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Urgency urinary incontinence (UUI) is highly prevalent in elderly individuals and has a great impact on quality of life. Transcutaneous tibial nerve stimulation (TTNS) can be an effective treatment option for UUI in older women. This is a single-center randomized clinical trial with a 12-month follow-up involving 106 women > 60 years of age. Kegel exercises and bladder retraining were performed alone or in combination with TTNS, which consisted of using a transcutaneous electrical nerve stimulator for 30 min once a week for 12 weeks with the following settings: continuous mode, 10 Hz, 200 ms, and 10 to 50 mA (according to hallux mobilization). Responders to therapy who experienced failure during follow-up were invited for a 3-week protocol with the same parameters as those used for the initial therapy. Patients were evaluated at baseline, 4 weeks after the 12-week protocol, and every 3 months for 12 months, through subjective satisfaction questionnaires, a 3-day bladder diary and the International Consultation on Incontinence Questionnaire-Short Form. King’s Health Questionnaire was applied pretreatment and 4 weeks after the last session of the 12-week protocol. A total of 101 women completed the initial 12-week protocol. TTNS patients reported 66.7% subjective global satisfaction vs. 32.0% in the control group (p

Practice nurses need to find out about all the different types of urinary incontinence and how they can be treated, before they can offer help to patients showing symptoms, writes Alison Bardsley Urinary incontinence is a common problem that is often under-reported due to the embarrassing nature and social stigma attached. Urinary incontinence can have a considerable effect on an individual's quality of life, but can be significantly improved with correct assessment, treatment and management. Conservative treatment options, including pelvic floor exercises, bladder retraining and fluid modification, are recommended before referral to secondary services. This article provides an overview of the main types of urinary incontinence, and summarises recent guidelines for the assessment, diagnosis and effective conservative treatment options for them, and when a referral to specialist care is required.

We report a rare case of a 4-year-old girl with involuntary watering of eyes and facial redness during painless voiding since early infancy. Here, we describe her response to urotherapy with improvement of involuntary tearing during micturition, which although neither life threatening nor debilitating, may be quite bothersome for children and their parents, leading to anxiety, emotional burden, or embarrassment. We hypothesize that the lacrimal glands and the bladder and bowel have common central nervous system pathways and that bladder retraining and bowel management might be a potential treatment for this rare condition.

Daytime wetting is a common problem in early childhood. This article explains how the infant's bladder develops and how children are able to develop bladder control. The need for more structured toilet training at an earlier age than is standard today is proposed to prevent children having difficulty attaining and maintaining bladder control, which may be associated with delays in becoming continent and the development of daytime wetting. The article discusses common daytime wetting problems and describes how they can be assessed using a structured, standardised approach to history taking. Management using bladder retraining in the form of modified urotherapy is outlined, which aims to retrain the bladder without the need for surgery or pharmaceutical treatment.

Functional bladder problems in children are often insidious and are frequently ignored by the child, by parents, and by many caregivers. Consideration of both the urinary and bowel outlets, and more recently, of the corticospinal tracts and brain reveal great complexity in this condition. In this article, the author addresses many of these issues in depth with a familiar personal experience derived from many years of dedicated consideration of these problems. Bladder dysfunction in the child is in many ways the pediatric urologist's hypertension diagnosis. Like antihypertensive therapy, bladder retraining strategies must be adhered to for life.

Fiona McCrimmon discusses the diagnosis and management of overactive bladder, a problem particularly prevalent in women and older people

This article discusses the non-surgical management of both genuine stress incontinence and detrusor instability. Although the traditional treatment for genuine stress incontinence is surgical, there are numerous circumstances under which non-surgical treatment should be considered. Such non-surgical treatment includes various types of physiotherapy, especially pelvic floor exercises, the use of drugs, especially oestrogen and α-adrenergic agents, and the use of mechanical devices. The treatment of detrusor instability is primarily non-surgical and treatment modalities include the use of drugs, the use of behavioural therapy, especially bladder retraining, and the use of maximal electrical stimulation. The anticipated results from each modality of treatment will be discussed together with guidance to appropriate references for those who wish to explore the subject further. Wherever possible, the author has chosen to quote randomized trials rather than cohort studies.

