, and functional bladder capacity. A voiding schedule is developed from the patient's voiding diary. Women with frequency symptoms undergo bladder retraining to expand the bladder's capacity. Patients use relaxation techniques (deep breathing and positive self-acknowledgments), distraction methods (hand-held computerized games, puzzles, problem solving), Kegel exercises, and/or perineal pressure to delay nonscheduled voids. The initial assigned voiding interval may vary, from 30 minutes to 60 minutes being the most common interval. The voiding interval may be increased by 15 or 30 minutes based on the patient's tolerance of the schedule. Self-charting of voiding patterns often leads to increased bladder awareness. Over 6 weeks, the patient will increase the interval between voiding with a goal of 2 to 3 hours between voids (Table 12-2.1). Women who rarely void are taught to schedule their voids at regular

Table 12-2.1. Bladder training instructions

Many of our bodily functions are influenced by habit, and if these habits are bad we can change them.This is certainly true of the bladder.The object is for you to reestablish your brain's control over your bladder function rather than the other way around.

To change your bladder control habit, start by urinating (voiding, peeing, emptying your bladder) every 45 minutes during the day.You must urinate by the clock, whether you need to urinate or not.At night, urinate only as the need arises. But, the next morning you must get back on a rigid schedule.

Remember, if you are scheduled to urinate at 6:30, but at 6:10 you get a strong urge to urinate, you must try to wait until 6:30 to urinate even if you leak urine before the scheduled time.Should you develop urgency in between the voiding intervals, immediately sit down in a comfortable position.Take slow deep breaths in and out through your mouth and try imagining yourself in a favorite vacation spot or use some other relaxation technique until the urge passes.

When you are able to follow this schedule for 7 days without losing control of your bladder, increase the interval between voids by 15 minutes. (That is, increase the time between urinating to 60 minutes, etc., until you can comfortably go 2 to 3 hours without urinating.)

This requires a lot of discipline on your part but you can do it,and you will be pleased with how well you and your bladder get along in the future.

Bladder Training Week Timed Voiding Interval (min)

Week #1

Week #2

Week #3

Week #4

Week #5

Week #6

intervals. Follow-up visits to review the diaries are usually scheduled for between 1 to 2 weeks. Reassurance, enthusiastic support, and follow-up are important, because this treatment modality is driven by patient compliance. General bladder training recommendations include:

• Fluid restriction after 6 pm to decrease nocturia.

• Routine bladder emptying. Women with stress incontinence can significantly reduce their symptoms if a full bladder is avoided. Patients will make a concerted effort to set aside time to void, once this connection is made.

• Taper caffeinated and carbonated beverage usage to avoid caffeine withdrawal headaches. High caffeine intake is more than 3 cups of coffee per day.

• Do not rush to the bathroom. This increases abdominal pressure and contributes to poor muscle coordination.

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