Conservative Management and Behavioral Modifications for Overactive Bladder
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- Khan, A. & Anger, J.T. Curr Bladder Dysfunct Rep (2011) 6: 13. doi:10.1007/s11884-010-0076-1
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Overactive bladder is a chronic condition that has significant effects on quality of life. Management of this condition often emphasizes the use of anticholinergic therapy. However, there are often intolerable side effects that result in poor compliance with these medications. Conservative management and behavioral modification are effective management tools as initial therapies or in conjunction with medical therapy. This review focuses on nonpharmacologic therapies and their role in the management of overactive bladder.
KeywordsOveractive bladderConservative managementBehavioral modification
Overactive bladder (OAB) is defined by the International Continence Society as urinary urgency with or without urge urinary incontinence (UUI), usually with frequency and nocturia . According to the National Overactive Bladder Evaluation Program (NOBLE), which sampled 5,204 adults 18 years of age and older, the overall prevalence of OAB among women was 16.9% and increased markedly after age 64 . Two subtypes of OAB exist: frequency and urgency without urge incontinence (OAB-dry) and frequency and urgency accompanied by urge incontinence (OAB-wet). About 33% of patients with OAB experience OAB-wet . Although the overall prevalence of OAB is similar among men and women, women are more likely to experience OAB-wet (55.0% of women with OAB vs 16.3% of men) .
OAB affects many aspects of people’s lives, including physical, sexual, and social activities; productivity in one’s occupation; and psychological well-being . In fact, OAB has been found to correlate strongly with symptoms of depression and has been found to be associated with a lower quality of life than other age-matched cohorts with chronic conditions (eg, diabetes) [5, 6]. OAB is a risk factor for falls in the older adult population, particularly when associated with UUI. Brown et al.  compared the risk of falls between women older than 65 years of age with and without urinary incontinence and found that 19–42% experienced falls, up to 9% of which resulted in fractures. When symptoms of incontinence were present, 26% of the patients had falls, 34% of whom sustained fractures.
Emphasis is placed on the use of anticholinergic agents as the mainstay of therapy for OAB. However, most patients prescribed anticholinergics stop taking their medication because of poor efficacy or side effects. A survey of 250 women with OAB who were prescribed anticholinergics found only 18% compliance 6 months after initiation of therapy . Recent adherence rates with newer medications remain low, averaging only 32% compliance [9•]. Given that a true cure for OAB is difficult to achieve, maximizing improvement of symptoms with conservative management may be the best long-term plan to minimize morbidity. In this review, we focus on nonpharmacologic conservative treatments of OAB, with an emphasis on behavioral therapy.
Assessing and Developing a Treatment Plan for a Patient with Overactive Bladder Symptoms
When assessing a patient with overactive bladder symptoms, several important factors should be considered. First, a comprehensive history should be obtained with a thorough assessment of voiding complaints, including symptoms; frequency; severity; and any associated stress, urge, or mixed incontinence. A neurological history and other new complaints should be elicited. Second, underlying and treatable causes of OAB should be identified. A urinalysis should be obtained to evaluate for a urinary tract infection or microhematuria. A pelvic examination will assess the patient’s anatomy and evaluate for any prolapse resulting in outlet obstruction.
A voiding diary kept by the patient records and defines voiding patterns. The different components of the voiding diary include documentation of the number of voids, the volume of each void, functional bladder capacity, pad usage, and frequency of incontinence episodes (urge vs stress). The patient records data for a 24-hour period, beginning documentation after the first void of the day and completing the cycle after the first void of the following day. Ideally, more than one 24-hour period is recorded to capture daily variation in voiding patterns. The voiding diary can aid in devising a functional plan with the patient.
An understanding of the patient’s goals can guide the development of a treatment plan. Treatment will vary greatly based on whether a patient wants to minimize symptoms to a level that is tolerable, or if the patient seeks complete resolution of symptoms. A time frame also should be established for how long conservative therapy will be attempted prior to changing or adding additional therapies. The patient’s mobility also should be considered when devising a treatment plan. If a patient is immobile and will have difficulty reaching the bathroom, this must be taken into consideration during the consultation and formation of the treatment plan.
Before initiating any pelvic floor muscle training (PFMT), a pelvic examination should be performed to assess the patient’s anatomy, to evaluate for any prolapse or urethral kinking, and to evaluate 1) whether the patient knows how to isolate and contract her pelvic floor muscles and 2) the strength of her contractions. If the patient is unaware of which muscles to contract, additional training will be needed for her to make progress with PFMT.