Conservative management is the primary option for most women with stress, urgency, or mixed incontinence. Treatment is readily available, is free from complications, and is effective for patients awaiting or unsuitable for surgery. Good results can be obtained with pelvic floor muscle exercises (PFMEs), which underpin all conservative management, with or without lifestyle intervention (e.g., weight loss, smoking cessation, reduced caffeine intake), bladder retraining, and anti-incontinence devices (e.g., vaginal cones). However, a lack of randomised controlled trials using standardised treatment programmes makes it difficult to identify the advantages and disadvantages of different conservative approaches. Poor long-term patient compliance and inadequate training for nurses and therapists involved in conservative management of urinary incontinence are likely to have a significant negative impact on outcomes. Better patient support and improved education for professionals, together with more research into optimal methodology, are needed to ensure that full benefits are achieved.

Seventy-four patients presenting with a mixed pattern of urinary symptoms were randomly allocated to undergo either inpatient or outpatient continence programs as initial treatment, without prior urodynamic investigation. Both programs consisted of physiotherapy, bladder retraining, fluid normalization, dietary advice and general support and advice. Nine out of 39 in the outpatient group and 8 out of the 35 of the inpatient group failed to complete the study. There was a significant decrease in frequency, nocturia, number of incontinent episodes and visual analog scores for both groups. In addition the outpatients had a significant reduction in loss on pad testing, and a significantly greater improvement in their visual analog score. In each group 63% were cured or improved to the extent that they did not require further treatment. Staff costs per outpatient were half those for an inpatient. We conclude that outpatient conservative treatment as detailed above is a successful first-line treatment of urinary incontinence in women. It is as successful and possibly better than inpatient treatment, and is significantly cheaper.

Objective: Bladder scans are used extensively in adult urology to estimate urinary volumes. For children, smaller devices have been developed. Scarce literature shows conflicting results regarding the accuracy of measurements in children. The BladderScan® BVI 6200 has been developed to overcome some of the inaccuracies. We tested this device to see whether it can replace conventional ultrasound in a bladder retraining program. Patients and methods: 84 children (mean age 7.8 years) were included. Measurements with the BVI 6200 were compared to measurements with a graduated cylinder or with conventional ultrasound before and after micturition. All volumes were expressed in milliliters. The measured volumes were compared to each other in a Bland-Altman analysis. Results: Mean (bias) of the different measurements fell within 10% difference of measurements. The spread of the different measurements around the mean was however very large, with a broad spread of over- and under-estimations of different measured volumes. Conclusion: The BVI 6200 is not reliable enough to replace conventional ultrasound for measurements of bladder volumes. It is not advisable to use it in a bladder retraining program. © 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.

This review evaluates the main conservative treatments (general measures, physiotherapy, electrostimulation, mechanical devices, and bladder retraining) with particular emphasis on their effectiveness in the management of urinary incontinence. This is difficult because of the paucity of clinical comparison studies using objective end points, and further work needs to be done to establish more clearly the effectiveness of these measures. However, because the therapies are of low risk, relatively low cost and are reversible, they should be included in the counselling of all incontinent patients regarding treatment options.

Sixty patients complaining of frequency, urgency, nocturia, urge incontinence and stress incontinence were randomly allocated to either undergo conservative treatment by way of combined physiotherapy and bladder retraining as an inpatient without prior urodynamics, or to have urodynamic investigations and treatment tailored to the urodynamic diagnosis. The assessment period was 3 months and assessment was made pre- and posttreatment by urinary diary, pad testing and subjective questionnaire. There was a significant improvement posttreatment for each parameter studied, with the exception of pad testing. There was no significant difference between the two groups for any parameter. Two-thirds of patients were cured to the extent that they did not require further treatment, and again there was no difference between the two groups. We conclude that patients attending for the first time with an uncomplicated story of urinary incontinence can be effectively treated conservatively without prior urodynamics.

Introduction: The aim of this study was to examine the efficacy of transcutaneous electrical tibial nerve stimulation (TTNS) to treat urge urinary incontinence (UUI) in older women. Material and Methods: The study design was a randomized clinical trial conducted on 51 elderly women ( 60 years) with UUI. All were treated with 12 weeks of bladder retraining and pelvic floor muscle exercises, and 25 were randomly selected to receive TTNS in addition to the standard therapy. The cases were evaluated at the baseline and after the end of therapy by 3-day bladder diary, quality of life questionnaires (QoL), and subjective response. Results: Of the patients, 68.0% in TTNS group reported cure or improvement vs. 34.6% in the control group (P 0.017). TTNS showed significant improvement in most areas of QoL and in UUI parameters when compared with the control group. Conclusion: TTNS is efficacious to treat UUI in older women.

