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Bladder Retraining

Introduction

The normal bladder fills and empties four or five times each day with little voluntary effort or thought on the part of its owner. Most of the time, while the bladder is filling up, there is very little sensation from it. Only when the bladder is nearly full is a desire to void experienced. When the time or occasion is convenient, the bladder is emptied by simply relaxing and thinking about it. Passing urine does not normally require straining or precise muscular control. It is a bodily function, which proceeds to completion automatically once it is started. In fact, the more one thinks about the act, the more difficult it becomes.

If however, when the desire to void is experienced, it is not convenient to pass urine, then it is possible to keep the bladder under control by an act of will. In order to achieve this it is necessary to suppress the tendency of the bladder to contract when it is full, thereby keeping the pressure within the bladder low. This is learned in childhood between the ages of 2 and 4 years. To do so requires an intact central nervous system, a normal bladder and urethra, motivation and training.

Incorrect training as a child or incomplete learning of bladder control results in what everyone knows as a “weak bladder” and is sometimes laughingly referred to as a “Japanese bladder”. This implies that the owner cannot suppress the bladder and experiences the need to void urgently and frequently, often both by day and night. Children with this problem appear to always “leave it until the last minute”. When in addition, the child has an abnormally sound sleep pattern, persistent bed-wetting may also be a problem. Adults find, that fluids – especially tea, coffee or alcohol “just run through” them.

What is happening in fact, is that when the bladder is full, it contracts to empty. This gives rise to a knee-crossing, eye-watering, urgent desire to void, which is very difficult to control. This unstable bladder contraction is familiar to everyone from time to time, commonly occurring after a party, when after a long drive home, the extreme fullness of the bladder makes it difficult to get the key in the front door quickly enough. It then becomes touch and go whether we get to the toilet in time. When this happens only rarely, it is all part of being human. When the same thing happens 10 to 15 times a day it becomes a real problem, especially when the urgency of the desire exceeds the speed at which the toilet can be reached, in which case leakage of a few drops of urine, or even total flooding can occur. This type of urinary leakage is called urge incontinence.

Urge incontinence is a common complaint and causes considerable inconvenience and embarrassment to its sufferers. The frequency, which often accompanies it, becomes a family joke to all but the victim. Nocturia or the need to pass urine during the night is an additional burden faced by some and leads to constant tiredness. The incontinence causes a constant fear of public disgrace through odour or wetness and progressive loss of self-esteem and self-confidence results. Depression and anxiety frequently accompany these problems and tend to make matters worse.

The natural consequence of this is that most people, who have the problem, take evasive action. In the first instance, fluid restriction is tried in an effort to avoid the frequency. Changes of underwear are kept in the handbag in case of accidental wetness. Just in case voiding becomes a way of life – the bladder becoming emptied long before it is near full to avoid being “caught short” in the supermarket or on the bus.

Often, daily activities are reorganized around the known availability of public toilets, the sites of which are carefully memorized. Car trips of any distance become a nightmare, with frequent stops for petrol, the tank never being completely filled in case another pee-break is required down the road. The result is that the bladder is never asked to hold very much urine and slowly but surely it gets from bad to worse. At this point, some people become bladder hermits becoming more and more reluctant to leave their home. At the back of many people’s mind is the deep-rooted fear of becoming a smelly, wet old lady or gentleman.

One of the problems with the unstable bladder is that it just doesn’t go away. The leakage that results seldom responds to the usual operations for incontinence and drug treatment is not always helpful or may cause troublesome side effects. There is in fact no easy way out of the problem. Bladder retraining however, is effective and can revolutionize the lives of sufferers from both urge incontinence and troublesome frequency. It does require your complete cooperation and a good deal of perseverance. If you are not prepared to make this a top priority in your life and make every effort to comply with the instructions, you probably are wasting your time.

The Bladder Retraining Programme

This programme takes about three (3) months to completely alter your bladder function even though some people get considerable benefit within the first week or two. Your attitude of mind and willingness and determination to succeed are important ingredients in the curative process. Once you have learnt to keep control of your bladder and once again become the master of it instead of a slave to it and have practiced this skill repeatedly, you will never again have your bladder problem.

Although success cannot be guaranteed, there is every chance, that three months of hard work will improve you significantly. The programme is designed to help people with this problem, but not everyone is the same and not everyone tries as hard.

Your unstable bladder contracts inappropriately in response to filling (often to only low volume) or to provocation (such as change of posture – i.e. standing from a lying position, running water, exercise or intercourse). When it does contract, it pulls open the neck of the bladder, which is normally closed and water tight exactly as it does when you are about to pass water. When this happens, you naturally try and hold on using the muscles around the urethra (the water pipe which runs from the bladder to the outside). Whether you leak or not depends upon two factors:

  • how strong the muscles are, and

  • how strongly the bladder is contracting.

Obviously, the duration of that unstable bladder contraction may affect whether control can be maintained or not, as does your motivation to remain dry.