Conflicting theories exist regarding the role of fluid management and bladder contractions. Swithinbank et al.  showed that fluid restriction is associated with an improvement in symptoms. This is based on the belief that limiting fluid intake promotes slower bladder filling, which in turn allows the bladder to reach its capacity slowly, without triggering unstable contractions. Hashim et al.  studied the effects of restricting or increasing fluid intake on incontinence by having individuals increase or decrease their fluid intake by 25% or 50%. In the fluid restriction group, significant improvement was noted in frequency, urgency, and nocturia, although it was difficult for patients to decrease intake by 50%. The increased fluid group had worsened daytime frequency . In the recent Behavior Enhances Drug Reduction of Incontinence (BE-DRI) trial, 307 women with UUI were randomly assigned to therapy with tolterodine alone versus tolterodine therapy with behavioral modification. Fluid restriction instructions in the latter group were to drink 50–70 oz of fluid in a 24-hour period with a goal urine output of no more than 40–50 oz. In the fluid restriction group, more improvement was noted in urgency and incontinence .
On the other hand, limiting fluid intake may promote detrusor overactivity by filling the bladder with concentrated urine, which may in theory may be irritating to the bladder. Williams and Pannill  found that chronically low-volume voids may predispose the bladder to decreased capacity and detrusor tone while at the same time exacerbating fecal compaction and urinary tract infections and ultimately irritating the bladder and provoking OAB symptoms. Further study by Dowd et al.  showed that fluid restriction worsened incontinence symptoms, but increased intake improved symptoms.
Lifestyle factors thought to play a role in OAB and incontinence include intake of caffeine, carbonated beverages, and alcohol, as well as smoking and obesity. Unfortunately, conflicting evidence exists regarding these factors. However, modification of lifestyle factors such as obesity, smoking, or caffeine and alcohol intake was recently found to be independent of the efficacy and tolerability of anticholinergic therapies for OAB symptoms .
A positive or neutral association between caffeine and OAB has been found in several studies. Arya et al.  found a higher degree of detrusor instability on urodynamics in women who had a high caffeine intake compared with low or no intake. Tomlinson et al.  found improvement in incontinence in women who eliminated caffeine, and Bryant et al.  showed significant improvement in frequency and urgency. Swithinbank et al.  and Dowd et al. , however, found no difference in symptoms and incontinence episodes between caffeinated and decaffeinated study groups.
Dallosso et al.  conducted a survey of 12,000 women and found a significant association, with OAB symptoms correlating with weekly ingestion of carbonated beverages. Interestingly, this same survey was given to men, and no significant correlation was found . Studies evaluating the effects of alcohol have been performed in men and suggest higher nocturia in those who drink more than 150 g of alcohol per week .
Studies also point to an effect of smoking on OAB symptoms. A large Norwegian study evaluating 27,000 women found a higher risk of OAB in those who smoked, and it was highest in those who smoked more than 20 cigarettes daily. Women with a history of smoking 15 or more cigarettes daily were almost 3 times more likely to have severe urge incontinence compared with nonsmokers .
Other factors also have been linked to OAB, such as low concentrations of artificial sweeteners. In vitro studies on rat bladders showed an enhanced contractile response when they were exposed to constituents in artificial sweeteners through upregulation of calcium channels in the bladder mucosa .
Dietary Management and Weight Reduction
A few studies have shown that increasing fruit and vegetable intake may diminish OAB symptoms. Dallosso et al.  showed that total bread and vegetable intake minimized the onset of OAB symptoms. Women who ingested chicken two or more times per week had fewer OAB symptoms than those who ate chicken less than once per week . Soy consumption also has been shown to yield preliminary improvement in OAB symptoms, possibly by decreasing gene expression of connexin-43 protein in in vivo rat bladders .
Recent evidence also suggests that hyperlipidemia plays a role in the development of OAB by promoting detrusor ischemia. Rats induced to be obese and hyperlipidemic via a high-fat diet were found to have more urinary frequency and lower voided volumes than healthy rats. The obese and hyperlipidemic rats were then treated with bladder injections of saline, stem cells derived from adipose tissue, or intravenous injections of adipose tissue stem cells. The obese rats treated with intravesical saline had the shortest micturition interval when compared with all other groups, and they were found to have less smooth muscle and less nerve and blood vessel density within their bladder walls. This suggests that therapy with adipose tissue stem cells may prevent some of these histologic changes that predispose to development of OAB. This theory is based on the premise that stem cells may transform into muscle- or nerve-like cells .
Epidemiologic studies show a strong correlation between a body mass index (BMI) within the range of overweight/obese and stress urinary incontinence (SUI), and weight loss has correlated with a significant improvement in symptoms and bother . However, there is also emerging evidence of a link between BMI and OAB and UUI. Studies evaluating the prevalence of UUI have shown an increased association with low physical activity and increasing BMI. Overweight and obese women had a 1.25- to 1.74-fold increase in rate of OAB symptoms compared with underweight and healthy weight women . The NOBLE study found that women with a BMI greater than 31 kg/m2 had a 2.2 times higher prevalence of UUI than those with a BMI less than 24 kg/m2 . Weight loss, such as that occurring in women undergoing bariatric surgery, also has been shown to improve symptoms of UUI [26, 27] in addition to symptoms of SUI [28, 29].