Overactive bladder syndrome is a common condition that adversely affects the quality of life. It is mainly treated with a combination of bladder retraining and antimuscarinics. In a quest to reduce the side effect profile of these drugs, whilst improving their efficacy, more bladder-selective antimuscarinics were developed. One of the more recent of these antimuscarinics which has come to the market is fesoterodine. This review examines the evidence of the safety and efficacy of this drug.A literature search performed identified two main multi-center trials which highlight the safety, efficacy and tolerability of fesoterodine. These together with the pharmacologic properties of the drug are discussed at length throughout the review. An expert opinion is then formulated based on the current evidence available and on comparison with other antimuscarinics.It is concluded that fesoterodine has the added advantage of flexible dosing over some other antimuscarinics. It does, however, have a similar tolerability and side effect profile to other antimuscarinics and is, therefore, unlikely to revolutionize the treatment of the overactive bladder.

Forty-eight patients with genuine stress incontinence and low urethral closure pressure have undergone a suburethral sling procedure using polytetrafluoroethylene. Forty-five of the 48 patients have been followed up beyond 3 months, allowing assessment of postoperative complications. Ten patients required intermittent self-catheterization, 6 continuing beyond 3 months secondary to obstructed voiding or vesical dysfunction. Six slings were removed due to graft infection and/or vaginal mucosa erosion. All patients who were continent prior to removal remained so afterwards. Two slings were loosened secondary to obstructed voiding (1 patient experienced improved voiding, the other continued intermittent catheterization). Sixty-two per cent (28/45) of the patients followed, developed at least one documented urinary tract infection. Thirty-four of the 45 patients followed, underwent postoperative multichannel urodynamic testing. Ten patients (29%) demonstrated postoperative detrusor instability (5 were new onset, 5 were persistent). Six improved with medication and bladder retraining drills. Twenty-eight of the 34 patients tested (82.4%) were objectively cured of genuine stress incontinence. In spite of the complications noted, this suburethral sling procedure offers a high success rate and is a viable alternative in treating patients with genuine stress incontinence and low urethral closure pressure. Modifications in surgical technique have been made to reduce postoperative complications in the future.

Urinary incontinence is a common problem with serious effect on the quality of life. Bladder training aims to increase the interval between voids, either by a mandatory or self-adjustable schedule, so that incontinence is avoided. This study aimed to assess the effectiveness of inpatient bladder retraining.A retrospective case-note analysis was conducted over a period of 24 months. Outcome measures were decrease in incontinence episode frequency (IEF) and nocturia and increase in interval between voids. Subjective improvement was assessed on a four-point scale.The study revealed statistically significant decrease in IEF and nocturia and increase in the interval between voids. Twenty-three percent was cured of their symptoms, 36% reported improvement, 27% did not find any change, whereas 14% reported that they were worse off their after bladder retraining.The study confirms the usefulness of inpatient bladder retraining as a treatment option, especially in people refractory to outpatient management.

Overactive bladder (OAB) syndrome is the term used to describe the symptom complex of urinary urgency with or without urge incontinence, usually with frequency and nocturia. Drug treatment continues to have an important role in the management of women with OAB. Other treatment options include conservative management with lifestyle interventions, modification of fluid intake, and physiotherapy including bladder retraining. Surgery remains the last resort in the treatment and is usually reserved for intractable detrusor overactivity, as it is associated with significant morbidity. This article reviews the management of the overactive bladder with specific focus on newer developments in the medical treatment of OAB in women.

Conservative therapy is an accepted treatment option for persons with urinary incontinence (UI) and overactive bladder (OAB). These interventions improve symptoms through identification of lifestyle habits (e.g., smoking, excess weight, dietary bladder irritants, inadequate fluid intake, bowel habits, physical activities and exercises) and changing a person’s behavior, environment, or activity that are contributing factors or triggers (Newman, 2005). Interventions such as bladder retraining (BT) and pelvic floor muscle (PFM) rehabilitation or training (PFMT) attempt to decrease incontinence and OAB symptoms through increasing awareness of the function and coordination of the PFM to gain muscle identification, control, and strength and to decrease bladder overactivity. These interventions are referred to as behavioral treatments as they involve learning new skills and altering behavior through extensive one-on-one patient instruction. Toileting programs (e.g., habit training and prompted voiding [PV]) are used for more care-dependent persons. The International Consultation on Incontinence has published recommendations from evidence-based research for conservative treatments. These are outlined in Table 1. This chapter discusses the use of conservative therapy in clinical practice.