You may be aware already of some of the things that make your bladder worse: cold, wet days, winter, running water, anxiety and stress or period time are often mentioned. Similarly, you may have found some things which help you control the bladder and get to the toilet in time: crossing the legs and pressure on the perineum (the area between the legs or saddle area). It is important to try and learn more about your bladder and the way it works while you are on the programme. It is especially important for you to quickly find out what you can and cannot do with safety. Once you have determined for yourself your own limits, you can learn to stay in control of your bladder and slowly improve what you can do.

The aim of the training programme is to increase your bladder capacity until it can hold the normal amount of between 400 and 500 milliliters (mls). In achieving this, you will learn how to suppress your bladder contractions by using various techniques, which you will be taught and then practise over and over again until they become second nature to you. In addition, the muscles around the bladder outlet and in the floor of the pelvis will slowly be strengthened by exercises. It is however, important to realise, that the art of bladder control lies in learning to control the pressure inside the bladder from the brain rather than by learning to run faster! Sometimes, problems at home or at work can not only make the bladder behave badly, but also make it difficult to concentrate on the programmes (set out below). We are aware of this and can help to overcome them.

1. How to start

The Bladder Diary (Time and Volume Chart)

You are asked to keep a record of how your bladder works on a time and volume chart. On this, you should record

  • The volume of urine which you pass in mls

  • The time of day when you do so

  • The time interval since you last passed urine.

You are also requested to record in the appropriate column, whether you have leaked during the interval and the circumstances of urine loss. For example, you may have leaked with coughing or sneezing (stress incontinence) when unable to get to the toilet in time (urge incontinence), when laughing or even when asleep. Do not be too bashful or ashamed to write down what is happening to you. If you aren’t honest about the extent of your problem, it makes it difficult to help you.

Once your pattern of bladder behaviour has been determined, a regime of treatment exercises will be given to you and this will vary from one person to the next. This may involve simple deferment exercises, in which you will be taught how to put off going to the toilet. You may be given a minimum voiding time programme or receive additional help from drug therapy.

In filling out the chart, be honest, be accurate, be consistent and be intelligent. Try to compare the volume you measure with the volume you thought was in the bladder when it signaled it was full. You may notice that the bladder can sometimes feel fuller with a small volume than with a large one. Notice that the urine is often more irritant when it is a darker colour than when it is paler. Notice how often your bladder tells lies about how full it is. Try to relate small volume voids to specific incidents or events that provoked them: for example – showering, having bowels open, anxiety or whatever. Find out by trial and error whether coffee or tea or alcohol provoke your bladder to misbehave.

2. The Programmes

2.1 Timed Deferment Programme

This technique of training involves trying to increase the effective capacity of the bladder by “stretching” it. Instead of rushing to the toilet as soon as you get the “call of nature”, you are asked to wait for 5 minutes before going, each and every time you get the desire to pass urine.

You will be asked to increase your fluid intake to at least 2 litres a day. It is sensible to do the majority of this drinking in the morning and afternoon, wisely drinking little liquid after the evening meal if you want to have a quiet night! You may find it difficult to drink this quantity at first but do try. People who say they cannot do it are just not trying and have the wrong mental attitude.  It can be done. It may be, that over the years, your stomach has got used to dealing with small quantities of liquid in just the same way that your bladder has. With effort and determination you can change both just give it time and keep on trying.

You may not at first be able to defer micturition (passing urine) by 5 minutes every time you want to go. Perhaps you can only manage 2 or 3 minutes. That doesn’t matter. Each person has to start somewhere. What does matter is that you try and do it every time you get the urge to empty the bladder and record on the time and volume chart the number of minutes that you managed to hold on.

A word or two of warning is appropriate at this time. Firstly, don’t try to hold on too long at first. It is better to hold on for 3 minutes and get to the toilet dry, than to hold on for 6 and get wet. You must learn to walk before you can run! And talking about running, the watchword is don’t. Get yourself out of the habit of running to the toilet. Most of the time it doesn’t help, because you cannot concentrate on keeping your bladder under control and you therefore get wet anyway. It is much better to try and get your bladder under control and then glide to the toilet like a lady.

You will need to learn some of the deferment techniques (see below – Section 2.3). As you proceed, you will be asked to slowly increase the period of deferment from 5 to 10 minutes each time and then from 20 to 30 minutes. During the time you are putting off going to the toilet you are learning how to suppress the bladder contractions and by filling the bladder with urine, stretching the wall so it will hold more.

During this time you must stop going to the toilet “just in case”. This practice encourages your bladder to hold only small quantities. The only time you are to void is when your bladder is full and after you have done your hold-on exercise. The exception to this rule is last thing at night before going to bed.

Get out of the habit of blaming your bladder and of telling yourself that you can’t do it. Your bladder is simply a muscular bag designed to hold urine. It does not have a mind of its own despite what you may think. It does what you will let it do or what you tell it to do. The more you give in to it and tell yourself there is nothing you can do about it, the longer you will have trouble. Never say you can’t - say you’ll try. You may be surprised by what you will achieve given time and determination.