Bladder training involves conditioning the bladder to void at increasing intervals, thereby slowly increasing the time between voids. This contrasts timed voiding, in which the patient voids at set intervals to prevent leakage episodes, and does not increase the time between these intervals. Timed voiding is beneficial in patients with diminished or no sensation of urgency.
When initiating a bladder training program, the voiding diary is very helpful in determining the length of the initial interval. It should be shorter than the most prolonged time between voids. The interval should then be increased by 15–20 min each week, as long as the patient can maintain continence. The ultimate goal is to increase the length of time between urges to a level with which the patient is comfortable.
Bladder training has been shown to be a successful measure in the management of OAB. Initial studies showed promising results, with 85% of patients responding immediately and 48% showing a sustained response 3 years later . A review of 12 trials studying bladder training in the Cochrane Incontinence Group Specialized Trials Register suggested that bladder training provides better results than no treatment. When compared with pharmacologic therapy with oxybutynin or both imipramine and flavoxate, bladder training had a positive impact on perception of cure and quality of life, with limited adverse events .
Patients may be taught to develop techniques to suppress symptoms of urgency. Payne  suggested varying techniques, including deep breathing, visual imagery, counting, or humming, in conjunction with pelvic floor exercises, until the urge surpasses. He recommends performing quick, rapid contractions of the pelvic floor when urgency symptoms develop. The benefit of these “flicks” is that they prevent muscle fatigue that occurs with a prolonged contraction and allow the patient to continue pelvic exercises throughout the duration of the urgency. Unfortunately, no evidence exists that shows that these techniques have any benefit in improving symptoms.
Pessaries are small vaginal disks that come in a variety of shapes and sizes that are fitted individually. They provide structure and support to the vagina and passively restore the anatomy that may be changed secondary to prolapse.
Pessary use does have a role in assessing and treating patients with OAB. Placement in a patient with prolapse may relieve symptoms that may be secondary to poor emptying from outlet obstruction . It is theorized that prolapse and chronic outlet obstruction lead to denervation of the bladder, thereby making the bladder supersensitive to acetylcholine. It also has been shown in animal models that there is hypertrophy of the afferent spinal nerves in obstructed bladders, causing a more pronounced spinal reflex [34•]. A review of four studies including a total of 12,514 women, 1,071 of whom had prolapse or OAB symptoms and the presence of pelvic organ prolapse, showed a greater prevalence of OAB symptoms among prolapse patients. There was conflicting evidence between an association of which compartment had prolapsed and the stage of prolapse with degree of symptoms. Any prolapse reduction therapy resulted in improvement of OAB symptoms [34•]. Studies that looked at pessary use only also showed significant improvement in OAB symptoms. Among prolapse patients fitted with a pessary, Clemons et al.  showed improvement in urge incontinence in 46% of patients, and Fernando et al.  showed an improvement in urge in 38% and UUI in 29%.
The incontinence pessary specifically compresses the urethra against the symphysis pubis, elevating the bladder neck. Incontinence pessaries are most often used in patients with SUI. However, Hanson et al.  studied success rates with varying types of pessaries and found improvement in 40–86% of patients with UUI, and the best success was with the incontinence pessary.
Pelvic Floor Muscle Training
The role of PFMT in incontinence has been well-studied, and several studies showed marked improvement in incontinence, with stronger contractions and increased bulk of the pelvic floor musculature. PFMT is beneficial in providing stability to the pelvic floor and sphincter mechanism, as well as strengthening the inhibitory reflex to the bladder when contractions develop. Shafik et al.  studied detrusor and urethral sphincter pressures in response to pelvic floor contractions and found a decrease in detrusor pressures and an increase in urethral pressures that thereby inhibited the micturition reflex. Wilson et al.  demonstrated significant improvement in women who performed proper PFMT in conjunction with other therapies for their OAB symptoms.
PFMT may be performed by the patient (active PFMT) or by simulated muscle contraction via an external appliance through electrical or magnetic stimulation (passive PFMT).
Active Pelvic Floor Muscle Training
The International Consultation on Incontinence committee recommends that proper pelvic floor exercises be performed by completing 3–5 sets of 10–12 contractions, each held for 6–8 s, with a 6- to 8-second rest period between each contraction, and these exercises should be repeated every day . A study by Cammu et al.  found marked long-term patient satisfaction with their symptoms, with 67% of the patients in their study remaining satisfied 10 years following initiation of therapy and only 8% resorting to surgical therapy.