Most patients presenting with idiopathic bladder instability and urge incontinence are managed by conservative therapy with anticholinergic medication, biofeedback, bladder retraining, and pelvic floor exercises. Bladder instability has a significant impact on the patient’s quality of life, and the success rate of conservative therapy has been poor. It has been estimated that 62.5% of surveyed patients with urge incontinence were “not satisfied” with currently available treatments.1, 2

This is a retrospective review of 50 consecutive patients with urinary frequency, urgency and urge incontinence, admitted in 1995 and early 1996 for bladder retraining in the form of timed voiding. At discharge 80% of the women were subjectively cured or satisfactorily improved, but this was significantly reduced to 32% of the 37 who replied to a postal survey between 12 and 29 months (mean interval 21.3 months) later. There were no significant associations between outcome and urodynamic diagnosis, reduced cystometric capacity, length of symptomatology, previous treatment or requirement for additional therapy, but this may have been in part due to small numbers. In conclusion, bladder retraining is a method of treatment for patients with both sensory urgency and detrusor instability which appears to be at least as successful as other modes of treatment for these conditions.

Our purpose was to determine patient compliance with a telephone-based retraining program.This was a retrospective study of 123 women with urinary urgency or urge incontinence who were offered bladder retraining with facsimile machine submission of a retraining diary and weekly telephone feedback.Completion was defined as having/=4 follow-up sessions and/=6 weeks of retraining. Seventy-one percent (87/123) began the retraining program; 63% (55/87) of them completed it, for an overall compliance rate of 45% (55/123). When we compared those who completed retraining with those who started but did not complete it, only concurrent use of pharmacologic therapy was significantly different (87% vs 53%, respectively; P.001). This difference remained significant after we controlled for other independent variables, including urodynamic diagnosis and physician.A total of 55% of women to whom telephone-based bladder retraining was recommended either never started or were noncompliant with the treatment. Bladder retraining success in the "real world" may be substantially lower than that described in well-funded labor-intensive clinical trials.

Diabetes insipidus is a life-threatening condition in which the kidneys excrete huge quantities of diluted urine. Diabetes insipidus as a sequela of head trauma is unusual, but not rare. When it arises in conjunction with a spinal cord injury (SCI), diabetes insipidus not only is life threatening but also raises challenges for bladder retraining. This article describes the pathogenesis, diagnosis, and management of diabetes insipidus. A case study is used to demonstrate the patient course and nursing implications, with emphasis on two nursing diagnoses: fluid volume deficit and alterations in urinary elimination.

Treatment of detrusor instability remains unsatisfactory. Many different types have been tried and although few women are ever completely cured, many may have their symptoms improved by one or other of these therapies. The most troublesome symptoms of detrusor instability vary from patient to patient and from time to time. Not all patients will require treatment and some will only need to use simple measures when their symptoms are worst. Many women with detrusor instability benefit from an explanation of their condition and are then able to control their own symptoms by behaviour modification such as drinking less fluid and avoiding tea, coffee and alcohol. For more severe symptoms the following methods of treatment are available: (a) drugs, (b) bladder retraining, (c) phenol injections, (d) augmentation cystoplasty.

A total of 14 female patients with complete urinary incontinence underwent urethral reconstruction by a variety of techniques. Included were 2 patients with acquired urethral defects, 5 with congenitally short urethras, 2 with epispadias, 3 with remnant ureteroceles and 2 with cloacal anomalies. Complete continence was restored in 10 patients, 3 were improved markedly and there was 1 failure owing to obstruction with overflow incontinence. In several patients full control was acquired slowly and was hastened by bladder retraining. Urodynamic studies proved to be extremely valuable for the postoperative as well as preoperative assessment of these patients. (J. Urol., 138: 521–524, 1987)

The records of 21 children with neuropathic bladder disease are reviewed. The natural history in these cases has been consistent with that of an acquired disorder and the results of urodynamic testing have supported Hinman’s contention that the disease is basically a functional one, caused by a discoordination between detrusor contraction and sphincter relaxation. Bladder retraining and specific medication have yielded far better results than were obtained previously by surgical measures alone

In an "incontinence clinic," a study of 309 elderly patients showed the most common causes of incontinence to be: unstable bladder (57 percent), outflow obstruction (13 percent), and atonic bladder (7 percent). Pure stress incontinence was rare (2 percent). One third of the patients improved, one third had to be catheterized, and one third did not improve. An individually designed program of bladder retraining for the patient, coupled with support and instruction for the relatives and for the professional care providers, offered the best chance of success.

