Behavioral Therapy

Behavioral therapy includes techniques which are safe and non-invasive. They are recommended as primary treatment or in addition to other medical or surgical treatments. The following are considered components of behavioral therapy:

• Pelvic muscle exercises
• Pelvic floor rehabilitation
• Bladder retraining
• Diet modification

Pelvic Muscle Exercises (Kegel Exercises)

During your pelvic examination, we will examine the strength and tone of your pelvic floor muscles. The pelvic floor muscles play an important role in continence and maintaining your pelvic organs in the normal position. During times of increased stress, like coughing or exercise, these muscles contract around the urethra and prevent urinary leakage. If these muscles, or the nerves supplying the muscles, are damaged or weakened, the mechanism maintaining continence fails.

Thankfully, many women can learn to strengthen their pelvic floor muscles. Just like lifting weights for upper and lower body muscles, repetitive exercise can increase the ability of pelvic floor muscles to function properly. Of course, this requires motivation and dedication. But for many women, properly performed Kegel exercises can cure or improve urinary incontinence and mild symptoms of vaginal prolapse.

How to do pelvic muscle (Kegel) exercises

1. The pelvic floor muscles can be identified by stopping your urine flow. Some women incorrectly contract their buttock and abdominal muscles, however, it is important to isolate the muscles surrounding the vagina and urethra. During your examination, we can help you to identify the correct muscle group.
2. You should feel your vagina tighten. You may put a finger in your vagina to confirm that you are doing the exercises correctly.
3. These exercises are best performed with an empty bladder. You may learn to identify the muscles by stopping your urine flow, however, you should not do this on a normal basis. This may interrupt the normal voiding mechanism. Although you should concentrate on performing these exercises correctly (just like you would do at the gym), you may choose to do them during routine activities like watching TV or sitting at a stop light in your car.
4. You should do a set of 15 contractions in the morning and 15 more in the afternoon. Each contraction should be held for 3-5 seconds.
5. If we identify extremely weak muscles or if you have attempted these exercises at home unsuccessfully, we may recommend pelvic floor rehabilitation.
6. Continued pelvic floor exercises are extremely important after surgery for prolapse or incontinence, and should become a lifelong habit. Remember surgery may be only part of the solution as strong pelvic floor muscles can aid in preventing a recurrence of urinary leakage problems.

Pelvic Floor Rehabilitation

If we identify extremely weak, uncoordinated, or dysfunctional muscles or if you have attempted pelvic floor (Kegel) exercises at home unsuccessfully, we may recommend pelvic floor rehabilitation. During pelvic floor rehabilitation, you will work one-on-one with our therapist to help you locate and isolate your pelvic floor muscles. Together you will use computer-assisted visual aids and variety of exercise devices to normalize the function of your pelvic floor muscles. The initial consultation is usually one hour. Based on this evaluation and the progress you make, further rehabilitation sessions may be recommended.

Bladder training

Bladder training involves a number of behavioral techniques to improve bladder function. Depending on the nature of your problem, some of these techniques may be recommended to you.

Timed voiding

Often timed voiding is a simple solution for women who leak only with a full bladder. Other women have problems emptying their bladder because they continually allow it to become too full. This is especially true for working women, those constantly “on the go”, those who put off their own toileting needs for their children’s needs, or those with mobility problems. With this technique, patients void at clock intervals of every 1 to 3 hours. Obtaining an alarm or timer for this purpose is very effective. For those women with home-health assistance, prompting from a care-giver can help solve this difficult problem.

Bladder retraining

Often women with an overactive bladder have a sudden, uncontrolled urge to void. The most common reaction is to rush to the bathroom, however, this usually results in a large volume of urinary leakage along the way to the restroom. The goal of bladder retraining is to gain control of the bladder by learning effective defense mechanisms. Usually these techniques require behavioral modification as well as pelvic floor muscle contraction, so a combined program of pelvic floor rehabilitation is often required. One should realize that contraction of the pelvic floor muscles stops the flow of urine at the urethra, and relaxes the bladder muscle to make the urge sensation resolve. The behavioral modifications involve resisting the natural reaction to rush to the bathroom. The program of urge control involves the following:

• Stop what you are doing
• Rapidly contract the pelvic floor muscles, then relax
• Breathe deeply
• Walk to the restroom in a controlled manner after the urge feeling stops

Timed interval voiding

Once the above plan becomes effective, advanced modifications are performed. With timed interval voiding, patients can fight the urge to void using the same method just described. However, instead of walking to the restroom immediately after the urge feeling stops, patients complete distracting activities or resume the activities they were performing prior to the start of the urge sensation.

