Physical Therapy Haven

I have come to realize that the psychosocial aspect of physical therapy is of greater importance than I anticipated giving credit to when I first began my career. We address behavior with the majority, if not all, patients we treat whether we recognize it or not. We convince them to perform their home exercises, avoid painful activities, use different body mechanics, break bad habits; we encourage, lecture and reinforce their behavior in order to improve their symptoms. Within the realm of pelvic floor rehabilitation, it is no surprise then that behavior has a starring role in symptom management and resolution. Education on behavior influence and modification is a typical necessity for successful treatment of symptoms of urinary incontinence.

As many of us can attest, we were taught as children to go to the bathroom before bed, before we left the house, when we returned home, etcetera, etcetera to prevent an "accident." Somewhere along the way, we begin to lose that mentality and decide to start listening to our body's urge to urinate instead. However, as life would have it, some of us experience a urinary incontinent episode here or there for various reasons, which usually causes reversion back to the routine our advisors taught us in order to avoid an embarrassing leak. The return to this behavioral habit can often contribute to the development of urinary incontinence, specifically urge incontinence.

Our bladder is actually quite a smarty-pants - it is trainable and loves to develop habits. Due to the mechanoreceptors within the bladder, it senses how much fluid we allow it to hold by the amount of stretch/pressure it feels. A normal bladder can hold about 16oz of fluid which allows for 3-4 hour voiding intervals during the day. When we begin to increase our frequency of urination without feeling an actual urge in order to avoid leaking, over time we are training our bladder to trigger an urge to urinate at that chosen level of volume instead of it's full capacity. If your mind is like mine, you are likely beginning to visualize a cycle in the form of a chart. 

Obviously there are some limitations to this cycle as there are many things that affect bladder control, function and the development of incontinence. It is simply a generalization of the effect behavior can have over our bladder. However, many of the patients I treat who have urinary urge incontinence are able to see drastic changes in bladder control and urgency symptoms with only education on behavior modification. The symptoms of urinary incontinence are so discouraging and embarrassing that they often feel like their bladder has total control of not only urination, but of their life. When it is reinforced that our bladder doesn't have to control them, it puts the ball back in their court and I usually see a happy little light bulb turn on above their head.

The education provided is individually based, as everyone has different triggers, varying levels of behavior involvement and symptom severity. However, I typically begin with assessing their response to an urge, which is most often associated with fear and anxiety due to a history of incontinent episodes. This association of an urge to urinate with fear and anxiety places undue control within the bladder's non-existent hands. The involuntary detrusor muscle surrounding the bladder begins to contract more consistently increasing the urgency and decreasing the effectiveness of the brain and pelvic floor musculature to withstand the pressure of the urge due to activation of the parasympathetic nervous system. Understanding this concept, it is very important to teach a variety of methods to decrease this association of fear and anxiety with an urge in order to improve cortical control over the bladder and diminish urinary urgency symptoms.

Urinary incontinence is a much larger problem than most men and women are willing to admit. Understanding how something as simple as behavior modification can influence these embarrassing and life controlling symptoms should prompt us to get the word out, screen your patients (friends and family for that matter), and provide or direct them to the help they deserve.