Time To Re -Think Bladder Training?

Overactive bladder (OAB) is an idiopathic symptom-complex defined by urinary urgency (often with frequency, nocturia and incontinence)1 that appears to encompass multiple different underlying mechanisms.  Despite support for behavioural therapy as first line treatment for OAB, the literature doesn’t address the specific impact of the cognitive aspect of bladder training. We need a better understanding of the rationale of bladder training and specifically develop urgency management strategies that are more effective in those presenting with a central component to their symptoms2.

Traditional Behavioural Therapy for Overactive Bladder

Behavioural therapy, which includes Pelvic Floor Muscle (PFM) exercise, bladder training, and lifestyle advice (eg fluid intake modification) is considered first line treatment for OAB3.  A recent ICS consensus statement on bladder training states that mechanisms underpinning bladder training remain on the whole poorly understood4. The focus of the urge suppression component of bladder training has traditionally been mental distraction.  

Urgency and Central Mechanisms

In February 2017 we published a blog article titled Understanding Urgency and Centralisation in OAB  that explored an emerging body of research providing evidence that central mechanisms play a role in urgency. Dr Rebekah Das, who completed a PhD exploring the characterisation of the symptom of urgency, proposed that urinary urgency is no longer considered a direct representation of detrusor overactivity, rather a multidimensional sensory experience of complex and uncertain aetiology, which like pain and other adverse sensations has both affective and physical dimensions5.
Other publications have explored this concept with Griffiths and his team using fMRI in OAB patients and controls concluding that women with OAB had white matter damage interfering with pathways critical to bladder control6. More work by Dr Reynolds and his group reported evidence of central sensitisation in patients with chronic bladder urgency7. They concluded that an understanding of the pathophysiology and clinical manifestations of central sensitisation in OAB could provide a novel approach to managing this condition and improving outcomes7
This exciting new area of research will help us refine management strategies available for the treatment of OAB.  It highlights the need for a thorough assessment of patients presenting with OAB, using a biopsychosocial framework to identify co-existing factors that are likely contributing to symptoms. We have been routinely using the Central Sensitisation Inventory (CSI) as one way to screen for the presence of central mechanisms for ALL our patients over the past 2 years. We have observed clinically that many of our OAB patients are scoring positive on the CSI.

A Cognitive Approach to Bladder Training

Emerging evidence has proposed an adapted cognitive-behavioural approach to bladder training and urge suppression. Mindfulness-based stress reduction, which focuses on non-judgmental awareness of sensory experiences as a stand-alone intervention has been found to have a positive impact on OAB8. Marti et al9 focused on patients understanding the relationship between their cognitive and affective responses to urgency and the subsequent behavioural response. 
To address the multidimensional nature of urgency, it is proposed that an alternative approach to bladder retraining might include the following:

A reflection on what is happening when you
 experience your symptoms –
  • The environment – where are you? 
  • How you are feeling physically and emotionally?
  • What you are thinking in response to the sensations?
Then, the following approaches can be adopted:
  • Mindful awareness of bladder sensation rather than urge suppression: acknowledging the sensation of urgency is just a sensation, which is an output of the brain. This mindful acceptance reduces panic, fear and can help patients to “ride the wave” of intense urgency. 
  • Relaxation and visualisation techniques: visualising a calm and relaxed bladder and relaxed controlled breathing can reduce the strength of the urgency sensation.
  • Education about bladder function and the role of the brain: a clear understanding of healthy bladder function can reduce the anxiety response to episodes of urgency. We know that patient’s pain experiences change when they understand the multiple contributing factors. So too can patients with urgency when they understand the many factors influencing their experience of urgency.
  • Cognitive behavioural therapy: identifying situations triggering urgency and the accompanying emotions, then encouraging behavioural change.
This exciting research, along with our clinical experience, highlights the value of individualised assessment, including psychosocial screening for patients experiencing bladder urgency.  Identifying and phenotyping patients that will respond better to a mindful and cognitive based approach with their bladder training may prove to be a positive step forward in improving outcomes for these patients.  

A Case Study

A recent patient, who is a 47-year-old female, para 2 with a 3-year history of bothersome and worsening OAB-wet and mild POP symptoms. She came to WMHP after having no improvement in her symptoms following 6 months of PFM training and traditional bladder training under the guidance of another Melbourne based Pelvic Health Physio.  
Hearing her story raised suspicions around central mechanisms and so she was asked to compete a CSI, which was positive for a sensitised nervous system. Further screening revealed anxiety, depression, insomnia and a fear of leakage as well as fear of movement and exercise.
We introduced 4 things in her treatment plan:
  1. Education regarding the role of the brain in her OAB symptoms
  2. Changed the focus of her bladder training to be more mindfulness based 
  3. Prescribed a movement practice that she wasn’t fearful of, that helped her calm her sensitised nervous system and reduced her feelings of anxiety and depression 
  4. Implemented sleep hygiene strategies
After 3 months she reported only occasional urgency, no urge incontinence episodes in the prior 6 weeks and felt quite certain that the difference was the change in focus from local techniques to more central ones.
  1. Haylen B, Ridder D, Freeman R, Swift S, BerghmansB LJ, Monga A, et al. An International Urogynecological Association (IUGA)/ International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J. 2010;21(1):5–26. https://doi.org/10.1007/s00192-009-0976-9.
  2. Reisch B, Das R, Gardner B, Overton, K, 2021 Cognitive components of behavioural therapy for overactive bladder: a systematic review. International Urogynaecology Journal, 10:1007/s00192-021-04720-2 
  3. Tse V, King J, Dowling C, English S, Gray K, Millard R, et al. Conjoint Urological Society of Australia and New Zealand (USANZ) and Urogynaecological Society of Australasia (UGSA) Guidelines on the Management of Adult Non-Neurogenic overactive Bladder. BJU Int. 2016;117(1):34–47.
  4. Booth J, Bliss, D, Consensus Statement on bladder training and bowel training, Neurourology and Urodynamics, DOI: 10.1002/nau.24345,  March 2020 
  5. Das, R (2014) Characterisation of the sensation 'desire to void' in individuals with and without overactive bladder. School of Health Sciences, University of South Australia, Doctor of Philosophy.
  6. Griffiths D, Clarkson B, Tadic SD and Resnick NM Brain Mechanisms Underlying Urge Incontinence and its Response to Pelvic Floor Muscle Training J Urol 2015; 194(3):708-15
  7. Reynolds W, Mock S, Zhang X, Kaufman M, Wein A, Bruehl S et al. Somatic syndromes and chronic pain in women with overactive bladder.  Neurourol & Urodyn 2016; 36(4):1113-1118
  8. Baker J, Costa D, Guarino JM, Nygaard I. Comparison of mindfulness-based stress reduction versus yoga on urinary urge incontinence: a randomized pilot study with 6-month and 1-year follow-up visits. Female Pelvic Medicine & Reconstructive Surgery. 2014;20(3):141–6.
  9. Marti B, Valentini F, Robain G. Contribution of Behavioural and Cognitive Therapy to Managing Overactive Bladder Syndrome in Women in the Absence of Contributive Urodynamic Diagnosis. Int Urogynecol J. 2015;26(2):169–73. 


March 2022