Passive Pelvic Floor Muscle Training
Electrical stimulation facilitates passive contractions of the pelvic floor or inhibits unstable detrusor contractions. Either of these effects is achieved based on the setting of the appliance. Probes are applied within the vagina or anus, and the settings may be adjusted to vary in frequency, type of current, and intensity. High-frequency electrical stimulation (50–200 Hz) is often used to promote contractions of the pelvic floor, which in turn promotes increased strength and bulk. In contrast, low-frequency stimulation (5–20 Hz) is used to activate the inhibitory nerves to the bladder to decrease overactivity. Patients can keep these devices at home and undergo the therapy at home. Early studies showed some promising results on urodynamics, with improvement in detrusor instability in 49% of female patients; however, there was no significant clinical improvement . A review of the literature by the International Consultation on Incontinence committee found many small case reports with inconsistent results .
A recent study comparing the effect of oxybutynin, electrostimulation, and PFMT on detrusor overactivity on surveys and urodynamics showed improvement in all groups, with improvements in 77%, 52%, and 76% of the women undergoing therapy with oxybutynin, electrostimulation, and PFMT, respectively . The downside to this therapy is that some women do not want to place anything within the vagina or rectum. Otherwise, there are few side effects or risks to the patient.
Magnetic stimulation differs from electrical stimulation in that the patient sits in a chair that delivers extracorporeal magnetic therapy directed to the pelvic floor. Low- and high-frequency therapies are both used. Both are aimed toward developing strong musculature. Slow pulsatile contractions are produced with low-frequency waves, and short, high-speed contractions are produced with high-frequency waves. No internal probe is required. The downside of the treatment is that it must be performed twice weekly within the clinic, although the machinery takes little training and requires minimal supervision. There is movement toward development of a device that can be placed within the patient’s pocket. The adjacent organs, including the rectum, uterus, and other muscles, also respond to the treatment and may contract.
One study compared electrical stimulation with magnetic stimulation  and showed that there was improvement on urodynamic studies in patients using either modality, but magnetic stimulation provided slightly better bladder capacity (improvement by 105%, compared with a 16.3% increase) and eliminated detrusor overactivity in three patients compared with none in the electrical stimulation group.
Biofeedback is the process of using a tool with the goal of receiving and providing information to the patient regarding the efficacy of the therapy.
The least expensive appliances are vaginal cones, which may offer a therapeutic benefit as well as provide feedback. They are small devices that vary in size and weight. The patient places a cone within the vagina and tries to hold the weight in place. If she senses that it is falling, a reflexive contraction of the pelvic floor is triggered. This helps teach the patient which are the proper muscles to contract. It also allows her to strengthen her pelvic floor while preventing the weight from falling out of the vagina. When she has progressed to a strength level in which she can comfortably hold the weight in place for 15–20 min, she can advance to the next heavier weight. A study by Herbison et al.  found that cones were better than no therapy. However, they were not much better than PFMT.
As with electrical stimulation, some women do not want to undergo any therapies that necessitate placement of objects within the vagina. Also, some women may use accessory muscles or adjust their position to hold the weight in place rather than perform proper pelvic floor contractions.
Other biofeedback techniques employ the use of machinery and placement of electrodes on the perineum to gauge muscle response by assessing squeeze pressures of the anus or vagina. These therapies have the disadvantages of requiring expensive equipment, inadvertent transmission of abdominal pressures that may skew the results, and the need for professional supervision.
A study comparing electrical stimulation, biofeedback-assisted PFMT, and PFMT found a subjective improvement/cure rate on King’s Health Questionnaire of 51.4% for electrical stimulation, 50% for biofeedback-assisted PFMT, and 38.2% for PFMT alone .
Trials comparing combined therapies have yielded promising results. A study by Wallace et al.  comparing the combination of PFMT, biofeedback, and bladder training showed improvement when compared with PFMT and biofeedback alone. Of the 125 women surveyed, there was an overall 1.18 relative risk improvement in perception of improvement when combining all three modalities, and a 1.39 relative risk improvement in quality of life compared with PFMT and biofeedback alone . This was not sustained at 3-month follow-up, however.
OAB is a chronic condition that affects millions of people in the United States. Several conservative measures and behavioral therapies are available to the patient that can be used as initial therapy or as an adjunct to anticholinergics. Patient goals should be addressed, and a realistic treatment plan should be developed with the patient when initiating therapy for OAB. Patient education is crucial for implementation and maintenance of the treatments. There is a need for ongoing randomized trials comparing different modalities of conservative management. With active patient and physician participation and interaction, conservative management and behavioral modification is a reasonable treatment strategy in the management of OAB.
No potential conflicts of interest relevant to this article were reported.