Under a schedule set up by our staff, patients wait a designated time interval (5 minutes, for example) until going to the restroom. The initial interval between voids will be determined by your bladder diary and other information gained from your examination. Once the initial time interval is mastered, the time to void is gradually increased. After a step-by-step program, eventually you will work up to a reasonable time interval that will allow you to live your life without constantly running or thinking about a restroom. As part of this program, we will work with you to phase out incontinence protection as your bladder control strengthens.

Diet modification

After discussing your symptoms and reviewing your bladder diary, we will make recommendations on how to modify your diet and fluid intake to improve your bladder and bowel function. Some general recommendations that we make to most patients include:

• Drink 4-6 glasses of fluid a day. Many women with bladder problems mistakenly feel they should increase their water intake to improve their symptoms. Often, this only exacerbates the problem. Since much of the food we eat contains water, 4-6 glasses are adequate for most women.
• Decrease or eliminate caffeinated and alcoholic beverages. Caffeine and alcohol increase the body’s production of urine and may be irritating to the bladder. Other foods and beverages containing a large amount of oxylates can also be irritating to the lining of the bladder and some of the genital areas. We will discuss the specifics of a low oxylate diet if we believe it should be a part of your treatment plan. However, some of the items with a large amount of oxylates include some citrus fruits and berries, tea, spinach and tomatoes. Other foods that may be irritating to the bladder or contribute to urinary leakage are artificial sweeteners and carbonated beverages.

Food Category	Low-oxylate Foods (Recommended)	High-oxylate Foods (Not recommended)
Fruits	Melons (other than cantaloupes), blueberries, pears	Apples, apricots, avocados, bananas, cantaloupes, citrus fruits, cranberries, grapes, nectarines, peaches, pineapples, plums, pomegranates, strawberries, and juices made of these fruits
Vegetables	Potatoes, peas	Fava beans, lima beans, onions, rhubarb, tofu, tomatoes, spinach
Milk & Dairy	White Chocolate, cottage cheese, American cheese, frozen yogurt & milk	Aged cheese, sour cream, eggs, yogurt and chocolate
Carbohydrates &Grains	Pasta, rice, some breads	Rye & Sourdough bread
Meats & Fish	Poultry, some fish and some meats	Aged, canned, cured, processed, or smoked meats & fish, anchovies, caviar, chicken livers, corned beef, and meats that contain nitrates or nitrites
Nuts	Almonds, cashews, pine nuts	Most other nuts
Beverages	Bottled or spring water, decaffeinated, acid free coffee & tea, some herbal teas	Alcoholic beverages, beer, wine, carbonated drinks, coffee, tea, and cranberry juice (see fruits)
Seasonings and condiments	Garlic and some other seasonings	Mayonnaise, ketchup, mustard, salsa, miso, soy sauce, vinegar, ethnic foods like Chinese, Indian, Mexican, and Thai
Preservatives & Additives		Benzol alcohol, citric acid, monosodium glutamate, aspartame, (NutraSweet), saccharin, foods containing preservatives & artificial ingredients & colors
Miscellaneous	Take Citracal (not Citracel), 1 tablet with each meal to bind the oxylates in your diet. This can also serve as your calcium supplement	Tobacco, caffeine, diet pills, junk foods, recreational drugs, cold and allergy medications

• Add high fiber foods to your diet and avoid constipation. Severe constipation can significantly contribute to pelvic floor dysfunction. A rectum full of stool may make it difficult to empty the bladder. Chronic straining to pass stool may lead to vaginal prolapse which in turn, causes bladder problems. We may discuss the need for medication to combat constipation.
• Quit smoking. We strongly recommend this for multiple heath reasons, but smoking also contributes to bladder dysfunction as it causes bladder irritation that can lead to symptoms of urinary frequency and urgency. More importantly, smokers are at a much higher risk for bladder cancer.