2.2 Minimum Voiding Time Programme

This type of bladder training relies upon stretching the bladder by going to the toilet only at rigidly fixed intervals. After you have filled out a time and volume chart as a baseline, you will be given a time interval to aim at. You may for example be asked to void every 2 hours to start with. You then should void every 2 hours but never before that time interval. As your bladder expands, the time interval is increased.

Obviously, it is easy to cheat during this programme by not drinking and managing to hold on for 4 hours by having a small quantity in the bladder. The aim of this programme is exactly the same as that of the timed deferment programme above, namely to stretch the bladder in a progressive manner. You should read the above section (Section 2.1) again and remember the advice it contains.

2.3 Deferment Techniques

This section deals with some of the deferment techniques that can be used to control the bladder. Not every method will help everybody and only practice with a number of them will teach any particular person what will work for them.

(1) Pelvic Floor Contraction

This is what you almost instinctively do to prevent urinary leakage when you get the urgent call to void. It has several effects. Firstly, it elevates the base of the bladder and closes the sphincter muscles around the urethra and anus. It is the closure of the muscles around the urethra that prevents urine leakage during unstable contractions (or not as the case may be). Secondly, the contraction of the pelvic floor and sphincter muscles suppresses the bladder contraction by a reflex in the spinal cord. It does this more quickly if the pelvic floor contraction is vigorously applied very early on in the course of an unstable bladder contraction before very high pressures are reached. The reflex inhibition of the bladder contraction is also better if the urine never flows and if the “brake” can be applied with persistence. Obviously, if the pelvic floor and sphincter muscles can be relaxed before the bladder contraction has gone away, leakage will occur. With practice, you will find that the bladder contractions do go away if they meet sufficiently determined resistance. Once the bladder contraction has been suppressed in this way there is no longer any danger of leakage on the way to the toilet. In fact, at a later stage, you will find that it may be 20 or 30 minutes before you get another desire to void.

(2) Perineal Pressure

This technique may already be known to you. At least you will be familiar with the fact, that the bladder is easier to control when you are sitting, than when you’re standing.  Pressure on the perineum, especially the area between the vagina and rectum (or the scrotum and rectum in males) reflexively suppresses unwanted bladder contractions. This is not always easy to achieve in daily life however. In practice, try sitting on the arm of a chair when you get the desire to void, getting the pressure right in the midline and also between the rectum and vagina. Augment this by also contracting the pelvic floor muscles and concentrate on suppressing the bladder contraction. Sitting on your heel or on the edge of a firm chair may be equally helpful. Don’t give up until you feel the bladder contraction has gone and even then keep the brake on by contracting the pelvic floor and sphincter muscles while you stand up.

(3) Penile Squeeze

This technique is an extension of what little boys do the world over when they are learning to control their bladders. Girls of all ages find it impossible! The penis is squeezed between thumb and forefinger just behind the glans (tip). The grip should be firm and applied front to back not side to side. This squeeze technique is used to increase the bladder suppression achieved by central control and pelvic floor contraction. It can be applied via the trouser pocket to avoid embarrassment. Don’t let go until it is safe to do so. (A similar technique is useful in males to avoid premature ejaculation. The same reflex mechanism is involved.)

(4) Mental Distraction

This is vital to the success of all techniques and fundamental to the whole training programme. When the bladder contracts under inappropriate circumstances, the urgent desire to void brings the toilet to mind inevitably. It is important to get the mental image of the W.C. out of mind by concentrating on something else, such as mental arithmetic. Attempt to take 9’s or 7’s away from 100 – 93, 86. 79, 72 and so on. Often, by the time you have finished, the bladder contraction has gone away. Alternatively, try controlled breathing (below), word games, reciting poetry or whatever you find easy and helpful. Just keep you mind off that toilet!

(5) Breathing Exercises

Controlled respiration is just another form of mental distraction. There are two techniques: shallow panting or controlled slow inspiration and expiration to your maximum lung capacity. The important point is to concentrate hard on the breathing instead of the bladder (or toilet). Of course, you will have to put the brake on by contracting the pelvic floor and sphincter muscles and keep them on until the bladder contraction dies away.

Any or all of the techniques can be used. It is really a matter of trying them all to see what suits each individual. Repetition and determination are the keys to success.  At first you may find it safer to run to the toilet and then practice the deferment techniques. This is not a good idea and you should try to learn how to control the bladder wherever you are, rather than giving way to it. The sooner you start to get back in control the better. Stand or sit still when you get that desire to void and get your bladder under control. If you are in the street, stop and look in a shop window or at a garden, do your deferment exercise, then walk on dry and triumphant.

3. Progress

Try not get discouraged by setbacks, which not uncommonly occur. If you have a bad day, don’t give up and make it a bad week. Start each day afresh with a positive attitude. Your bladder will not give up without a fight, after all, the chances are, that you have had the problem for years. Note down any problems on the way and discuss with your therapist at the next opportunity.