Four months post-injury, Mark is into the ongoing rehabilitation phase of his hospitalization. He is free of continuous ventilator support with a vital capacity of 1200 cc. Neurologically, his level has descended to the C5 level, which has allowed him to function with moderate assistance from a motorized wheelchair. He is still immobilized in a Halo vest which will be removed when X-ray examination reveals that adequate fusion has occurred. Mark has not developed pulmonary embolus. After an initial problem with orthostatic hypotension, he can sit upright without symptomatology. Although he will probably continue to have difficulty with temperature regulation, Mark has learned how to control his environment in order to maintain his comfort and safety. Bowel training was difficult because of Mark's initial problem with paralytic ileus. With persistent adherence to the bowel program, however, Mark has become bowel continent. This process was facilitated once he was able to be mobilized and use a bedside commode. Mark continues on his bladder retraining program. As could be anticipated with an adolescent patient, adherence to the strict program of fluid regulation and restriction was difficult. It is anticipated that Mark will eventually be catheter-free and bladder continent in the future. Mark will require two to three months of further rehabilitation, after which he will return to his home and school. Mark faces a future centered from a wheelchair. With adequate medical, nursing, psychological, social and vocational follow-up, however, he can live a near normal life-span. With a positive support system he can build on the comprehensive care he received initially, and rebuild a life for himself.

This study evaluated weekly urine cultures of patients with neurogenic bladder disease who underwent intermittent urinary catheterization for bladder retraining. One group of 53 patients in 1974 received regular instillations of 0.1% neomycin after each catheterization. A similar group of 55 patients in 1975 did not receive neomycin and constituted a control group. Distribution of age, sex, diagnosis, and duration of bladder retraining was comparable in both groups. Quantitative bacterial colony counts of 10 4 to 10 5 or greater per ml of urine were considered significant. There was no difference in the incidence of bacteriuria between the neomycin-treated group and the control group (53 versus 49%, respectively), and most patients in each group had colony counts >10 5 /ml. Escherichia coli was seen less frequently in neomycin-treated patients (43.4 versus 62.5%), but a greater percentage of infections due to Pseudomonas aeruginosa , group D streptococci, and yeasts was noted in the neomycin-treated group than in the control group (41.5 versus 22.5%).

Sixteen children with dysfunctional voiding without demonstrable neurological deviation were studied 6 months and five years after completed bladder retraining. The initial good effect on voiding symptoms and urinary tract infections/bacteriuria was confirmed. Moreover, the effect seems to last for several years. Bladder retraining can thus be considered a safe, cheap and relatively effective treatment in many children with symptoms of bladder dysfunction and/or recurrent urinary tract infections.

Ninety-two (24.6%) of 374 patients referred to our gynecologic urology unit were found to have instability of the detrusor muscle with no recognizable associated pathologic conditions: idiopathic detrusor instability. Thirty-nine (42.4%) of these 92 patients demonstrated the instability only after detrusor activation maneuvers such as coughing, heel bouncing, or positional changes. The cure rate among patients with both "spontaneous" and "provoked" contractions of the detrusor muscle was comparable to the cure rate among those whose bladder contractions were apparent only after detrusor activation maneuvers (p greater than 0.9). The success rate of bladder retraining drills (BRD) as the sole mode of therapy was not significantly different from that observed with BRD combined with anticholinergics (p greater than 0.6).

Bladder retraining (through use of intermittent catheterisation while learning various voiding techniques) is generally successful in most males with paraplegia, but has not been widespread among paraplegic women, primarily because of the lack of an effective external collecting device. Therefore, more attention needs to be directed toward prevention of incontinence than would be necessary in men. A highly organised bladder retraining programme has evolved at a Mayo Clinic affiliated spinal cord injury rehabilitation unit and bladder retraining has been applied to a majority of paraplegic women who were rehabilitated there. Over an 18 month period 72 women paraplegics were rehabilitated and 40 entered a bladder retraining programme. Bladder retraining was considered significant if the residual urine volumes were reduced to less than 150 ml and there was an absence of significant incontinence. Twenty-seven (67 per cent) were successful. Eighteen of 26 (69 per cent) are women with upper motor neuron detrusor dysfunction who were successful and six of seven (86 per cent) of women with lower motor neuron dysfunctions were successful. However, only three of seven (43 per cent) with mixed neurogenic detrusor dysfunction were successful. Various factors—age, duration of neurogenic bladder, history of indwelling catheter, incontinence grade prior to bladder retraining, bladder capacity, history of urinary tract infections, peak intraurethral pressure, neuroactive drug use, voiding techniques utilised—which could have an influence on success rates will be discussed in detail. Our study indicates that the majority of paraplegic women with neurogenic bladder dysfunctions can be successfully bladder retrained if a highly structured bladder retraining programme is available and utilised.